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1 210 Silvia Street West Trenton, NJ NJ-HEALTH ( ) TDD/TTY: Member Handbook Si desea recibir un ejemplar en español del manual para los miembros de, llame a Servicios para Miembros, sin cargo, al NJ-HEALTH ( ). Esta oficina atiende durante las 24 horas, todos los días., a partnership, is a product of Horizon HMO. Horizon HMO is a wholly owned subsidiary of Horizon Blue Cross Blue Shield of New Jersey. Horizon HMO and Horizon Blue Cross Blue Shield of New Jersey are independent licensees of the Blue Cross and Blue Shield Association Registered marks of the Blue Cross and Blue Shield Association. and SM Registered and service marks of Horizon Blue Cross Blue Shield of New Jersey Horizon Blue Cross Blue Shield of New Jersey Three Penn Plaza East, Newark, NJ (W1209)

2 Welcome You and your family deserve quality health care coverage and now that you have joined, you can count on it. You will find that covers the NJ FamilyCare/Medicaid Program benefits plus additional benefits, special programs and your own personal doctor. You also get the special comfort of knowing that you are with the plan backed by Horizon Blue Cross Blue Shield of New Jersey. And the best part is all of this is covered at little or no cost to you. So welcome and thanks for joining. Take a look through this member handbook to understand all the benefits we offer. Remember if you have questions any time, day or night call our Member Services department toll free at NJ-HEALTH ( ). If you have hearing or speech difficulties, please call our TDD/TTY number toll free at You may also write to at: Member Outreach Department 210 Silvia Street West Trenton, NJ We are here to help you. What is Inside Becoming a Member Premiums and Co-Payments Member Services Your ID Card Your Personal Doctor Emergency Your Benefits and Services Your Family and Your Rights and Responsibilities More About Bills Ending Your Membership Fraud, Waste and Abuse Complaint/Grievance and Appeal Procedures Words to Learn There are many words in this handbook and the medical world that you may not know. Look for this sign ( ) for definitions that will help you get the most from your membership. i ii

3 Becoming a Member Who Can Join? You can join if you live in New Jersey and you are receiving Medicaid through one of these programs: Aid to Families with Dependent Children (AFDC)/Temporary Assistance for Needy Families (TANF) AFDC-related New Jersey Care for Pregnant Women and Children Supplemental Security Income (SSI) for Aged, Blind, Disabled (ABD) and Essential Spouses New Jersey Care for Aged, Blind, Disabled and Essential Spouses Division of Youth and Family Services You can also join if you qualify for the NJ FamilyCare Program. Eligibility for the NJ FamilyCare/Medicaid Program is based on the number of people in your family and your family s total monthly income. You, your spouse and/or your family members must be New Jersey residents and, in most cases, you must have been without medical insurance for at least three months.* There are some exceptions to this rule, so please call Member Services. *Legal immigrants who are lawfully admitted for permanent residence, including parents and their children, can apply for the NJ FamilyCare Program, even if they have lived in this country less than five years. Signing Up and Getting Started To become a member, call the NJ State Health Benefits Coordinator toll free at People with hearing difficulties may call the State's TDD/TTY number toll free at Your membership must be approved by the Division of Medical Assistance and Health Services (DMAHS). It will take about 30 to 45 days for your membership to start. Until Division of Medical Assistance and Health Services (DMAHS) approves your membership, your current health insurer will most likely continue to provide your health care services. For services you were receiving with your previous insurer, Horizon NJ Health will coordinate your care once your membership becomes effective. The Health Benefits Coordinator will share your answers to the health care questions on the enrollment application with. By signing your enrollment application, you allow the release of your medical records to. At the time you sign up with Horizon NJ Health, it is also important that you tell the Health Benefits Coordinator and about any doctors that you are currently seeing. Selecting Your Doctor You and each of your family members will need to choose a personal doctor, known as a Primary Care Provider (PCP). Take a look through the Horizon Provider the person or location (such as a hospital) that gives medical care NJ Health Provider Directory for a PCP near you. A copy of the Directory is included in your Welcome Kit, by calling Member Services and on the Web site at You can have a different PCP for each family member. For example, you can choose a pediatrician for your child and a general family doctor for yourself. An authorized person acting for you may help you in choosing a PCP. Member Services can also help you with your choice of doctors. Special Needs Members has a Care Coordination Unit (CCU) to help our members with special health care needs. If you or a family member has a complex or chronic medical condition, physical or developmental disability or a catastrophic illness, you may be eligible for care management. If you have special health care needs, please show this by answering the questions on your Plan Selection Form when you sign up for. You can ask for an evaluation to see if you qualify for the special needs program. Or you may have your PCP, specialist, social worker, community-based case Specialist - a doctor who has been specially trained in a chosen field of medicine manager or any other concerned agency ask for an evaluation for you. Call our Member Services department toll free at NJ-HEALTH to ask for an evaluation to see if you qualify for this program. People with hearing or speech difficulties can call our TDD/TTY service at A Care Coordination nurse or social worker, familiar with where you live, will complete a screening assessment. The Care Coordination team will let you know what level of care management you or your family member needs. You will work with the Care Coordination team and your PCP or specialist to create a plan of care that addresses your physical and psychosocial needs. This will be done no later than 10 days after the effective date of enrollment if your Plan Selection Form has indicated that you have special needs. If special conditions are identified by a provider, a care plan will be completed within 30 days. Your care plan will list community resources as part of your overall health care support system. We will help you connect with these resources to include them as part of your care plan. Depending on your level of care, you will get a copy of your care plan. You can use this as a reference when making appointments with different providers. As your needs change, your care plan will be updated. Your care plan will also tell you how you can contact your specific Care Coordinator. You can talk about any problems or concerns you may have with your Care Coordinator. Keeping Your Membership Once you are a member of, you will continue to be a member until you disenroll or you lose Medicaid eligibility or if special circumstances require DMAHS to disenroll you, such as a nursing facility stay greater than thirty days. Most members must have their eligibility checked every year. AFDC/TANF members are checked for eligibility every six months. If your application was first processed at your local County Board of Social Services, they will contact you when it is time for a renewal. If your NJ FamilyCare ID number begins with a 23 or 24, you may call the Health Benefits Coordinator toll free at to find out your renewal date or to ask for a renewal form. People with hearing or speech difficulties may call Renewal Process A Renewal Application must be completed every year. You must include a current month of income verification, and family size and other supporting documentation when you send in your renewal application. Return all materials in the self-addressed envelope provided with your renewal application 30 days before your renewal date. If you have questions or need help completing the Renewal Application, call the Outreach Center toll free at for help. People with hearing or speech difficulties can use our TDD/TTY service at Please look at the section on Ending Your Membership in this handbook for more information on the disenrollment process. 1 2

4 Premiums and Co-payments Families in the NJ FamilyCare Program may be required by the State of New Jersey to pay a premium or co-payment for service. Premiums for NJ FamilyCare D members range from $40.00 each month for a family, to $133.00* a month. The amount is based upon the Co-payment - the amount a person must pay for a health care service at the time the service is given family s income level. If you do not pay your monthly premiums on time, it may result in disenrollment from the program. The NJ FamilyCare Program will collect all premiums. Children under 21 years of age and pregnant women do not have co-payments. Your co-payment amount is indicated on your member ID card. The family limit on all monthly premiums and co-pays for members may not exceed five percent of the annual family income. It is important for members to keep track of their monthly payments and notify the State if their contributions exceed 5% of the family income in one calendar year. Member Services ( NJ-HEALTH) Our helpful, multilingual Member Services staff is ready to help you get the most out of your membership, 24 hours a day, 7 days a week, including weekends and holidays. Any time you have a question about your benefits, how works or how to get the care you need, give us a call. The toll free numbers are printed on your member ID card and on our Web site at To help you learn how works and how to get the most out of your benefits, *2009 Figures Premium - the monthly cost of health insurance paid by the member Benefit - service given to an person paid for by the insurance plan a Member Services Outreach staff will call you at the start of your membership. This is the perfect time to ask any questions you may have. We also offer educational and outreach activities throughout the year. Member Services will be happy to give you the details about times and locations of outreach events. Call NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at Translation Services and Audio/Visual Information We have staff members who know many languages, including sign language. When we do not have someone who speaks your language, we will find someone who does. We can arrange for a translator to talk over the phone with you and your doctor to help during your doctor s visit. The translator will make sure your doctor knows what you are saying and you know what the doctor is saying. With the translator s help, you can get answers to all of your questions. can coordinate a sign language interpreter to be with you at the doctor s office. There is no cost to you to use our translation or sign language interpreter services and they are easy to use. Just call Member Services toll free at NJ-HEALTH. All information for members is available in Spanish. If you need information printed in another language, call Member Services. Materials for the visually and hearing impaired are also available through Member Services. Your ID Card Always Carry it With You Before your membership begins, a Horizon NJ Health ID card for each covered member in your family is mailed to you. Always carry your ID card with you. It is one of the most important cards you have. Show your card when you need health care; when you are seeing your personal Horizon NJ Health doctor or dentist; when you have been referred to a specialist; when you get a prescription; for lab work or at the hospital emergency room (ER). You can use your card as long as you are a member. What is on the Card Name of the Enrollee Effective date The effective date is your starting date of enrollment with Horizon NJ Health and the date your benefits begin. Your Primary Care Provider s (PCP) name and phone number. Member ID Number Primary Care Provider Primary Care Provider Phone Issue Date Effective Date * Independent licensees of the Blue Cross and Blue Shield Association.*, a product of Horizon HMO* BC/BS Plan Codes 280/780 NAME MEMBER ID NO: YHZ DOCTOR PHONE ISSUE DATE EFFECTIVE Independent licensees of the Blue Cross and Blue Shield Association.*, a product of Horizon HMO* BC/BS Plan Codes 280/780 NAME MEMBER ID NO: YHZ DOCTOR PHONE ISSUE DATE EFFECTIVE Shows if you have dental benefits. The amount of co-payments you pay for visiting your doctor, the emergency room or filling a prescription (if any). Our toll free Member Services phone number is on the back of the card. Information on what to do in case of an emergency is on the back of the card. If it is Lost or Stolen If your ID card is lost or stolen, call Member Services right away. We will cancel your old card and send you a new one. Your Health Benefits Identification (HBID) Card As well as your ID card, you should also carry your Health Benefits Identification (HBID) card sent to you by the State of New Jersey. You will need this card to get certain services not covered by your membership with (see the Your Benefit and Services section). * Horizon NJ Health Dental No Copayments Plan Dental Emergency PCP Copay Specialist Copay Rx Generic Rx Brand Dental Benefit Indication Copay Amount 3 4

5 Your Personal Doctor Where All Your Care Begins As a member of, you choose a personal doctor or a nurse practitioner, called a Primary Care Provider (PCP) from a list of doctors and dentists that work with Horizon NJ Health. This list, called a Provider Directory, is updated each month. If you need an updated list, please call Member Services at NJ-HEALTH or visit the Horizon NJ Health Web site at People with hearing or speech difficulties can call our TDD/TTY service at Your PCP Arranges for All of Your Care Call your doctor's office first at any time, 24 hours a day, whenever you need medical care. Your doctor will know how to help. All nonemergency health care services must be made through your PCP. Your health services are covered 24 hours a day, 7 days a week. covers the services of all Primary Care Providers, specialists, certified nurse midwives, certified nurse practitioners, clinical nurse specialists, physician assistants and independent clinics. Your PCP may use other health care practitioners to help give timely care for you and your family. If you are a member with a special medical need, you may ask to have a participating specialist as your PCP. This request must be made through 's Care Coordination Unit (CCU). Call Member Services and they will put you in touch with a CCU Case Manager. Make an Appointment Right Away After you have become a member of Horizon NJ Health, we will call you to make sure you have received your ID Card, new member materials and answer any questions you may have. We also want you to call the office of your Primary Care Provider (PCP) and make an appointment for a checkup. Why? Because a baseline physical will let your doctor measure your health now, review your past health history and help avoid any future health problems. Your PCP s office should schedule appointments for routine visits within 28 days of your request. Now would also be a good time to schedule a dental exam. Children and adults should have their teeth cleaned at least once a year. If your effective date of enrollment is different from that given to you by your Health Benefits Coordinator, will notify you, or where applicable, an authorized person of the new date of enrollment. If you need to see your PCP before you get your ID card, call Member Services. A Member Services Representative will make arrangements for you to see your PCP. Very Important: Keep Your Appointments! It is the only way your doctor and dentist can make sure that you and your family are getting the quality care you deserve. If you cannot keep an appointment, call and let your doctor or dentist know immediately. What if? Questions and Answers About Your Doctor and Your Care Q. What if I cannot reach my doctor right away? A. There could be times maybe at night or on weekends when your doctor is not in the office. Call your doctor's office anyway. Someone from that office will be able to help or they will have a doctor call you. If your situation is an emergency, call 911 or go to the nearest emergency room. Q. What if I want a second opinion? A. You can ask for another doctor's opinion for any medical or surgical diagnosis. Just talk to your PCP. He or she will make all of the arrangements or if you want, you may call Member Services for help finding another doctor. Q. What if I want to change my doctor? A. You can change your PCP at any time. Member Services will help you choose a new doctor and send you a new ID card with the new doctor s name and phone number. reserves the right to deny a request to change to a new PCP. Some situations where may deny a request include: A member has already changed their PCP twice in a given year If a PCP asks that a member not be included on his or her list of patients If a PCP has too many patients to take any more Creating a positive, healthy relationship with your PCP is important. If your PCP believes that he/she cannot do this with a member, your PCP may ask that the member be changed to another PCP. Other times where a PCP may ask that a member be changed to another provider include: Unable to solve conflicts between the member and their PCP If a member fails to follow health care instructions where such non-compliance stops the physician from safely or ethically proceeding with the member's health care services If a member has taken legal action against the PCP Q. What if I need to see a specialist? A. Your PCP will make the arrangements to send you to a participating specialist and your PCP will give you a Referral Form - a paper authorizing a patient's visit to a specialist Referral Form to take with you. You must have a Referral Form to see a participating specialist. An eye doctor for a medical problem (such as cataracts or an eye infection) or a heart specialist, are types of doctors you need a Referral Form to see. You do not need a referral form to visit your Ob/Gyn or for a mammogram. If you have a condition that needs ongoing care from a participating specialist, you can ask your PCP for a standing referral. A standing referral is a referral that lets you to go to your specialist as often as the specialist needs to see you to treat your medical condition or the specialist may be able to act as your PCP and specialty care provider. Q. What if my condition requires care from a doctor who does not participate with? A. contracts with thousands of doctors and specialists throughout New Jersey. If we do not have a doctor to care for your condition, we will work with your PCP or dentist to make sure you get the care you need. You may also get special approval from for an out-of-network provider, if your medical condition requires. If you use an out-of-network provider without approval from, you will be responsible to pay for those services. Emergency! Go or Not Go? When should you as a prudent layperson* go to the hospital emergency room? ONLY go when your situation is an emergency, involving a severe illness or injury. If an emergency exists, go to the nearest emergency room (ER) or call 911. In an emergency, you do not need to get approval from or a doctor to go to the emergency room. Sometimes it can be hard to tell if you have a real emergency. *A prudent layperson is someone who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (Or with respect to a pregnant women, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. 5 6

6 Here are some examples of emergency situations when you should definitely go: Chest pain Broken bones Difficulty breathing, moving or speaking Poisoning Heavy bleeding Drug overdose Car accident When you are in labor during pregnancy, follow your Ob/Gyn s instructions on what to do when labor starts If your situation is a real emergency, it is most important that you get the care you need immediately. Go to the nearest hospital or provider to treat your emergency, even if the hospital or provider does not participate with. All hospitals must provide emergency care. Emergency Checklist Something has happened and someone is hurt. Now what? Here are some questions you should ask: Is it severe or life threatening? If there is time, call your doctor's office. Tell them what has happened. No time? Call 911 for an ambulance. Tell them your name, where you are and the type of emergency. Once at the emergency room, they will perform an ER Screening Exam to find out if an emergency exists. This is a covered benefit for all members. You are covered for emergencies 24 hours a day, 7 days a week. This includes follow-up care both in and out of the hospital. In the case of an emergency, call your doctor if you can, your doctor will know how to help. He or she can send you to the closest participating hospital and let the hospital know you are coming. If there is no time to call your doctor, call 911. Within 24 hours, call your doctor to tell him or her of the visit to the ER. If you cannot call, ask a friend or family member to make the call. You should visit your PCP for follow-up care, not the ER. Your PCP will coordinate your care after the emergency. Out of Town? If you have an emergency out of town, go to the nearest hospital and remember to show the hospital staff your ID card. You do not need to get prior approval from for emergency services. If you need medical attention that is not an emergency, call your doctor right away to get help finding medical care from a provider in the area. will need to coordinate your care between your local doctor and the out of network doctor. Urgent Care If you are not sure if your illness or injury is an emergency, call your doctor or dentist first. Some examples of illness or injury that can wait until you talk to your doctor or dentist are: Cold, cough or sore throat Earache Cramps Bruises, small cuts or minor burns Rashes or minor swelling Backaches related to pulled muscle Toothache Swelling around a tooth Remember, if your child is sick, your doctor will see your child the same day for most cases. If your situation is not an emergency, but it is medically necessary for you to get treatment within 24 hours, call your doctor. This is known as urgent care. Your doctor will make the necessary arrangements to treat your medical condition within 24 hours. If it is not an emergency, your doctor can make the arrangements for you to come into the office quickly for care. Your Benefits and Services As a member of, you get the benefits and services you are entitled to with the NJ FamilyCare Program. You pay little or nothing for the medical care and services you get through. Make sure you know how works, especially when it comes to emergency care, seeing your own doctor and when you need a referral. Otherwise, by using services not in the plan, you might be billed for services that are not covered by or authorized by your Primary Care Provider. Before care is given, your doctor should tell you if a service is not covered and that you will be billed for that service. If you are not sure whether a service is covered, just call Member Services and ask. Call toll free at NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at Utilization Management wants to make sure you are receiving the best, most proper care for your health. To do this, we have a Utilization Management (UM) Process. This process assures that you get prompt, efficient and quality service from doctors, hospitals, dentists and other providers. Ambulatory surgical center - site that provides surgical care but does not provide overnight care Our staff of dedicated UM nurses and doctors will work with your PCP and specialists. will help with referrals to specialists, admissions, discharges and length of stay issues when a member is admitted to a hospital or ambulatory surgical center. We will offer advice to doctors about alternatives and disease management programs, when necessary. Most of all, we work hand in hand with your PCP or specialist to assure that you get the continuous care you need throughout your illness and recovery. If you have questions about our Utilization Management Process, please call our Member Services department at NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at Dental Services Good oral health is important to your body s overall health. You should visit your dentist at least once a year for a check-up and cleaning. Dental visits should start when a child turns one year old. Your dental benefits will depend upon your age and benefit plan. Let your dentist know what coverage you have when you schedule your appointment. You do not need a referral from your PCP or prior authorization from for routine dental care, such as cleanings and X-rays. If you need to make an appointment with a dental specialist, an oral surgeon for example, you will need to get a referral from your dentist. You can review a list of participating dentists in a Provider Directory. If you need a directory or help selecting a dentist, call Member Services. Vision Services Members are covered for one routine eye exam every year. You do not need a referral from your PCP for routine eye care. If Ophthalmologist - a doctor who treats people with eye problems, who treats eye diseases and does surgery you need more exams during the year, or you need a vision specialist, such as an Ophthalmologist, you will need to get a referral from your PCP. Vision services are only available from participating eye doctors. Check the Provider Directory for a list of eye doctors. 7 8

7 What Covers Mental Health Services provides mental health benefits for members of the Division of Developmental Disabilities (DDD) only. Members can call Magellan Behavioral Health toll free at , Monday to Friday from 8:00 a.m. to 6:00 p.m. Hearing and speech impaired persons may use their TTY equipment or service to call Benefit Abortions and Related Services Medicaid and NJ FamilyCare A Benefit Package NJ FamilyCare B by Medicaid Program with case management NJ FamilyCare C NJ FamilyCare D Most members get mental health and/or substance abuse services through the Medicaid Program. You do not need a referral from your PCP to see a mental health or substance abuse provider. If you need medication to help your mental health and/or substance abuse needs, your mental health and/or substance abuse provider can prescribe the medication for you. If you think you or a member of your family needs help with a mental health or substance abuse problem, you can contact: 1. Your PCP; 2. The mental health or substance abuse association for your county; or 3. A Care Manager at NJ-HEALTH. One of our Care Managers can help you get the care you need. To get services for adults 18 years and older, call your PCP or the NJ Division of Mental Health Services at To get services for children younger than 18 years of age, call the Office of Child Behavioral Health at You can also call Member Services. Mental health/substance abuse benefits are based on your NJ FamilyCare Program plan. Please call Member Services if you have a question on a specific benefit. What Covers To get benefits covered by the Medicaid Program, call your Medicaid caseworker, a Medical Assistance Customer Centers (MACC) office in your area, your PCP or Member Services to arrange to see a provider of your choice. Acupuncture Audiology Blood and Blood Plasma Chiropractic Services Dental Diabetic Supplies and Equipment Durable Medical Equipment & Assistive Technology Devices Emergency Medical Care/Emergency Services EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Coverage limited to when performed as a form of anesthesia in connection with covered surgery Coverage is limited to spinal manipulation Coverage limited to spinal manipulation with a $5 co-payment with a $5 co-payment except for preventive dentistry visits with a $10 co-payment for emergency room services Coverage includes medical exams, dental, vision, hearing, and lead screening services. for treatment services identified through the exam that are covered by the member s benefit package for members under the age of 16 Coverage limited to administration of blood, processing of blood, processing fees and fees related to autologous blood donations Not Coverage is limited to preventive dental services (including X-rays and sealants) for children under the age of 12. Not with a $35 co-payment for emergency room services, except when referred by a PCP for services that should have been provided in PCP s office or when admitted to the hospital Coverage is limited to well-child care, newborn hearing screenings, immunizations, lead screening and treatment 9 10

8 Services Not by Medicaid, the NJ FamilyCare Program or Services not covered by either or New Jersey Medicaid or the NJ FamilyCare Program include: All services not medically necessary, provided, approved or arranged by a participating physician or other provider (within his/her scope of practice) except emergency services Cosmetic services or surgery except when medically necessary and approved Experimental organ transplants Infertility diagnosis and treatment services (including sterilization reversals, and related office [medical and clinic] visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures) Rest cures, personal comfort, convenience items, services and supplies not directly related to the care of the patient Custodial care covered by for FamilyCare A members for the first 30 days Respite care Services involving the use of equipment in facilities, the purchase, rental or construction that have not been approved by the State of New Jersey Services provided by or in a Veteran's Administration institution Services provided without charge. Programs offered free of charge through public or voluntary agencies should be utilized to the fullest extent possible Services provided by or in an institution owned or operated by the federal government, such as Veteran's Administration institution Services provided without charge. Programs offered free of charge through public or voluntary agencies should be utilized to the fullest extent possible Services provided or initiated while on active duty in the military Services provided outside the United States and territories Family Planning Benefit Group Homes and DYFS Residential Treatment Facilities (Services) Hearing Aid Services Home Health & Visiting Nursing Services Hospice Services Hospital Services (Inpatient) Hospital Services (Outpatient) Intermediate Care Facilities/ Mental Retardation Laboratory Services Medicaid and NJ FamilyCare A Benefit Package NJ FamilyCare B NJ FamilyCare C, when services are provided by a Provider or covered by Medicaid Program with case management when not provided by a Provider by Medicaid Program with case management by a provider, including drugs and DME. For ABD members, covered by Medicaid Program with case management, including room and board in an institutional (non-private) residence by Medicaid Program Not. Routine testing related to the administration of clozapine and other atypical anti-psychotic drugs for non-ddd members is covered by Medicaid Program NJ FamilyCare D Coverage 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. Except for members earning up to 33% of FPL, services must be rendered by a Horizon NJ Health provider Not for members under the age of 16 Coverage is limited to skilled nursing for home bound members that are provided or supervised by a RN and a home health aide when the purpose f the treatment is skilled care. Coverage includes medical social services that are necessary for treatment of the member s medical condition with a $5 co-payment except for preventive services with a $5 co-payment when not part of office visit. Routine testing related to the administration of clozapine and other atypical anti-psychotic drugs is covered by Medicaid Program 11 12

9 Services resulting from any condition or accidental injury related to employment when benefits are available from any workers compensation law, temporary disability benefits law, occupational disease law or similar law Any service covered under any other insurance policy or other private or governmental health benefit system or third party liability Any service or items furnished for which the provider does not normally charge Services provided by an immediate relative or household member 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 Medicaid program Services provided in an inpatient psychiatric institution, that is not an acute care hospital, to individuals over 21 years of age and under 65 years of age Specialty Foods for members with metabolic conditions and genetic disorders Maternity Services Medical Day Care Medical Supplies Benefit Mental Health - Inpatient Hospital Services Including Psychiatric Hospitals Mental Health Outpatient Services Mental Health, Home Health Medicaid and NJ FamilyCare A, including related newborn care by Medicaid Program with case management Not Benefit Package NJ FamilyCare B NJ FamilyCare C for DDD members by. Non-DDD members are covered by Medicaid Program for DDD members by. Non-DDD members are covered by Medicaid Program for DDD members by. Non-DDD members are covered by Medicaid Program NJ FamilyCare D Coverage limited to diabetic supplies for DDD members by. Non-DDD members are limited to 35 days per year and are covered by Medicaid Program for DDD members by with a $25 co-payment. Non-DDD members are covered by Medicaid Program with a $25 co-payment by Medicaid Program, limited to 20 visits per year Services Not by Medicaid, the NJ FamilyCare Program or Horizon NJ Health for NJ FamilyCare D Biofeedback Court-ordered services Experimental and investigational services Radial keratotomy Recreational therapy Rehabilitative services for substance abuse Religious non-medical institutions care and services Residential treatment center psychiatric programs Skilled nursing facility services Sleep therapy Special remedial and educational services Temporomandibular joint disorder treatment, including treatment performed by prosthesis placed directly in the teeth Nurse Midwife (Maternity) Nurse Midwife (Non-maternity) Nurse Practitioner with a $5 co-payment for each visit (except for prenatal care visits) with a $5 co-payment with a $5 co-payment for each visit (except for preventive care services) with a $5 co-payment for first prenatal visit only with a $5 co-payment, except for preventive care services. $10 co-payment for non-office hours visit and home visits with a $5 co-payment for each visit during normal office hours (except for preventive care services). $10 co-payment for non-office hours visit and home visits 13 14

10 Thermograms and thermography Weight reduction programs or dietary supplements, except surgical operations, procedures or treatment of obesity when approved by Your Family and Wellness Services for You and Your Family We want your family to get quality care and to stay well. That is why has many services and programs to keep your family healthy. Women's Services and Prenatal Care If you are going to have a baby or if you need women's health services, you can call an Obstetrician/Gynecologist (Ob/Gyn) or a Certified Nurse Midwife (CNM) directly and make an appointment. You do not need a referral from your Horizon NJ Health PCP. You must choose an Ob/Gyn or a CNM who is part of the network. It is important that you visit your Ob/Gyn for regular care. PAP Test - a cervical cancer test If you are 18 years of age or older or sexually active, you should have a PAP test once a year. Your Ob/Gyn can coordinate all of your care. For a list of participating doctors, check your Provider Directory or call Member Services. If you think you are pregnant, call your Ob/Gyn or CNM right away for an appointment. As a mother-to-be, you can join the Mom's GEMS Program. GEMS stands for Getting Early Maternity Services. Mom's GEMS is designed to help you get good prenatal care, regular checkups, nutrition advice and post-partum information after your baby is born. Prenatal Care - care for pregnant women Post-Partum - care for a woman after she has delivered a baby Nursing Facility Care Optical Appliances Optometrist Services Organ Transplants Benefit Medicaid and NJ FamilyCare A will cover the first 30 days of nursing facility care. After the 30th consecutive day in a nursing facility, the member will be disenrolled from Horizon NJ Health and receive services from the Medicaid FFS program All members may have a yearly eye exam regardless of age. Members who need additional exams require a referral from their PCP Benefit Package NJ FamilyCare B Not NJ FamilyCare C NJ FamilyCare D Members are eligible for eyeglasses or contact lenses from the select assortment of fashion frames or contact lenses manufacturers covered by the plan. Eyeglasses and contact lenses are covered as follows: Members ages 0-20 or 60 and older are eligible for eyeglasses or contact lenses every year if their prescription changes, or more frequently if medically necessary Members ages 21 to 59 are eligible for eyeglasses or contact lenses every two years if their prescription changes, or more frequently if medically necessary. Contact lenses are covered for the initial contact lens supply and related fees in full when the selected plan covered brands are prescribed. Cost above the $100 contact lens allowance will be an out of pocket expense to the member if not medically necessary. If contact lenses are medically necessary the allowance of $100 per lens is covered and any addition cost requires prior authorization. The benefit period is measured from the date the eyeglasses or contact lenses are dispensed with a $5 co-payment. All members may have a yearly eye exam regardless of age. for one routine eye exam per year with a $5 co-payment per visit If the individual is placed on a transplant list prior to initial enrollment with, coverage is limited to transplant related physician costs for donor and recipient. The Medicaid Program with case management covers the donor and recipient inpatient hospital costs For members placed on a transplant list while a member, coverage includes all donor and recipient transplant costs for members who have transplants conducted within two months after disenrollment from 15 16

11 If you are pregnant or have children, you may be eligible for an extra program called WIC (Women, Infants and Children). This program gives you nutritional benefits, such as free milk, eggs, and cheese. To apply to WIC in New Jersey, contact your local WIC agency to set up an appointment. They will tell you what to bring to the WIC appointment to help see if you can join. If you would like more information, call our Member Services number at NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at Family Planning Services Are you interested in family planning and contraceptive services? These are available through Horizon Blue Cross Blue Shield of New Jersey. To find out where you can get these services, call Horizon Blue Cross Blue Shield of New Jersey Medicaid Managed Care Family Planning Unit at NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at When you call, a representative will help you find the services you need and will tell you about the location of the doctors and clinics that are closest to you. Remember to take your Horizon NJ Health ID card when you go to your appointment. You can also get family planning and contraceptive services from other clinics and doctors who accept Medicaid and the NJ FamilyCare Program, but who are not in the network. Use your HBID card (see page 4 for more information about this card) if you visit them. For NJ FamilyCare D, Family Planning Services are only available through Horizon NJ Health, not through the Medicaid Program. There are exceptions to this rule for certain NJ FamilyCare D members. Call Member Services for more details. Benefit Orthodontic Treatment Services Orthotics Outpatient Diagnostic Testing Partial Care Services Medicaid and NJ FamilyCare A by Medicaid Program Benefit Package NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D for members under the age of 19 when orthodontia services were prior authorized and begun (banding or extraction of teeth as part of an authorized comprehensive orthodontic treatment plan) while enrolled with Horizon NJ Health as a Medicaid or NJ FamilyCare Plan A, B, or C member Member must be eligible for FamilyCare and continue enrollment with Horizon NJ Health until services are completed is not responsible for completion of orthodontia services that were prior authorized and initiated when the member was enrolled with another Medicaid HMO Not When authorized by the Division of Medical Assistance and Health Services, one (1) mental health inpatient day may be exchanged for up to four (4) home health visits or four (4) outpatient services, including partial care. This is limited to an exchange of up to a maximum of 10 inpatient days for a maximum of 40 additional outpatient visits

12 Is Your Family Growing or Changing? Do you have a new family member or a new baby? Call Member Services and tell us right away and we will add your new family member to your Horizon NJ Health membership. Also, it is very important to be sure to tell your Board of Social Services caseworker or the Health Benefits Coordinator. Your child must be enrolled in Medicaid or the NJ FamilyCare Program to be enrolled in. CHAMPS CHAMPS stands for Children s Health Assessment and Maintenance of Preventive Services. Designed for Horizon NJ Health kids, CHAMPS helps maintain the health of your children from birth and all the way up until they are 21 years old. CHAMPS is a program that helps keep your child s immunizations and well-child visits on track. By making sure your child is immunized, you can protect your child from serious illnesses, such as: Benefit Partial Hospital Program Personal Care Assistant Services Podiatrist Services Medicaid and NJ FamilyCare A Benefit Package NJ FamilyCare B by Medicaid Program with case management by Medicaid Program with case management Not NJ FamilyCare C with a $5 co-payment NJ FamilyCare D When authorized by the Division of Medical Assistance and Health Services, one (1) mental health inpatient day may be exchanged for two (2) days of treatment in partial hospitalization up to the maximum number of covered inpatient days. with a $5 co-payment. 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 Mumps Diphtheria Polio Tetanus Rubella Hepatitis B Chicken Pox Pertussis Influenza Pneumococcal Invasive Disease EPSDT - stands for Early and Periodic Screening, Diagnostic and Treatment. This is a group of tests that are required for children up to age 21 to make sure children are getting appropriate care CHAMPS helps screen children for medical problems early and keeps checking for problems as the child grows. The doctor checks vision, teeth, hearing, nutrition, growth and development. Our doctors also give lead screenings to find out if your child has been exposed to dangerous levels of lead in paint or other sources. Your child's doctor will be able to give these checkups, treat the problems and call in specialists, if they are needed. Horizon NJ Health covers all these services for members up to the age of 21 years

13 also covers prescription and non-prescription drugs, in-home ventilator services and private duty nursing, when recommended as a result of EPSDT screening. Test Your Child for Lead Poisoning It is important that your child be tested for lead poisoning, first at 9 months to 18 months old, preferably at 12 months, and again by age 2. Lead case management is given to all pediatric members up to 6 years of age who have high blood lead levels. Lead case managers are nurses who work with you to help keep your child lead free. The lead program gives you information about keeping your home lead free and safe. You will get information on blood lead levels, preventive measures including housekeeping, hygiene, appropriate nutrition and why it is so important that you follow your doctor s instructions when dealing with lead problems. A nurse will work with your child s PCP, the Department of Health, WIC and laboratories to make sure that any high blood lead levels found in your child are lowered, so that your child stays healthy. For more information about lead, please call Horizon NJ Health toll free at and ask for the Lead department. People with hearing or speech difficulties can call our TDD/TTY service at Prescription Drugs (Retail Pharmacy) Benefit Medicaid and NJ FamilyCare A Benefit Package NJ FamilyCare B for all members except ABD members and other dual eligible individuals. No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents. Certain cough/cold and topicals are not covered for certain age groups by Medicaid for all ABD eligibles and other dual eligible individuals. No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents. Certain cough/cold and topicals are not covered for certain age groups Brand and generic Suboxone and Subutex, atypical antipsychotic drugs and methadone (including administration) are covered by Medicaid for all members NJ FamilyCare C for all members except ABD members and other dual eligible individuals with a $1 co-payment for generic drugs and a $5 co-payment for brand name drugs. No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents. Certain cough/cold and topicals are not covered for certain age groups by Medicaid for all ABD eligibles and other dual eligible individuals. No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents. Certain cough/cold and topicals are not covered for certain age groups Brand and generic Suboxone and Subutex, atypical antipsychotic drugs and methadone (including administration) are covered by Medicaid for all members NJ FamilyCare D for all members except ABD members and other dual eligible individuals with a $5 co-payment. If a greater than 34-day supply, a $10 co-payment applies. No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents. Certain cough/cold and topicals are not covered for certain age groups by Medicaid for all ABD eligibles and other dual eligible individuals with a $5 co-payment. No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents. Certain cough/cold and topicals are not covered for certain age groups Brand and generic Suboxone and Subutex, atypical antipsychotic drugs and methadone (including administration) are covered by Medicaid for all members 's Asthma Breathe Easy Program has a special program for our members who have asthma. It is the Asthma Breathe Easy Program, which can help you or your child greatly lower the risk of asthma attacks. Peak flow meters and spacers are available with a prescription from your PCP. Through the program you will learn what triggers your asthma attacks and how to avoid them. It really works. This program has helped many children and adults. To find out more about Prescription Drugs (Physician Administered) by Medicare Part B Co-payments for Medicare Part B covered drugs, classified as DME and utilized in a member s home, are covered by Medicaid. For example, oral immunosupressants, albuterol when administered through a nebulizer, and insulin and certain other drugs administered through an infusion pump 21 22

14 the Asthma Breathe Easy Program, talk to your doctor or call toll free at and ask for the Asthma Program. People with hearing or speech difficulties can call our TDD/TTY service at Benefit Medicaid and NJ FamilyCare A Benefit Package NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D Diabetes Disease Management Program has a special program designed for any member who has been diagnosed with diabetes. The Diabetes Disease Management Program can help members learn to better manage their diabetes. You can get prescriptions for insulin and syringes from your PCP. Diabetic testing machines and supplies are also available with a prescription from your PCP. Primary Care, Specialty Care and Women's Health Services with a $5 co-payment for each visit. No co-payment for well-child visits, lead screening/treatment, age-appropriate immunizations, prenatal care, or PAP smears with a $5 co-payment for each visit during office hours. $10 co-payment for each home visit or office visit after normal office hours No co-payment for well-child visits, lead screening/ treatment and age-appropriate immunizations, or preventive dental services for children under 12 $5 co-payment for first prenatal visit, then no subsequent co-payments The program s Diabetes Educators can also give you diabetic education materials about meal planning, insulin and medication use and will help members find a diabetic specialist and/or nutritionist. For more information about the program, call and ask for the Diabetes Disease Management Program, talk to your doctor or call Member Services. Congestive Heart Failure Program The Congestive Heart Failure (CHF) Program is available to help you improve your quality of life, reduce hospitalizations and emergency room visits and to provide you with more information about CHF. Through the CHF Program, members are given helpful hints to reduce symptoms of CHF, such as how a proper diet and medications can control blood pressure. The program can help coordinate your health care between your PCP and specialist. To find out more about the CHF program, talk with your PCP or call toll free at and ask for the CHF Management Program. Private Duty Nursing Prosthetics Radiology Services (Diagnostic & Therapeutic) Rehabilitation Services (Outpatient Physical Therapy, Occupational Therapy and Speech) for children under the age of 21 by Medicaid Program with case management by Medicaid Program with case management for 60 days per therapy, per year Private Duty Nursing is covered when authorized by. Coverage 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 with a $5 co-payment when not part of an office visit by Medicaid Program with case management, with a $5 co-payment Limited to 60 business days per therapy, per year. Speech therapy for developmental delay is not covered

15 Hypertension Program Hypertension is most commonly called high blood pressure. s Hypertension Management program will help members learn about high blood pressure, its signs and symptoms, medications and how to manage their blood pressure. Call Horizon NJ Health toll free at and ask for the Hypertension Management Program. COPD Program COPD stands for Chronic Obstructive Pulmonary Disease. The program is available to members with COPD to help them learn more about this disease and HIV/AIDS Program has a case management program to help members diagnosed with HIV or AIDS. The program works closely with members and their providers to create and coordinate the best plan of care. Please call toll free to enroll in this case management program. People with hearing or speech difficulties can call our TDD/TTY service at Prescription Services Most prescription and non-prescription drugs are covered at a low cost to you, as long as your doctor orders them and they are part of the approved Horizon NJ Health formulary. A committee of doctors and pharmacists review the list to make sure that the medicines are safe and effective. If your doctor decides that you must have a medication that is not included in the formulary, he or she can call and get special permission for you to get the medication. COPD - a lung disease that makes it hard to breathe how to reduce symptoms. Call , toll free and ask for the COPD Management program. Prescription - an order written by a doctor for a drug, test, or other health service Formulary - a list of approved medicines that covers While you are waiting for a prior authorization determination for your medication, the Benefit Self-initiated care from a non-participating provider without referral or authorization Sex Abuse Examinations Transportation Services Higher Mode (ambulance, mobile intensive care units, invalid coach) Transportation Services Lower Mode (public transportation, livery, clinic van, taxicab or a county-administered transportation service) Waiver and demonstration program services (except DDD-waiver) Medicaid and NJ FamilyCare A Benefit Package NJ FamilyCare B NJ FamilyCare C. Invalid coach transportation is not covered for members who choose to see a provider outside of their county of residence Transportation to a Medical Day program is not covered by Horizon NJ Health when the member is requesting transportation to a non-hospital service provider located more than 30 miles from the member s residence and a participating provider closer to home to provide medically necessary covered services is not available Transportation to a Medical Day program is not covered by Medicaid Program NJ FamilyCare D The member shall be held responsible for the cost of care, except for care delivered in an emergency situation by Medicaid Program with case management Social Necessity Days by Medicaid Program, limited to no more than 12 inpatient hospital days Not Substance Abuse for DDD members by. All others covered by Medicaid Program with case management Coverage limited to ambulance for medical emergency only Transportation to a Medical Day program is not covered by only if referred out of county when the services could have been rendered in county Not Limited to Detoxification only 25 26

16 pharmacy will provide a 72-hour supply of your medication. The Pharmacy Department will work with your doctor to fulfill your prescription needs. If you have questions, call toll free at You can have prescriptions filled at any participating pharmacy. For a list of pharmacies or to find the pharmacy nearest to you, call Member Services. The participating pharmacies are also listed in the Provider Directory and on the Horizon NJ Health Web site at requires the use of formulary generic medications when available. Visit the Web site at for more information on pharmaceutical management procedures including the formulary listing, policies and limitations. Limitations include quantity limits, days supply/fill limitations, age limits, and gender restrictions. In addition, paper copies of the pharmaceutical management procedures are available by contacting the Pharmacy Department at The Pharmacy Lock-In Members who see many different doctors may have many types of drugs prescribed to them. This can be dangerous. The Pharmacy Lock-In program is designed to coordinate a member s care given by pharmacies and doctors. To make sure your pharmacy care is coordinated; you should use only one pharmacy to fill your prescriptions. This will let the pharmacist learn about your health and be better able to help you with your medication needs. Members who use many pharmacies or doctors may be reviewed each month to make sure that they get the proper coordination of care. If it is decided that using only one pharmacy will help the member get better care, the member may be "locked-in" to using only one pharmacy. We will send letters to the member, pharmacy and doctor when a "lock-in" is needed. Individual Care for You There may be times when you need more than just health care services. has established a special program for our members who need extra personal care. Our Care Coordination Unit is here to help coordinate complex health care and psychosocial needs for members who have been identified as having special needs. This includes members with Developmental Disabilities, Physical Disabilities, Complex Chronic illness, Severe Mental illness or substance abuse for DDD registered members. can offer help with: Acute Case Management for Adults and Children Asthma Cancer Community Programs Congestive Heart Failure Diabetes End Stage Renal Disease Immunizations Infant Care Infectious Disease HIV/AIDS Lead screenings Pregnancy Sickle Cell Special Needs Call our Social Case Management Program if you have questions or concerns about: Baby Needs Parenting Assistance Personal Care Attendants (Home Health Aides) Housing Issues Advocacy Food Clothing WIC Medicaid Mental Health Programs Substance Abuse Programs Domestic Violence Support Groups Transport Programs Call Member Services if you need more information on these services. Member Services are available 24 hours a day, seven days a week at NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at Homebound? Need Medical Transportation? If you are a homebound member and you need special services or transportation for your medical care, call, toll free at NJ-HEALTH and we can help arrange transportation for you. Remember do not call an ambulance for routine transportation. Call us at NJ-HEALTH and we can help arrange the care you need. For Mobility Assistance Van call. For Livery in Essex, Hudson and Atlantic Counties call Logisticare at For Livery service in other counties please call the county welfare agency. Your Rights and Responsibilities As a member of, you have certain rights that you can expect from Horizon NJ Health and you have responsibilities that can expect from you. Your Member Rights You have the right: To have access to a Primary Care Provider or a backup doctor, 24 hours a day, 365 days a year for urgent care. To obtain a current directory of doctors within the network. To have a choice of specialists and a description of the referral process. To have a second opinion. To request a standing referral when a medical condition warrants. To receive care from an out of network provider when a participating Horizon NJ Health provider is not available. If a member has a chronic disability, to be referred to specialists who are experienced in treating their disability. To have a doctor make the decision to deny or limit a member s coverage. To have no gag rules in. That means doctors are free to discuss all medical treatment options even if the services are not covered. To know how pays its doctors, so a member will know if there are financial incentives or disincentives tied to medical decisions. To be treated with respect and with recognition of their dignity and right to privacy, at all times. To receive care without regard to race, color religion sex, age or national origin. To participate with their doctor in making decisions about their health care. To information and open discussion about the member s own medical condition, and the right to choose from different ways of treating their condition, regardless of cost or benefit coverage. The right to have the member s medical condition explained to a family member or guardian, if the member is unable to understand and have it documented in the member s medical records. To refuse medical treatment with an understanding of the results of refusal. To call 911 in a potential life-threatening situation without prior approval from. To have pay for a medical screening exam in the emergency room to determine whether an emergency medical condition exists. To postpartum stays in the hospital no less than 48 hours for a normal vaginal delivery and no less than 96 hours following a cesarean section. To receive up to 120 days of continued coverage if medically necessary from a doctor who has been terminated by Horizon NJ Health including: up to 6 months after surgery 6 weeks after childbirth 1 year of psychological or oncologic treatment No coverage may be continued if the doctor is terminated for cause

17 To timely notification of changes to the member s benefits or the status of their provider. To make an Advance Directive about medical care. Federal law requires providers to ask about a member s Advance Directive. To receive information about Horizon NJ Health, its services, doctors and providers and the member s rights and responsibilities. To offer suggestions for changes in policy and procedure including the member s rights and responsibilities. To have access to a member s own medical records (at no charge to the member.) To privacy of the member s medical information and records. To refuse the release of personal information (except when required or permitted by law.) To be informed in writing if Horizon NJ Health decides to end a member s membership. To tell when a member no longer wishes to be a member. To appeal a decision to deny or limit coverage, first within, and then through an independent organization. To make a complaint about the organization or the care provided in the member s primary language. To know that a member or their doctor cannot be penalized for filing a complaint or appeal. To contact the Department of Banking and Insurance or the Department of Human Services whenever the member is not satisfied with s resolution of a complaint or appeal. For a member to give consent and make informed decisions about treatment of a member s minor dependents. Treatment of Minors will provide care for members younger than 18 following all laws and treatment and will be at the request of the minor's parent(s) or other person(s) who have legal responsibility for the minor's medical care. Under certain circumstances, New Jersey law allows minors to make health care decisions for themselves. will allow treatment in the following cases: Minors who go to an emergency room for treatment and that treatment must be rendered because of an emergency medical condition. The minor will be treated without parental consent Minors who want family planning services, maternity care or sexually transmitted diseases services. Services will be rendered as medically necessary without parental consent. Your Responsibilities As a member of, you also have responsibilities: The responsibility to treat health care providers with the same respect and kindness that the member expects to be treated. The responsibility to talk openly and honestly, and seek care regularly from a doctor. The responsibility to abide by Horizon NJ Health s rules for medical care. The responsibility to give information to a doctor and in order for them to provide care. The responsibility to ask questions of their doctor(s) so that the member can understand their health problems, the care they are receiving and participate in developing mutually agreed-upon treatment goals. The responsibility to follow their doctor s advice that was agreed upon; or consider the results if they choose not to. The responsibility to keep appointments and call in advance if an appointment must be cancelled. The responsibility to read all the Horizon NJ Health materials and follow the rules of membership. The responsibility to follow the proper steps when making complaints about care. The responsibility to take advantage of educational opportunities to learn about health issues. The responsibility to pay any copayments and/or premiums when applicable. To inform the Health Benefits Coordinator and about any doctors the member is currently seeing upon the time of enrollment. More About evaluates and approves new technology: reviews guidelines from Horizon Healthcare of New Jersey Inc., leading medical literature and published clinical guidelines and we speak with experts in specific areas, including practicing physicians. We do all of this to make sure that you are receiving the best, most up-to-date care. If you would like a copy of the clinical or preventive guidelines, please call Member Services at NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at The guidelines are also on our Web site at We Value Your Opinion Every few months, hosts a Community Health Advisory meeting with members, community health advocates and community leaders to talk about ways to improve member services, health education and outreach activities. If you would like to join us at this meeting, please call s Communications and Public Affairs Department at Member Satisfaction Survey Results Each year members are asked what things we and our providers do well and what things could be done better. This is called the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. Answers to these questions help us to improve the services that we provide. Results of the most recent member satisfaction survey are available on our Web site at or can be mailed to you by calling Member Services. How Your Doctor is Paid Physicians in our network are paid by Horizon NJ Health in different ways. Your physician may be paid each time he/she treats you (fee-for-service) or a physician may be paid a set fee each month for each member whether or not the member actually gets services (capitation). Your doctor may also get a salary. member satisfaction, quality of care, control of costs and use of services. does not stop physicians from discussing all treatment options with their patients, even if the service(s) is not a covered benefit. If you would like more information about how your doctor is paid, call Member Services at NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at Bills The only time you should get a bill from a Provider is when you have: Been treated for a service not covered by. Sought care from a non-participating provider without a referral or authorization from. Received a service not covered by Medicaid or the NJ FamilyCare Program. Not complied with s rules and services. Not paid your FamilyCare co-pay when services were delivered. In these cases, you will be responsible to pay the entire cost of the service and must make payment arrangements directly with the provider. In all other cases, you should not get bills for any covered medical services. Please note this does not apply to the co-payments or deductibles required for certain NJ FamilyCare C and D members. If you do receive a bill for any covered medical service, call s Member Services department about the bill. Member Services may ask you to send the bill to: Attention: Member Bills 1st Floor 200 Stevens Drive Philadelphia, PA NJ FamilyCare C and D members must pay premiums and co-payments. These payment methods can include financial reward agreements to pay some physicians more (bonuses) based on many things, such as: 29 30

18 Medicaid benefits received after age 55 may be reimbursable to the State of New Jersey from the member s estate. The recovery may include premium payments made on behalf of the beneficiary to Ending Your Membership There are a few ways that your Horizon NJ Health membership could end: You Can Choose to End Your Membership If you decide to end your membership or change to another health plan, call Member Services at NJ-HEALTH or call the Health Benefits Coordinator at They will help you with the steps. Medicaid and NJ FamilyCare Program members may end their membership, without cause, during the first 90 days after the effective date of enrollment, and then after every 12 months. You will be locked into the Medicaid or the NJ FamilyCare Program until the end of the 12th month of your membership. ABD members with Medicaid, DDD members and DYFS members can enroll in another plan at any time. ABD members who have both Medicaid and Medicare may change to another HMO or disenroll to a Medicaid fee-for-service arrangement at any time. Except for ABD members, non-duals including DDD and DDD/CCW members, if a member moves out of New Jersey, you may need to leave. Members may leave with cause at any time. If you are a Medicaid member or NJ FamilyCare A member, you must choose another health plan for you and your family members before your membership ends. Once a member asks to be disenrolled, it will take about 30 to 45 days from the date you ask until the time you are actually enrolled in the new health plan you select. During this time, will continue to provide your health care services. The Health Benefits Coordinator will help you understand this process. If you lose eligibility, you will be disenrolled from. If you get your eligibility back within 60 days, you will be reenrolled in. If you become eligible again after 60 days, you may be enrolled in a different HMO if you do not select or if cannot accept any more members in your county. Members may leave with good cause at any time. Good cause reasons include: A member has an established relationship with a doctor in another plan to treat an on-going illness A pregnant member who has a relationship with a PCP in another plan may move to that plan A member has a more convenient access to a doctor who participates in another plan The member has filed a grievance or appeal against and is not satisfied with the results or did not respond in a timely manner When is not providing services or access to care, as agreed upon with the New Jersey Division of Medical Assistance and Health Services If a member gets poor quality of care You Could Lose Your Membership If you reside outside the State of New Jersey for more than 30 days If you do not keep your appointment to renew your Medicaid eligibility at the county office, you may lose your Medicaid members If you refuse to uphold your responsibilities (by loaning your ID card to someone else, for instance), may choose to end your membership. You will be told in writing about this decision and the date that your membership will end. You have the right to file an official complaint, if you are dissatisfied with this decision If you do not send in a renewal application to the NJ FamilyCare Program every 12 months, you will lose your membership. Certain parents who are terminated for not sending in their renewal application may not be allowed to re-enroll NJ FamilyCare Program C or D members may lose eligibility for non-payment of premiums If you are in a nursing facility for 30 consecutive days When You Leave When you leave, you will need to sign your enrollment application to allow us to send your medical records to your new health plan Return your ID card, along with the card from each of your family members back to us The Health Benefits Coordinator will also send your answers to the health care questions on the transfer form It will take between 30 and 45 days between when you ask to leave and the date your enrollment with ends. will continue to provide services until the disenrollment date If you decide to disenroll voluntarily from, you can list your reasons for leaving in writing Enrollment and disenrollment are always subject to verification and approval by the New Jersey Division of Medical Assistance and Health Services (DMAHS). For details, you can call your State Health Benefits Coordinator at (TDD/TTY ) Fraud, Waste and Abuse It is very important that you take personal responsibility for your health care and the costs of your care. Become an informed consumer and make sure you know as much as possible about the providers you use and the treatments they provide. Billions of dollars are lost to health care fraud, waste and abuse each year. Fraud, waste and abuse by providers and members threaten our health care system, and can victimize consumers. That means money is paid for services that may never have been given. It could also mean that the service that was billed was not the one that was performed. What is Fraud and Abuse? Fraud and abuse happens when someone knowingly gives false information that lets someone get a benefit to which they are not entitled. Examples of Provider Fraud and Abuse Forging or altering bills or receipts Billing for services not actually performed Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that are not medically necessary Billing more than once for the same service Examples of Member Fraud and Abuse Any lie told on purpose that results in you or some other person receiving benefits they are not entitled to Loaning or selling your Member ID card or the information on the card to someone else Forging or altering prescriptions Misuse of your Medicaid Card or Horizon NJ Health identification card could result in you losing eligibility for health care services. Fraud and abuse are also crimes and are punishable by legal action with possible time in jail. If you or someone you know is aware of health care fraud and abuse, you should immediately report it to s Fraud Hotline at When making a report, please remember to be clear about which person you believe is committing the fraud, tell us dates of service or items in question, and describe in as much detail as possible why you believe a fraud may have been committed. If possible, please include your name, telephone number, and address, so we can contact you if we have any questions during the investigation. Any information you give us will be treated with the strictest confidentiality and no medical information will be released without lawful authorization. When reporting suspected insurance fraud, you may remain anonymous. If you decide to provide your contact information, we will attempt to maintain confidentiality to the extent that is legally possible

19 Complaint/Grievance and Appeal Procedures has a complaint procedure for resolving disagreements that arise between a member, provider and/or. Disputes may involve 's benefits, the delivery of services or Horizon NJ Health's operation. A complaint, by phone or in writing, can usually be resolved by contacting Member Services. You may file your grievance and/or appeal in your primary language. Issues regarding emergency care will be addressed immediately. Issues regarding urgent care will be addressed within 48 hours. Complaint/Grievance Procedure If you have a complaint, simply call NJ-HEALTH to talk about your situation with one of our Member Services Representatives. People with hearing or speech difficulties can use our TDD/TTY service at If you want, you may send a written complaint to: Attn: Member Complaints 200 Stevens Drive Philadelphia, PA Complaint - a formal charge against when the member or provider disagrees on the type of service given or not given Members may also submit a verbal or written complaint directly to the Department of Banking and Insurance by phone at , by fax at or by using the on-line complaint form at: When we receive your call or letter, the following steps will occur: 1. A Member Services Representative will be available to discuss and resolve your complaint. If you submitted a complaint by mail, a Member Services Representative will try to contact you by telephone within 24 hours of receipt of the complaint to discuss and resolve your complaint. The Member Services Representative will document all the information discussed with you on an electronic form. 2. If you are not satisfied with the resolution offered by the Member Services Representative, you should tell the Member Services Representative and the complaint will be forwarded to 's Complaint Coordinator for further investigation. An oral appeal must be followed with a written, signed format except in the case of an expedited appeal. 3. The Complaint Coordinator will investigate the complaint and you will be notified in the following time frames: Complaints resolved within five business days will receive verbal notification. If is unable to reach you through a telephone call, you will receive written notification about the outcome. Complaints not resolved within five business days, will receive written notification about the outcome within 30 calendar days upon receipt of your complaint. If you are still not satisfied with this response, you may file Appeal - an appeal verbally or in a request for a writing. All appeals must be new decision submitted within 60 days of receipt of the complaint determination. Contact at: Appeal Process You, or your doctor (with your written approval), has the right to ask to review and change our decision if we have denied or reduced your benefits. This is called an appeal. There is a special process for doing this. You may also have the right to ask Medicaid to review s decision about your service. This is called a Medicaid Fair Hearing. You may request a Fair Hearing at any time. You may also file a complaint with the NJ Division of Banking and Insurance (DOBI). The appeal process has three stages. In both Stage 1 and Stage 2, will review its decision about the services you asked for. If you are not happy with our decision at the end of Stage 1 or Stage 2, or s decision was not made by the deadline set for each stage, you may ask to have your request for these services reviewed by someone outside of. This is a Stage 3 External Appeal. During the appeal process or the Medicaid Fair Hearing Process, you have the right to continue to get the service until the end of the appeal process. You may appeal if: Your appeal is made within the time allowed Your service was previously approved by The service was ordered by a Horizon NJ Health Provider The time period that the provider approved the services has not yet ended Stage 1 Appeal Your appeal must be started no later than 90 days after the date of the denial letter sent to you. You, or your doctor, must: Call toll free at , dial extension and select prompt 2 for the Utilization Management Appeals Department, or People with hearing or speech difficulties can use our TDD/TTY service at FAX your letter to the Appeals department at , or Send us a letter to: Appeals Coordinator 210 Silvia Street West Trenton, NJ Let us know: 1. Your name and ID number 2. Your doctor s name 3. That you want to appeal our decision 4. The reason you want to appeal 5. If the services are for urgent or emergency treatment must get back to you with a decision within five business days (weekends and holidays do not count). If your appeal is about services for urgent or emergency treatment, we will tell you the results of your appeal within 72 hours (three days weekends and holidays count). If we do not approve the services you are asking for in your appeal, will send you a letter and explain why. We will also tell you how to file a Stage 2 Appeal. Appeals Coordinator 210 Silvia Street West Trenton, NJ Your appeal will be reviewed by the Appeals Committee. will send you a written resolution within 20 business days of receipt. If you need help preparing an appeal, please call our Member Services department at NJ-HEALTH. People with hearing or speech difficulties can use our TDD/TTY service at

20 Stage 2 Appeal If you want to appeal s denial of your Stage 1 Appeal, then as soon as you can, but no later than 60 days after you receive the written denial of your Stage 1 Appeal, you, or your doctor, must: Call toll free at , dial extension and select prompt 2 for the Utilization Management Appeals Department, or People with hearing or speech difficulties can use our TDD/TTY service at FAX your letter to the Appeals Department at , or Send us a letter to: Appeals Coordinator 210 Silvia Street West Trenton, NJ Let us know: 1. Your name and ID number 2. Your doctor s name 3. That you want to appeal our decision 4. The reason you want to appeal 5. If the services are for urgent or emergency treatment will send you a letter letting you know that we have your appeal request. This will be done within 10 business days (weekends and holidays do not count) after we get your phone call or letter. We will get back to you with a decision on your appeal within 15 business days. If your appeal is about services for urgent or emergency treatment, we will get back to you within 72 hours (three days weekends and holidays count). At this appeal level, you are allowed to present important information about your appeal directly to the Appeals Sub-Committee either in person or by telephone. If we do not approve the services you are asking for in your Stage 2 Appeal, Horizon NJ Health will send you a letter and explain why. The letter will also let you know how to file a Stage 3 External Appeal. Stage 3 External Appeal If you want to appeal the denial of your Stage 2 Appeal, you may ask that someone outside of review your request for service. This is done by an Independent Utilization Review Organization, often called an IURO. Within 60 days after you get Horizon NJ Health s written notice of denial, you or your doctor must: Fill out the form called Application for the Independent Health Care Appeals Program, sent to you with the results of your Stage 2 Appeal decision from. Be sure to sign the form. Your signature allows the IURO to review your medical records and other medical information about you that may be needed for your appeal Send the completed form with a $2 check or money order made out to New Jersey Department of Banking and Insurance to: NJ Department of Banking and Insurance Consumer Protection Services Office of Managed Care 20 West State Street, 9th Floor P.O. Box 325 Trenton, NJ The IURO will give you its decision within 30 days after it gets all the materials it needs to make a decision. If your appeal is about services for urgent or emergency treatment, you should call the Department of Banking and Insurance at , extension or call toll free at and ask that your appeal be reviewed within 48 hours (two days weekends and holidays count). You still must complete the form. must accept the decision of the Independent Utilization Review Organization. Medicaid Fair Hearing In addition to your right to s appeal process, you may have the right to ask for a Medicaid Fair Hearing to review your request for service. This applies to all Medicaid and NJ FamilyCare A members as well as certain NJ FamilyCare D members. If you are not sure if you have a right to a Medicaid Fair Hearing, call Member Services toll free at NJ-HEALTH ( ). If you are eligible and want to ask for a Medicaid Fair Hearing, as soon as you can, but no later than 20 calendar days from the date of s denial letter, you must send a letter to Medicaid at: New Jersey Department of Human Services Division of Medical Assistance and Health Services Medicaid Fair Hearing Section P.O. Box 712 Trenton, NJ Let Medicaid know in your letter: 1. Your name and ID number 2. Your doctor s name 3. That you want a Medicaid Fair Hearing 4. The reason you want a Medicaid Fair Hearing 5. If the services are for urgent or emergency treatment 6. Your telephone number and a copy of the denial or termination notice that is being appealed. At the hearing, someone outside of Horizon NJ Health and Medicaid will review your request for services. This person is a judge from the Office of Administrative Law (OAL) who will listen to you and others that come to speak for you or with you at the hearing. You have the right to be at the Medicaid Fair Hearing or have a lawyer, friend, or other person go with or for you. The OAL judge will give Medicaid an opinion on your request and Medicaid will then decide whether to accept or deny your request. Medicaid will get back to you with its decision within 90 days, unless your request is for urgent or emergency treatment. If you want to appeal Medicaid s decision, you have the right to appeal to the Appellate Division of Superior Court. You may request help with your Horizon NJ Health appeal or Medicaid Fair Hearing by calling the Health Care Consumer Assistance Program toll free at TDD/TTY users may call Further Appeal You also have the right, at any time, to submit your appeal to the New Jersey Department of Banking and Insurance at the following address: New Jersey Department of Banking and Insurance Division of Enforcement and Consumer Protection P.O. Box 329 Trenton, NJ

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