«STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS Horizon HMO MEMBER HANDBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN ...»
• Mouth conditions — charges for doctor's services or X-ray examinations for a mouth condition. This exclusion applies even if a condition requiring any of these services involves a part of the body other than the mouth, such as treatment of Temporomandibular Joint disorders (TMJ) or malocclusion involving joints or muscles by methods including, but not limited to, crowning, wiring, or repositioning of teeth.
See page 94 of the “Glossary” for the definition of a mouth condition.
• Non-medical equipment which is primarily for personal hygiene or for comfort or convenience rather than for a medical purpose, including air conditioners, dehumidifiers, purifiers, heating pads, and similar supplies which are useful to a person in the absence of illness or injury or other condition.
• Nursing home care.
• Out-of-Area Urgent Care not arranged for through HMO BLUE USA which was provided while the person was in an area serviced by HMO BLUE USA, or when Horizon HMO was not contacted within the notification time.
• Outpatient supplies, including (but not limited to) outpatient medical consumable or disposable supplies purchased over the counter such as syringes, incontinence pads and reagent strips.
• Over-the-counter supplies, supplements, vitamins, medications, or drugs that do not require a prescription order under Federal law, even if the prescription is written by a physician. These include, but are not limited to, aspirin, vitamins, lotions, creams, oils, formulas, liquid diets, and dietary supplements.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —
• Personal comfort or convenience items including telephone or television service, haircuts, guest trays, or a private room during an inpatient stay.
• Prescription drug charges or copayments. If your prescription drug plan does not provide benefits for a particular drug, it does not mean that it will be eligible under Horizon HMO.
• Postage, handling and shipping fees.
• Private rooms in a hospital. If you occupy a private room in a hospital or facility, you must pay the difference between the private room rate and the average semiprivate room rate.
• Repatriation (returning a traveler to his/her home when unable to continue with travel due to medical reasons).
• Room and board charges for any period of time during which the Member was not physically present in the room.
• Self-administered services such as: self- or home-testing kits, self-care and self-help training whether prescribed by a doctor or not.
• Services or supplies:
✔ for breast prosthesis implants except when following a mastectomy on one breast or both breasts;
✔ for ptosis of the eyelids, except as Medically Necessary and Appropriate;
✔ for reduction mammoplasty, except as Medically Necessary and Appropriate;
✔ for septoplasty, except as Medically Necessary and Appropriate;
✔ for the treatment of Mental or Nervous Disorders or Chemical Dependency when the patient is not involved;
✔ for the treatment of organic brain disorders when, as determined by Horizon HMO, demonstrable and significant improvement from psychiatric treatment is unlikely.
✔ for the personal convenience or comfort of the member, including, but not limited to, such items as televisions, telephones, first aid kits, exercise equipment, air conditioners, humidifiers, saunas, Jacuzzis, pools, and hot tubs of any type.
✔ provided by or in a government hospital unless the services are for treatment:
– of a non-service-related medical emergency;
– by a Veterans' Administration Hospital of a non-service-related illness or injury or other condition; or – the hospital is located outside of the United States and Puerto Rico.
✔ unless otherwise required by law;
✔ provided by or in any locale outside the United States, except in the case of a Medical Emergency;
54 — HORIZON HMO MEMBER HANDBOOK ✔ provided for any illness, disease, injury, or other condition occurring while an individual is on active duty during military service;
✔ provided to the newborn child of a male or female child dependent;
✔ received as a result of:
– war, declared or undeclared;
– police actions;
– service in the armed forces or units auxiliary thereto; or – riots or insurrection.
✔ which are specifically limited or excluded;
✔ which are not provided or arranged for by the individual's PCP or Horizon HMO, unless otherwise stated.
• Services for cosmetic surgery (or complications that result from such surgery) on any part of the body except for reconstruction surgery following a mastectomy or when medically necessary to correct damage caused by an accident, an injury, therapeutic surgery or to correct a congenital defect.
• Services or supplies that are not medically needed and/or not at the appropriate level of care and charges in connection with such services or supplies. The fact that a physician may prescribe, order, recommend, or approve a service or supply does not, in itself, make it medically needed for the treatment and diagnosis of an illness or injury or make it a covered medical expense.
• Services that are commonly or customarily provided without charge to the patient.
Even when the services are billed, Horizon HMO will not pay if they are usually not billed when there is no coverage available.
• Services and supplies prescribed or provided by an ineligible provider.
• Services or supplies that require prior authorization that are not authorized before services are rendered.
• Services rendered before the effective date of coverage or after the termination of coverage date. However, if the covered patient is hospitalized as an inpatient and coverage terminates during the stay, that inpatient stay (as long as otherwise eligible) will be covered through to discharge.
• Services rendered or billed by an Assisted Living Facility.
• Shoes that are not custom molded, are not attached to a brace, or can be purchased without a prescription.
• Special medical reports not directly related to treatment of the Member (e.g. employment physicals and reports prepared in connection with litigation).
• Speech therapy to correct pre-speech deficiencies or to improve speech skills that have not fully developed (Exceptions: Autism and Pervasive Developmental Disorder).
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —
• Sports physicals.
• Stand-by services required by a Practitioner; services performed by surgical assistants not employed by a Facility.
• Sterilization reversal.
• Surgery, sex hormones, and related medical and psychiatric services to change a Member’s sex; services and supplies arising from complications of sex transformation and treatment for gender identity disorders.
• Supportive care — defined as treatment for patients having reached maximum therapeutic benefit in which periodic trials of therapeutic withdrawals fail to sustain previous therapeutic gains. In some instances therapy may be clinically appropriate (such as treatment of a chronic condition that requires supportive care) yet it would not be eligible for reimbursement under Horizon HMO.
• Taxes on services/supplies.
• Telephone consultations or provider charges for telephone calls.
• TMJ Syndrome — medical treatment of TMJ Syndrome, except as otherwise stated,
including but not limited to:
✔ Intraoral prosthetic devices;
✔ Nonsurgical intervention;
✔ Office Visits; or ✔ Physical Therapy.
• Transplants, unless otherwise specified in this contract, and non-human organ transplants.
• Transportation (non-emergency), other than ambulance/invalid coach service when certified by Horizon HMO; travel.
• Treatment of injuries sustained while the Member engaged, or tried to engage, in an illegal occupation or committed, or tried to commit, a felony.
• Vitamins and dietary supplements.
• Vocational and educational training and services.
• Weight reduction or control, special foods; food supplements; liquid diets; diet plans;
or any related products, except as otherwise stated.
• Weight loss programs such as Jenny Craig, Weight Watchers, and the cost of food associated with them.
• Wigs; toupees; hair transplants; hair weaving; or any drug used to eliminate baldness, unless otherwise stated.
56 — HORIZON HMO MEMBER HANDBOOK
• Work-related injury or disease including injuries arising out of, or in course of, work for wage or profit, whether or not the member is covered by a Workers' Compensation policy; Disease caused by reason of its relation to Workers Compensation law, occupational disease laws or similar laws; Work-related tests, examinations or immunizations of any kind required by the member's work (with the exception of one (1) annual physical exam per year used to satisfy an employment requirement).
• Work-related injury or disease. This includes the following:
✔ Injuries arising out of, or in the course of, work for wage or profit, whether or not you are covered by a Workers' Compensation policy.
✔ Disease caused by reason of its relation to Workers' Compensation law, occupational disease laws, or similar laws.
✔ Work-related tests, examinations, or immunizations of any kind required by your work.
✔ Work-related injuries will not be eligible for benefits under Horizon HMO before or after your Workers’ Compensation carrier has settled or closed your case.
This exclusion does not apply to employer-mandated physical examinations that are a prerequisite for participation in an employer-mandated physical fitness test required as a condition of continuing employment. However, such employer-mandated physical examinations are covered in-network only.
Please note: If you collect benefits for the same injury or disease from both Workers' Compensation and Horizon HMO, you may be subject to prosecution for insurance fraud.
Examples of Non-Covered Services:
Example 1: A physician orders inpatient private duty nursing for a surgery patient. Since, while confined in a hospital, nursing services are provided by the hospital, any charges for private duty nursing will not be paid.
Example 2: A person is studying to become a therapist and is required by the school to enter therapy. The treatment is intended to ensure that the new therapist is well-equipped to work with patients. The treatment is not covered because it is primarily educational.
Example 3: A physician orders a drug that is FDA-approved but is not commonly used to treat the particular condition. If Horizon HMO determines that the use is experimental, the plan will not pay for the drug.
Example 4: A hospital routinely requires an assistant surgeon or Registered Nurse First Assistant (RNFA) to be present at certain operations. Horizon HMO will only pay for assistant surgeons/RNFA’s that are determined to be medically necessary.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —
THIRD PARTY LIABILITYRepayment Agreement If you have received benefits from Horizon HMO for medical services that are either auto-related or work-related, Horizon HMO has the right to recover those payments. This means that if you are reimbursed through a settlement, satisfied by a judgment, or other means, you are required to return any benefits paid for illness or injury to Horizon HMO.
The repayment will only be equal to the amount paid by Horizon HMO.
This provision is binding whether the payment received from the third party is the result of a legal judgment, an arbitration award, a compromise settlement, or any other arrangement, whether or not the third party has admitted liability for the payment.
Recovery Right You are required to cooperate with Horizon BCBSNJ in recovering any amounts payable.
Horizon HMO may:
• Assume your right to receive payment for benefits from the third party;
• Require you to provide all information and sign and return all documents necessary to exercise Horizon HMO’s rights under this provision, before any benefits are provided under your group's policy;
• Require you to give testimony, answer interrogatories, attend depositions, and comply with all legal actions which Horizon HMO may find necessary to recover money from all sources when a third party may be responsible for damages or injuries.
SUBROGATION AND REIMBURSEMENTBenefits payable as a result of any injuries claimed against any person or entity other than this Health Plan are excluded from coverage under this Plan. If benefits are provided by this Plan that are otherwise payable or become payable by any third party action against any person or entity, this Plan is entitled to reimbursement only on the following
terms and conditions:
• In the event that benefits are provided under this Plan, the Plan shall be subrogated to all of the Member’s rights of recovery against any person or organization to the extent of the benefits provided (“Member” includes any person receiving benefits hereunder including all dependents). The Member shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. The Member shall do nothing after loss to prejudice such rights. The Member must cooperate with the Plan and/or any representatives of the Plan in completing such forms and in giving such information surrounding any accident as the Plan or its representatives deem necessary to fully investigate the incident.
• The Plan is also granted a right of reimbursement from the proceeds of any recovery whether by settlement, judgment, or otherwise. This right of reimbursement is cumulative with, and not exclusive of, the subrogation right granted in the precedinparagraph, but only to the extent of the benefits provided by the Plan.
58 — HORIZON HMO MEMBER HANDBOOK