Horizon NJ Health Member Benefit Matrix

Transcription

1 This Matrix provides a comprehensive overview of the benefits for preventive and medically necessary services provided to members enrolled with Horizon NJ Health. members enrolled with Horizon NJ Health through and do not incur a copayment. Members enrolled through, and VNTGE are required to pay a copayment for certain services. Please refer to the Member Identification ard for instances where a copayment is required. Not withstanding anything to the contrary, the following is the Matrix for the Medicaid ontract and sets forth the services which are reimbursable to the physician by Horizon NJ Health. s are established by the State of NJ and are subject to change. bortions and Related Services overage limited to spontaneous abortions/miscarriages (such as those under I-9 diagnosis codes 632, , ). Fee-for-Service coverage limited to elective/induced abortions. pplied ehavior nalysis () cupuncture overage limited to acupuncture provided by a licensed physician overage limited to acupuncture provided by a licensed physician when performed as a form of anesthesia in connection with covered surgery. udiology Services (See EPST for hearing screenings) overage limited to children under the age of 16 years lood and lood Plasma overage limited to administration of blood, processing of blood, processing fees and fees related to autologous blood donations. hiropractic Services overage limited to spinal manipulation overage limited to spinal manipulation. $5 copayment ognitive Therapy overage limited to children under the age of 21 and on a case by case basis as determined by the Medical irector. overage by Fee-for-Service coverage limited to beneficiaries enrolled in the ivision of isability Services Traumatic rain Injury (TI) Waiver program overage limited on a case by case basis as determined by the Medical irector ental $5 copayment except for preventive dentistry visits overage limited to members under the age of 19. $5 copayment except for preventive dentistry visits 1 September 4, 2012

2 ental - Orthodontics iabetic Supplies and Equipment Limited coverage Limited coverage only for members under the age of 21 only for members under the age of 21 where medical necessity to correct a facial deformity where medical necessity to correct a facial deformity can be demonstrated. can be demonstrated. $5 copayment urable Medical Equipment / ssistive Technology evices overage is limited to the specific durable medical equipment listed at the end of this document. Emergency Medical are/ Emergency Services $10 copayment for $35 copayment for emergency room services emergency room services, except when referred by PP for services that should have been provided in PP s office or when member was admitted to the hospital EPST Family Planning Group Homes and YFS Residential Treatment Facilities, including: medical examinations; dental, vision, hearing and lead screening services; only those treatment services identified through the examination that are covered by the benefit package when services provided by a participating HNJH physician. by Fee-for-Service when services provided by a non-participating HNJH physician. overage limited to services provided by HNJH participating providers. HNJH shall cooperate with the medical, nursing and administrative staff to ensure members have timely and appropriate access to participating providers and to coordinate care between participating providers and those providers employed by facility/group home overage limited to well-child care, newborn hearing screenings, preventive dental, immunizations, and lead screening and treatment overage includes medical history and physical exams (including pelvic and breast), diagnostic & lab tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling. ertain members may only access services by participating HNJH physicians Hearing id Services overage limited to children under the age of 16 years Home Health gency Services overage includes; nursing services by a registered nurse and/or licensed practical nurse; home health aide service; medical supplies and equipment; physical therapy, occupational therapy and speech therapy services; pharmaceutical services; and durable medical equipment overage limited to skilled nursing for home-bound member that is provided or supervised by a RN and a home health aide, when the purpose of the treatment is skilled care. overage includes medical social services that are necessary for treatment of the member s medical condition 2 September 4, 2012

3 Home Health gency Services Mental Health by Horizon NJ Health for clients only. ll other beneficiaries covered by Fee-for-Service by Fee-for-Services as follows: For members under the age of 19, covered with no service limits For members 19 years and older - limited to 20 visits per year Hospice Services Hospital Services - Inpatient in the community as well as in institutional settings. Room and board are included only when services are delivered in an institutional (non-private residence) setting. Hospice care for children under 21 years of age shall cover both palliative and curative care. Hospital Services - Outpatient with $5 copayment except for preventive services Infertility iagnosis and Treatment (including sterilization reversals, and related office [medical and clinic] visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures) Intermediate are Facilities/Intellectual isability Laboratory Services Maternity Services and related newborm care and hearing screening Medicaid Fair Hearing overage includes routine testing related to the administration of atypical antipsychotic drugs Members have a right to a Medicaid Fair Hearing, but the request must be filed with MHS within 20 days of the date of the adverse action by Horizon NJ Health overage includes routine testing related to the administration of atypical antipsychotic drugs $5 copayment when not part of office visit Only certain members have the right to a Medicaid Fair Hearing. The request must be filed with MHS within 20 days of the date of the adverse action by Horizon NJ Health Medical ay are Mental Health - Inpatient Hospital Services Including Psychiatric Hospitals by Horizon NJ Health for clients only. ll other beneficiaries covered by Fee-for-Service by Fee-for-Service as follows: For members under the age of 19, covered with no service limits For members 19 years and older limited to 35 days per year Mental Health Outpatient (excluding partial care services) by Horizon NJ Health for clients only. ll other beneficiaries covered by Fee-for-Service by Fee-for-Service as follows: $5 copayment for members under the ages 19 $25 copayment for members 19 years and older 3 September 4, 2012

4 Mental Health Home Health by Horizon NJ Health for clients only. ll other beneficiaries covered by Fee-for-Service by Fee-for-Service as follows: For members under the age of 19, covered with no service limits For members 19 years and older - limited to 20 visits per year Medical Supplies Limited coverage. See also urable Medical Equipment benefit Methadone (maintenance and administration) by Fee-for-Service Nurse Midwife $5 copayment for each visit (except for prenatal care visits) $5 copayment for first prenatal visit only $10 copayment for services rendered during non-office hours No copayment for preventive services or newborns covered under fee-for-service. Nurse Practitioner $5 copayment for each visit (except for preventive care services) $5 copayment for each visit during normal office hours (except for preventive care services). $10 copayment for each home visit or office visit after normal office hours Nursing Facility Services - custodial care, rehabilitation, post-acute care, skilled nursing care, and services in special nursing facilities such as ventilator facilities, pediatric long term care and treatment for IS. overage limited to the 30 days in nursing facility. If admission to an acute hospital is required during these 30 days, the 30 day count is suspended and resumes on readmission back to the nursing facility. NOTE: If the enrollee continues to receive nursing services (non rehabilitation) beyond 30 days, the enrollee will be disenrolled to the Medicaid fee for service program and HNJH will no longer be financially responsible. If admission is for rehabilitation services only, HNJH will continue to be responsible for cost of care. fter 30th day in a nursing facility for non-rehabilitation services, MHS will disenroll the member from HNJH and the member will receive services from the Medicaid FFS program. overage limited to 30 days of rehabilitation services following discharge from an acute care hospital if this is the appropriate setting for rehab to occur 4 September 4, 2012

5 Optical ppliances Optometrist Services Organ Transplants - Individual placed on transplant list while a HNJH member Organ Transplants - Individual placed on transplant list while in the FFS Program prior to initial enrollment with HNJH Selected eyeglasses and contact lenses are covered as follows: ge 18 and under - Replacement eyeglasses or contact lens annually if prescription changes. ge 19 to 59 - Replacement eyeglasses or contact lens every two years if prescription changes ge 60 and older - Replacement eyeglasses or contact lens annually if prescription changes. Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur. One routine eye exam per year overage includes all donor and recipient transplant costs One routine eye exam per year $5 co-payment overage by Horizon NJ Health limited to transplant related physician costs for donor and recipient. onor and recipient inpatient hospital costs covered by Fee-for-Service Orthotics Outpatient iagnostic Testing Partial are Program by Fee-for-Service Partial Hospital Program by Fee-for-Service Personal are ssistant (P) Services overage limited to maximum of 40 hours per week. ny additional hours above 40 hours per week covered by Fee-For-Service. Prior authorization required Personal Preference Program Services (only available through certain Waiver Programs) by Fee-for-Service Members may contact the NJ ivision of isability Services at , Option 2 Podiatrist Services $5 copayment $5 copayment. Routine hygienic care of feet, including the treatment of corns, calluses, trimming of nails, and other hygienic care in the absence of a pathological condition is not covered 5 September 4, 2012

6 Prescription rugs Retail Pharmacy Prescription rugs Medicare Part physician administered (typically billed with J-codes or Q-codes) for all members overage includes: atypical antipsychotics; Suboxone and Subutex or any other drug within this category when used for the treatment of opioid dependence; and drugs which may be excluded from Medicare Part coverage overage excludes: erectile dysfunction drugs; and drugs not covered by a third party Medicare Part formulary. for all members $1 copayment for generic drugs; $5 for brand name drugs overage includes: atypical antipsychotics; Suboxone and Subutex or any other drug within this category when used for the treatment of opioid dependence; and drugs which may be excluded from Medicare Part coverage overage excludes: erectile dysfunction drugs; and drugs not covered by a third party Medicare Part formulary. for all members overage excludes over the counter drugs $5 copayment for brand name and generic drugs. If greater than a 34-day supply, $10 copayment applies. overage includes: atypical antipsychotics; Suboxone and Subutex or any other drug within this category when used for the treatment of opioid dependence; and drugs which may be excluded from Medicare Part coverage overage excludes: erectile dysfunction drugs; and drugs not covered by a third party Medicare Part formulary. Primary are, Specialty are, and Women s Health Services $5 copayment for each visit. No copayment for well-child visits, lead screening/ treatment, age-appropriate immunizations, prenatal care or PP smears $5 copayment for each visit during office hours $10 copayment for each office visit after normal office hours No copayment for well-child visits, lead screening/treatment, age-appropriate immunization, or preventive dental services $5 copayment for first prenatal visit, no subsequent copayments Private uty Nursing for EPST age children only Prosthetics overage limited to the initial provision of a prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease, injury, or congenital defect. Repair and replacement services are covered only when needed due to congenital growth Radiology Services -iagnostic & Therapeutic $5 copayment when not part of an office visit 6 September 4, 2012

7 Rehabilitation Services - Outpatient PT, OT and Speech Self initiated care from a non-participating provider without referral/authorization Services provided outside of the United States and territories Sex buse Examinations and related diagnostic testing overage limited to 60 visits, per incident, per therapy, per calendar year The member shall be held responsible for the cost of care by Fee-for-Service overage limited to 60 visits, per incident, per therapy, per calendar year $5 copayment Speech pathology services rendered for treatment of delays in speech development are not covered, unless resulting from disease, injury or congenital defects Social Necessity ays by Fee-for-Service, limited to no more than 12 inpatient hospital days Specialty Foods (medical foods) overage limited to nutritional supplements requiring medical supervision for members with inborn errors of metabolism and related genetic conditions Medical foods and special diets for all other medical condition are not covered Substance buse (Inpatient and Outpatient) Transportation Emergency mbulance (911) by Horizon NJ Health for clients only. ll other beneficiaries covered by Fee-for-Service overage limited to ambulance for medical emergency only limited to detoxification by Fee-For-Service. For members under the age of 19, covered with no service limits For members 19 years and older - limited to 20 visits per year Transportation to medically necessary services - Livery transportation services, such as bus and train fare or passes, car service by Logisticare (State transportation contractor) NOTE: Members should call Logistiare at (866) to book a trip by 12:00 noon at least 2 days in advance of transportation need. Transportation to medically necessary services (including non-emergency ambulance, mobile intensive care units [MIUs] and invalid coach [including lift equipped vehicles]) by Logisticare (State transportation contractor) NOTE: Members should call Logistiare at (866) to book a trip by 12:00 noon at least 2 days in advance of transportation need. 7 September 4, 2012

8 VNTGE bortions and Related Services cupuncture udiology (See EPST for hearing screenings) lood and lood Plasma ognitive Therapy ental overage limited to spontaneous abortions/miscarriages (such as those under I-9 diagnosis codes 632, , ) overage limited to acupuncture provided by a licensed physician when performed as a form of anesthesia in connection with a covered surgery overage limited to children under the age of 16 years overage limited to administration of blood, processing of blood, processing fees and fees related to autologous blood donations overage limited on a case by case basis as determined by the Medical irector, $5 copayment for all dental visits. ental - Orthodontics only where medical necessity to correct a facial deformity can be demonstrated, $5 copayment iabetic Supplies and Equipment urable Medical Equipment/ssistive Technology evices Emergency Medical are/emergency Services EPST (Early and Periodic Screening, iagnosis and Treatment) Family Planning Hearing id Services Home Health & Visiting Nursing Services Hospice Services Hospital Services (Inpatient) Hospital Services (Outpatient) Laboratory Services Maternity Services Medical Supplies Nurse Midwife Nurse Practitioner Optical ppliances Optometrist Services Organ Transplants Outpatient iagnostic Testing Podiatrist Services Prescription rugs from a Retail Pharmacy overage is limited to the specific durable medical equipment listed at the end of this document., $35 copayment for each visit overage limited to well-child care, newborn hearing screenings, immunizations, and lead screening and treatment overage includes medical history and physical exams (including pelvic and breast), diagnostic and lab tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling. overage limited to children under the age of 16 years overage is limited to skilled nursing for home-bound member that is provided or supervised by a RN and a home health aide when the purpose of the treatment is skilled care. overage includes medical social services that are necessary for treatment of the member s medical condition in the community as well as in institutional settings. Room and board are included only when services are delivered in an institutional (non-private residence) setting. for both palliative and curative care.. Horizon NJ Health is not responsible when the primary admitting diagnosis is mental health or substance abuse related, $5 copayment for each visit, $5 copayment for each visit that is not part of an office visit. NOTE: Routine testing related to the administration of atypical antipsychotic drugs is not covered., including related newborn care and hearing screening overage limited to diabetic supplies, $5 copayment for each visit, $5 copayment for each visit Selected eyeglasses and contact lenses are covered as follows: Replacement eyeglasses or contact lenses annually if prescription changes. Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur. for one routine eye exam per year, $5 copayment If the individual is placed on transplant list while a Horizon NJ Health member, Horizon NJ Health is responsible for entire cost of non-experimental/non-investigational organ transplants. overage is limited to transplant related physician costs for donor and recipient if the individual was placed on transplant list while in the FFS Program prior to initial enrollment, $5 copayment for each visit, Routine hygienic care of feet, including the treatment of corns, calluses, trimming of nails and other hygienic care in the absence of a pathological condition, is not covered overage excludes over the counter drugs $1 copayment for generic drugs $5 copayment for brand name drugs $10 copayment for >34-day supply No coverage for erectile dysfunction drugs or atypical antipsychotic drugs ertain cough/cold, topicals, and anti-obesity drugs are not covered for certain age groups 8 September 4, 2012

9 Prescription rugs Medicare Part physician administered (typically billed with J-codes or Q-codes.) VNTGE Primary are, Specialty are and Women's Health Services Prosthetics Radiology Services iagnostic & Therapeutic Rehabilitation Services - Outpatient PT, OT and Speech Self-initiated care from a non-participating provider without referral/authorization Transportation Emergency mbulance (911) Transportation to medically necessary services - Livery transportation services, such as bus and train fare or passes, car service Transportation to medically necessary services ( including non-emergency ambulance, mobile intensive care units (MIUs) and invalid coach (including lift equipped vehicles) with a $5 co-payment for each visit overage limited to the initial provision of prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease, injury, or congenital defect. Repair and replacement services are covered when due to congenital growth, $5 copayment for each visit that is not part of an office visit overage limited to 60 visits per therapy per calendar year with a $5 copayment. Speech pathology services rendered for treatment of delays in speech development are not covered, unless resulting from disease, injury or congenital defects. The member shall be held responsible for the cost of care overage limited to ambulance for medical emergency only only if Horizon NJ Health refers a patient to an out of county or out of State provider only if Horizon NJ Health refers a patient to an out of county or out of State provider when the services could have been rendered in-county/in-state 9 September 4, 2012

10 Exclusions for ll eneficiaries The following services are not covered by Horizon NJ Health or the NJ Medicaid Fee-For-Service program: ll services not medically necessary, provided, approved or arranged by a contractor s physician or other provider (within his/her scope of practice) except emergency services. osmetic surgery except when medically necessary and approved. Experimental organ transplants. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinic), drugs, laboratory services, radiological and diagnostic services and surgical procedures. Respite are Rest cures, personal comfort and convenience items, services and supplies not directly related to the care of the patient, including but not limited to, guest meals and accommodations, telephone charges, travel expenses, take home supplies and similar cost. osts incurred by an accompanying parent(s) for an out-of-state medical intervention are covered under EPST by the contractor. Services involving the use of equipment in facilities, the purchase, rental or construction of which has not been approved by applicable laws of the State of New Jersey and regulations issued pursuant thereto. ll claims arising directly from services provided by or in institutions owned or operated by the federal government such as Veterans dministration hospitals. Services provided in an inpatient psychiatric institution, that is not an acute care hospital, to individuals under 65 years of age and over 21 years of age. Services provided to all persons without charge. Services and items provided without charge through programs of other public or voluntary agencies (for example, New Jersey State epartment of Health and Senior Services, New Jersey Heart ssociation, First id Rescue Squads, and so forth) shall be utilized to the fullest extent possible. Services or items furnished for any sickness or injury occurring while the covered person is on active duty in the military. Services provided outside the United States and territories. Services or items furnished for any condition or accidental injury arising out of and in the course of employment for which any benefits are available under the provisions of any workers compensation law, temporary disability benefits law, occupational disease law, or similar legislation, whether or not the Medicaid beneficiary claims or receives benefits there under, and whether or not any recovery is obtained from a third-party for resulting damages. That part of any benefit which is covered or payable under any health, accident, or other insurance policy (including any benefits payable under the New Jersey no-fault automobile insurance laws), any other private or governmental health benefit system, or through any similar third-party liability, which also includes the provision of the Unsatisfied laim and Judgment Fund. ny services or items furnished for which the provider does not normally charge. Services furnished by an immediate relative or member of the Medicaid beneficiary s household. Services billed for which the corresponding health care records do not adequately and legibly reflect the requirements of the procedure described or procedure code utilized by the billing provider. Services or items reimbursed based upon submission of a cost study when there are no acceptable records or other evidence to substantiate either the costs allegedly incurred or beneficiary income available to offset those costs. In the absence of financial records, a provider may substantiate costs or available income by means of other evidence acceptable to the ivision Exclusions For Plan Members The following services are not covered for NJ Familyare Plan participants either by Horizon NJ Health or MHS: Non-medically necessary services Intermediate are Facilities/Intellectual isability Private duty nursing unless authorized by the contractor 10 September 4, 2012

11 Personal are ssistant Services Medical ay are Services hiropractic Services Orthotic evises Residential treatment center psychiatric programs Religious non-medical institutions care and services Early and Periodic Screening, iagnostic and Treatment (EPST) services (except for well child care, including immunizations and lead screening and treatments) Transportation Services, including non-emergency ambulance, invalid coach and lower mode transportation Hearing id Services, except for children under 16 years lood and lood Plasma, except administration of blood, processing of blood, processing fees and fees related to autologous blood donations are covered osmetic Services ustodial are Special Remedial and Educational Services Experimental and Investigational Services Infertility Services Rehabilitative Services for Substance buse Weight reduction programs or dietary supplements, except surgical operations, procedures or treatment of obesity when approved by the contractor cupuncture and acupuncture therapy, except when performed as a form of anesthesia in connection with covered surgery Temporomandibular joint disorder treatment, including treatment performed by prosthesis placed directly in the teeth Recreational therapy Sleep therapy ourt-ordered services Thermograms and thermography iofeedback Radial keratotomy Respite are Nursing facility services udiologist services, except for children under 16 years ental services for beneficiaries age 19 or older Exclusions For VNTGE Members The following services are not covered for NJ Familyare VNTGE participants either by Horizon NJ Health or MHS: iofeedback osmetic Services osmetic surgery except when medically necessary and approved. ourt-ordered services ustodial are Radial keratotomy Recreational therapy Religious non-medical institutions care and services Respite are Services or items furnished for any sickness or injury occurring while the covered person is on active duty in the military. Services or items reimbursed based upon submission of a cost study when there are no acceptable records or other evidence to substantiate either the costs allegedly incurred or beneficiary income available to offset those costs. In the absence of financial records, a provider may substantiate costs or available income by means of other evidence acceptable to the ivision. Services provided outside the United States and territories. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinic), drugs, laboratory services, radiological and diagnostic services and surgical procedures. Sleep therapy Special Remedial and Educational Services Temporomandibular joint disorder treatment, including treatment performed by prosthesis placed directly in the teeth Thermograms and thermography Weight reduction programs or dietary supplements, except surgical operations, procedures or treatment of obesity when approved by the contractor URLE MEIL EQUIPMENT VILLE FOR FMILYRE PLN MEMERS overage is limited to the following pnea Monitors athroom Equipment (Permanently ffixed Equipment Not ) atheterization and Related Supplies 11 September 4, 2012

12 ommodes ME Repairs Enteral Nutrition and Related Services/ Supplies Hospital eds ( Manual, Semi-Electric and Full Electric) and Related Equipment Insulin Pumps and Related Supplies Manual Wheelchairs (Motorized Wheelchairs Not ) Nebulizers and Related Supplies Ostomy/Ileostomy/Jejunostomy Supplies Oxygen and Related Equipment/Supplies Pacemaker Monitors Parenteral Therapy and Related Services/ Supplies Patient Lifts and Related Equipment Pressure Mattresses/Pads (Low ir Loss and ir Fluidized eds Not ) Respiratory ssist evices and Related Supplies Suction Machines and Related Supplies Total Parenteral Nutrition (TPN) Equipment and Related Supplies Tracheostomy Supplies Traction/Trapeze pparatus Wheelchair ccessories Wound are Supplies Wound Vac and Related Supplies 12 September 4, 2012