«STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS Horizon HMO MEMBER HANDBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN ...»
STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
FOR EMPLOYEES AND RETIREES
ENROLLED IN THE
STATE HEALTH BENEFITS PROGRAM OR
SCHOOL EMPLOYEES’ HEALTH BENEFITS PROGRAMPLAN YEAR 2016
ADMINISTERED FOR THE DIVISION OF PENSIONS AND BENEFITS BY
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEYWELCOME Welcome to Horizon HMO!
Your Horizon HMO plan provides you with access to safe and effective care through many programs and services and a large network of participating physicians, facilities
and other health care professionals. Other Horizon HMO features include:
• Preventive health care benefits.
• An easy-to-use referral system.
• Direct access to your participating OB/GYN.
• Emergency medical care coverage.
• Discounts on health products and services.
To get the most from your Horizon HMO plan, please refer to this Member Handbook. It will help you understand your coverage and how your Horizon HMO plan works.
If you have questions about your Horizon HMO benefits, we are here to help you. Visit www.HorizonBlue.com/shbp or call Member Services at 1-800-414-7427 (SHBP).
TABLE OF CONTENTSIntroduction
Horizon Member Online Services
My Health Manager, powered By WebMD®
Health Benefits Program Eligibility
Active Employee Eligibility
Supporting Documentation Required For Enrollment Of Dependents
Audit Of Dependent Coverage
Multiple Coverage Under The SHBP/SEHBP Is Prohibited
Medicare Coverage While Employed
Aggregate of Pension Membership Service Credit
Eligible Dependents of Retirees
Multiple Coverage under the SHBP/SEHBP is Prohibited
Enrolling in Retired Group Coverage
Medicare Parts A and B
Medicare Part D
GENERAL CONDITIONS OF THE PLAN
Medical Need and Appropriate Level of Care
Health Care Fraud
Your Primary Care Physician (PCP)
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —Changing Your PCP
Physician Access Standards
Hospital Stays and Prior Authorization
Behavioral Health and Substance Abuse Care
Accessing Behavioral Health and Substance Abuse Care
Experimental or Investigational Treatments
Chronic Care Program
Case Management Program.
HORIZON HMO PLAN BENEFITS
In-Network Deductible (Horizon HMO2035)
In-Network Coinsurance (Horizon HMO2035)
In-Network Coinsurance Out-of-Pocket Maximum (Horizon HMO2035)................27 Annual In-Network Out-of-Pocket Maximum
Limits / Deductibles
COORDINATION OF BENEFITS
Allergy Testing and Treatment
Autism or Other Developmental Disability
Behavioral Health and Substance Abuse Care
ii — HORIZON HMO MEMBER HANDBOOK Dental Care
Diabetic Self-Management Education
Durable Medical Equipment and Supplies
Emergency Medical Services
Medical Emergency Screening Exam
Medical Emergency Procedures
Urgent and After Hours Care
Federal Government Hospitals
Gynecological Care and Examinations
Home Health Care
Hospice Care Benefits
Lead Poisoning Screening and Treatment
Lyme Disease Intravenous Antibiotic Therapy
Maternity/Obstetrical Care for Child Dependents
Organ Transplant Benefits
Patient Controlled Analgesia.
Pre-Admission Hospital Review
Pre-Admission Testing Charges
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —Prostate Cancer Screening
Radiology/Diagnostic Imaging Services
Scalp Hair Prostheses
Second Surgical Opinion
Shock Therapy Benefits
Skilled Nursing Facility Charges
Speech Therapy Benefit
Vision Care Benefits
Charges Not Covered By Horizon HMO
Third Party Liability
Subrogation And Reimbursement
When You Have A Claim
Submitting a Claim
Filing Deadline (Proof of Loss)
Itemized Bills are Necessary
Filling Out the Claim Form
Medicare Claim Submission
Questions About Claims
SHBP/SEHBP Medical Appeal Procedure
First Level Medical Appeal
Second Level Appeal
Expedited Review of Second Level Medical Appeals
External Appeal Rights
Standard External Appeals
SHBP/SEHBP Administrative Appeal Procedure
First Level Administrative Appeal
Second Level Administrative Appeal
iv — HORIZON HMO MEMBER HANDBOOK PRESCRIPTION DRUG BENEFITS
Employee Prescription Drug Coverage.
Employee Prescription Drug Plan Copayments – State Employees
Local Government and Local Education Employees
Employee Prescription Drug Plan Copayments – Local Government and Local Education Employees.
HMO Prescription Drug Plan Copayments – Local Government and Local Education Employees
Retiree Prescription Drug Coverage
Medicare Part D
Retiree Prescription Drug Copayments
State Retirees and Local Government Retirees
Local Education Retirees
Continuing Coverage When It Would Normally End
Cost of COBRA Coverage
Duration of COBRA Coverage
Employer Responsibilities Under COBRA
Employee Responsibilities Under COBRA
Failure to Elect COBRA Coverage
Termination of COBRA Coverage
Special Plan Provisions Under Horizon HMO
Work-Related Injury Or Disease
Medical Plan Extension Of Benefits
Termination For Cause
Summary Schedule Of Services And Supplies
Horizon HMO Eligible Services And Supplies
Horizon HMO Covered Services
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —APPENDIX IV
Required Documentation For Dependent Eligibility And Enrollment
Health Insurance Portability And Accountability Act
Certification of Coverage
Notice Of Privacy Practices
Protected Health Information
Uses and Disclosures of PHI
Questions and Complaints
Health Benefits Program Contact Information
Health Benefits Program Publications
An online version of this handbook containing current updates is available for viewing at:
www.nj.gov/treasury/pensions/health-benefits.shtml Be sure to check the Division of Pensions and Benefits Internet home page at: www.nj.gov/treasury/pensions for forms, fact sheets, and news of any new developments affecting your health benefits.
vi — HORIZON HMO MEMBER HANDBOOK
INTRODUCTIONThe State Health Benefits Program (SHBP) was established in 1961. It offers medical and prescription drug coverage to qualified State and local government public employees, retirees, and eligible dependents; and dental coverage to qualified State and local government/education public employees, retirees, and their eligible dependents. Local employers must adopt a resolution to participate in the SHBP.
The State Health Benefits Commission (SHBC) is the executive organization responsible for overseeing the SHBP. The SHBC includes the State Treasurer as the chairperson, the Commissioner of the Department of Banking and Insurance, the Chairman of the Civil Service Commission, a State employee representative chosen by the Public Employees’ Committee of the AFL-CIO, and a local employee representative chosen by the Public Employees’ Committee of the AFL-CIO. The Director of the Division of Pensions and Benefits is the Secretary to the SHBC.
The State Health Benefits Program Act is found in the New Jersey Statutes Annotated, Title 52, Article 14-17.25 et seq. Rules governing the operation and administration of the program are found in Title 17, Chapter 9 of the New Jersey Administrative Code.
The School Employees’ Health Benefits Program (SEHBP) was established in 2007.
It offers medical and prescription drug coverage to qualified local education public employees, retirees, and eligible dependents. Local education employers must adopt a resolution to participate in the SEHBP.
The School Employees' Health Benefits Commission (SEHBC) is the executive organization responsible for overseeing the SEHBP. The SEHBC includes the State Treasurer, the Commissioner of the Department of Banking and Insurance, an appointee of the Governor, an appointee from New Jersey School Board Association, three appointees from New Jersey Education Association, an appointee from New Jersey State AFL-CIO, and a chairperson appointed by the Governor from nominations submitted by the other members of the commission. The Director of the Division of Pensions and Benefits is the Secretary to the SEHBC.
The School Employees’ Health Benefits Program Act is found in the New Jersey Statutes Annotated, Title 52, Article 14-17.46 et seq. Rules governing the operation and administration of the program are found in Title 17, Chapter 9 of the New Jersey Administrative Code.
The Division of Pensions and Benefits, specifically the Health Benefits Bureau and the Bureau of Policy and Planning, is responsible for the daily administrative activities of the SHBP and the SEHBP. Every effort has been made to ensure the accuracy of the Horizon HMO Member Handbook, which describes the benefits provided in the contract with Horizon Healthcare of New Jersey. However, State law and the New Jersey
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —Administrative Code govern the SHBP and SEHBP. If there are any discrepancies between the information presented in this booklet and/or plan documents and the law, regulations, or contracts, the law, regulations, and contracts will govern. Furthermore, if you are unsure whether a procedure is covered, contact your plan before you receive services to avoid any denial of coverage issues that could result.
If, after reading this booklet, you have any questions, comments, or suggestions regarding this material, please write to the Division of Pensions and Benefits,
PO Box 295, Trenton, NJ 08625-0295, call us at (609) 292-7524, or send an e-mail to:
firstname.lastname@example.org 2 — HORIZON HMO MEMBER HANDBOOK
HORIZON BCBSNJ MEMBER ONLINE SERVICESHorizon Blue Cross Blue Shield of New Jersey offers members an easy, secure and quick way to track your health plan benefits and health information online through Member Online Services at HorizonBlue.com/Members. Member Online Services saves you time by allowing immediate access to important information about your Horizon BCBSNJ health plan.
Accessing health plan benefits and health information online, Members can:
• View benefits.
• Check claims status and payments.
• View authorizations and referrals.
• Request ID cards.
• Tell Horizon if they have other health insurance coverage.
• Find a participating doctor or hospital.
• Change a doctor or dentist.
• Manage Member Online Services account and preferences.
ACCESSING MEMBER ONLINE SERVICESTo become a registered user of Member Online Services, members should visit HorizonBlue.com and click Register in the upper right-hand corner. If members are having difficulty accessing Horizon BCBSNJ’s Member Online Services, members should e-mail Member_Portal@HorizonBlue.com. Representatives are available Monday through Friday, between 7 a.m. and 6 p.m., ET.
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