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«STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS Horizon HMO MEMBER HANDBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN ...»

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STATE OF NEW JERSEY

DEPARTMENT OF THE TREASURY

DIVISION OF PENSIONS AND BENEFITS

Horizon HMO

MEMBER HANDBOOK

FOR EMPLOYEES AND RETIREES

ENROLLED IN THE

STATE HEALTH BENEFITS PROGRAM OR

SCHOOL EMPLOYEES’ HEALTH BENEFITS PROGRAM

PLAN YEAR 2016

ADMINISTERED FOR THE DIVISION OF PENSIONS AND BENEFITS BY

HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY

WELCOME 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 CONTENTS

Introduction

Horizon Member Online Services

My Health Manager, powered By WebMD®

Horizon HMO

Health Benefits Program Eligibility

Active Employee Eligibility

State Employees

Local Employees

Enrollment

Eligible Dependents

Supporting Documentation Required For Enrollment Of Dependents

Audit Of Dependent Coverage

Multiple Coverage Under The SHBP/SEHBP Is Prohibited

Medicare Coverage While Employed

Retiree Eligibility

Aggregate of Pension Membership Service Credit

Eligible Dependents of Retirees

Multiple Coverage under the SHBP/SEHBP is Prohibited

Enrolling in Retired Group Coverage

Medicare Coverage

Medicare Parts A and B

Medicare Part D

Medicare Eligibility

GENERAL CONDITIONS OF THE PLAN

Medical Need and Appropriate Level of Care

Health Care Fraud

Your Primary Care Physician (PCP)

i

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —

Changing Your PCP

Making Appointments

Physician Access Standards

Physician Compensation

Specialty Care

Referrals

Hospitalization

Hospital Stays and Prior Authorization

Behavioral Health and Substance Abuse Care

Accessing Behavioral Health and Substance Abuse Care

Prior Authorization

Utilization Management

Experimental or Investigational Treatments

Chronic Care Program

Case Management Program.

HORIZON HMO PLAN BENEFITS

Copayments

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

GENERAL BENEFITS

Allergy Testing and Treatment

Ambulance

Audiology Services

Autism or Other Developmental Disability

Automobile-Related Injuries

Behavioral Health and Substance Abuse Care

Birthing Centers

Blood

Breast Reconstruction

Chiropractic Services

ii — HORIZON HMO MEMBER HANDBOOK Dental Care

Diabetic Self-Management Education

Dialysis

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

Hearing Aids

Hemophilia Treatment

Home Health Care

Hospice Care Benefits

Immunizations

Infertility Treatment

Laboratory Testing

Lead Poisoning Screening and Treatment

Lithotripsy Centers

Lyme Disease Intravenous Antibiotic Therapy

Mammography.

Mastectomy Benefits

Maternity/Obstetrical Care

Maternity/Obstetrical Care for Child Dependents

Nutritional Counseling

Occupational Therapy

Organ Transplant Benefits

Pain Management

Pap Smears

Patient Controlled Analgesia.

Physical Therapy

Physicals

Pre-Admission Hospital Review

Pre-Admission Testing Charges

iii

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

Surgery.

Therapy Services

Vision Care Benefits

Charges Not Covered By Horizon HMO

Third Party Liability

Repayment Agreement

Recovery Right

Subrogation And Reimbursement

When You Have A Claim

Submitting a Claim

Filing Deadline (Proof of Loss)

Itemized Bills are Necessary

Foreign Claims

Filling Out the Claim Form

Medicare Claim Submission

Questions About Claims

APPEAL PROCEDURES

SHBP/SEHBP Medical Appeal Procedure

First Level Medical Appeal

Expedited Review

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

Commission Appeal

iv — HORIZON HMO MEMBER HANDBOOK PRESCRIPTION DRUG BENEFITS

Employee Prescription Drug Coverage.

State Employees

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

COBRA COVERAGE

Continuing Coverage When It Would Normally End

COBRA Events

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

APPENDIX I

Special Plan Provisions Under Horizon HMO

Work-Related Injury Or Disease

Medical Plan Extension Of Benefits

Termination For Cause

APPENDIX II

Summary Schedule Of Services And Supplies

Horizon HMO Eligible Services And Supplies

Horizon HMO Covered Services

APPENDIX III

Glossary

v

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —

APPENDIX IV

Required Documentation For Dependent Eligibility And Enrollment

APPENDIX V

Health Insurance Portability And Accountability Act

Certification of Coverage

HIPAA Privacy

APPENDIX VI

Notice Of Privacy Practices

Protected Health Information

Uses and Disclosures of PHI

Restricted Uses

Member Rights

Questions and Complaints

APPENDIX VII

Health Benefits Program Contact Information

Addresses

Telephone Numbers

Health Benefits Program Publications

General Publications

Member Handbooks

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

INTRODUCTION

The 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:

pensions.nj@treas.nj.gov 2 — HORIZON HMO MEMBER HANDBOOK

HORIZON BCBSNJ MEMBER ONLINE SERVICES

Horizon 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 SERVICES

To 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.

–  –  –

You are your own best health advocate. But to get and stay healthy, it helps to have some guidance. That’s why we offer My Health Manager, powered by WebMD®.

My Health Manager is your personalized health guide. You can customize it to include news feeds, articles and reminders, plus take advantage of an online health record that gives you and your family the ability to store, manage and maintain health information in a centralized location.

My Health Manager also features these powerful tools:

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