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New Jersey statutes, administrative code, and agreements between the SHBP or SEHBP and Horizon HMO govern this plan. The following schedule of benefits is a summary description of plan benefits. It is not a complete listing. The schedule does not describe all the limitations or conditions associated with the coverage as described in other sections of this handbook. All pertinent parts of this handbook should be consulted regarding a specific benefit. Health decisions should not be made on the basis of the information provided in the schedule. Horizon HMO will administer the coverage listed in the Schedule of Covered Services and Supplies, subject to the terms, conditions, limitations, and exclusions stated within this handbook.

Please note: The fact that a doctor may prescribe, order, recommend, or approve a service or supply does not, in itself, make it medically needed for the treatment and/or diagnosis of an illness or injury or make it a covered medical expense. Certain services are subject to precertification.


–  –  –

*HMO1525, HMO2030, HMO2035 plans are not available to ACTIVE STATE employees or LOCAL GOVERNMENT employees.



Only eligible services provided by network providers are covered under Horizon HMO.

Some services require referrals which must be arranged through your PCP.

As detailed below, the Horizon HMO, HMO1525 and HMO 2030 plan benefit is 100 percent for most eligible in-network services. Office and therapy visits are subject to a copayment unless otherwise noted.

For Horizon HMO2035, the plan benefit is 80 percent for all in-network services except as noted. Before benefits are paid, the Horizon HMO2035 annual in-network deductible must be satisfied.

Allergy Testing

Ambulance Services

Ambulatory Surgery


Behavioral Health/Substance Abuse � Alcohol or Substance Abuse (Inpatient)

� Alcohol or Substance Abuse (Outpatient)

� Mental or Nervous Conditions Inpatient



–  –  –

Diagnostic Laboratory……………………………..........………100/80 percent coverage 84 — HORIZON HMO MEMBER HANDBOOK Diagnostic X-Ray

Dialysis Center Charges

–  –  –

Emergency Room 100/100 percent coverage, after the Emergency Room copayment (The emergency room copayment is waived if admitted) Hospital Charges

Home Health Care

Hospice Care

Inpatient Hospice Care

Inherited Metabolic Disease Medical Foods

Inpatient Physician Services

Maternity/Obstetrical Care

–  –  –

Pre-Admission Testing

Preventive Care Under the Patient Protection and Affordable Care Act, some preventive care services are covered with no out-of-pocket cost (no copayment), when you receive the services from an in-network health care professional and the sole reason for the visit is to receive the preventive care services. If your health care professional provides a preventive service as part of an office visit, you may be responsible for cost sharing for the office visit if the preventive service is not the primary purpose of your visit or if the provider bills you for the office visit separately from the preventive care.

–  –  –

� Annual Wellness Visit

� Immunizations

� Mammography

� Pap Smears

� Prostate Cancer Screening..................100/100 percent coverage (no copayment) � Well Child

� Well Child Immunizations

–  –  –

Surgical Services

Therapy Services, office based

(Speech, Physical and Occupational) Coverage is limited to 60 visits per calendar year for all three therapies combined, except that therapy services rendered for a diagnosis of autism or developmental disability will have no limit to the number of visits.

Transplant Benefits

–  –  –

Accidental Injury — Physical harm or damage done to a person as a result of a chance or unexpected occurrence.

Active Group Member (subscriber) — An employee who has met the requirements for participation and has completed a form constituting written notice of election to enroll for coverage for him or herself and, if applicable, any eligible dependents. Also includes eligible employees or dependents who continue coverage as a subscriber in the COBRA program.

Activities of Daily Living — Day-to-day activities, such as dressing, feeding, toileting, transferring, ambulating, meal preparation, and laundry functions.

Ambulatory Surgical Center — An accredited ambulatory care facility licensed as such by the state in which it operates to provide same-day surgical services.

Appeal — A request made by a member, doctor, or facility that a carrier review a decision concerning a claim. Administrative appeals question plan benefit decisions such as whether a particular service is covered or paid appropriately. Medical appeals refer to the determination of need or appropriateness of treatment or whether treatment is considered experimental or educational in nature. Appeals to the Health Benefits Commission may only be filed by a member or the member's legal representative.

Benefit Period — The twelve-month period starting on January 1st and ending on December 31st. The first and/or last Benefit Period may be less than a calendar year. The first Benefit Period begins on your coverage date. The last Benefit Period ends when you are no longer covered.

Calendar Year — A year starting January 1 and ending on December 31.

Case Manager — A person or entity designated by the plan to manage, assess, coordinate, direct, and authorize the appropriate level of health care treatment.

Civil Union Partner — A person of the same sex with whom you have entered into a civil union. A photocopy of the New Jersey Civil Union Certificate or a valid certification from another jurisdiction that recognizes same-sex civil unions and additional supporting documentation are required for enrollment. The cost of civil union partner coverage may be subject to federal tax (see your employer or Fact Sheet #75, Civil Unions, for details).

COBRA — Consolidated Omnibus Budget Reconciliation Act of 1985. This federal law requires private employers with more than 20 employees and all public employers to allow covered employees and their dependents to remain on group insurance plans for limited time periods at their own expense under certain conditions.


Coordination of Benefits — The practice of correlating the payments a plan makes with payments provided by other insurance covering the same charges or expenses, so that (1) the plan with primary responsibility pays first, (2) reimbursement does not exceed 100 percent of the actual expense, and (3) the plan does not pay more than it would if no other insurance existed.

Copayment — The fee charged to a member or patient to be paid directly to the participating provider or network specialist at the time treatment is rendered for certain covered services.

Cosmetic Services — Services rendered to refine or reshape body structures or surfaces that are not functionally impaired. They are to improve appearance or selfesteem, or for other psychological, psychiatric or emotional reasons.

Covered Person (member) — An employee, retiree, or COBRA participant or a dependent of an employee, retiree, or COBRA participant who is enrolled.

Coverage — The plan design of payment for medical expenses under the program.

Custodial Care — Services that do not require the skill level of a nurse to perform. These services include but are not limited to assisting with activities of daily living, meal preparation, ambulation, cleaning, and laundry functions. Custodial care services are not eligible for coverage under the plan, including those that are considered to be medically needed.

Deductible — The portion of the first eligible charges submitted for payment in each calendar year that HORIZON HMO2035 requires the member or covered dependent to pay. This does not apply to preventive services or services that require a copayment.

Dependent — A member's spouse, civil union partner, or same-sex domestic partner (as defined by Chapter 246, P.L. 2003); and unmarried child(ren) under the age of 26 who lives with and is substantially dependent upon the member for support. Children include natural, adopted, foster, and stepchildren. If a covered child is not capable of self-support when he or she reaches age 26 due to mental illness, or developmental or physical disability, coverage may be continued subject to approval.

Detoxification Facility — A health care facility licensed by the state it is in as a detoxification facility for the treatment of alcoholism and/or substance abuse.

Domestic Partner — A person of the same sex with whom you have entered into a domestic partnership as defined under Chapter 246, P.L. 2003, the Domestic Partnership Act. The domestic partner of any State employee, State retiree, or an eligible employee or retiree of a participating local public entity that adopts a resolution to provide Chapter 246 health benefits, is eligible for coverage. A photocopy of the New Jersey Certificate of Domestic Partnership dated prior to February 19, 2007 (or a valid certification from another State or foreign jurisdiction that recognizes same-sex domestic partners) and additional supporting documentation are required for enrollment. The cost of same-sex domestic partner coverage may be subject to federal tax (see your employer or Fact Sheet #71, Benefits Under the Domestic Partnership Act, for details).


Durable Medical Equipment — Equipment determined to be:

• Designed and able to withstand repeated use;

• Made for and used primarily in the treatment of a disease or injury;

• Generally not useful in the absence of an illness or injury;

• Suitable for use while not confined in a hospital;

• Not for use in altering air quality or temperature; and

• Not for exercise or training.

Eligible Services and Supplies — These are the charges that may be used as the basis for a claim. They are the charges for certain services and supplies to the extent the

charges meet the terms as outlined below:

• Medically needed at the appropriate level of care for the medical condition.

• Listed in covered services and supplies.

• Ordered by a doctor for treatment of illness or injury.

• Not specifically excluded (listed in the “Charges Not Covered by the Horizon HMO” section on page 49).

• Provided while you or your eligible family members were covered by Horizon HMO.

Emergency — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or a guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical

attention to result in the following:

• Placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.

• Serious impairment to bodily function.

• Serious dysfunction of bodily organ or part.

Claims will be paid for emergency services furnished in a hospital emergency department if the presenting symptoms reasonably suggested an emergency condition as would be interpreted by a prudent layperson. All procedures performed during the evaluation (triage) and treatment of an emergency condition will be covered.

Employer — The State, or a local government public employer that participates in the State Health Benefits Program, or a local education public employer that participates in the School Employees’ Health Benefits Program.


Facility Charges — Charges from an eligible medical institution such as a hospital, residential treatment center, detoxification center, ambulatory or separate surgical center, dialysis center, or a skilled nursing center.

Family or Medical Leave of Absence — A period of time of pre-determined length, approved by the employer, during which the employee does not work, but after which the employee is expected to return to active service. Any employee who has been granted an approved leave of absence in accordance with the Family and Medical Leave Act of 1993 shall be considered to be active for purposes of eligibility for covered services and supplies under your group's program.

Full Medicare Coverage — Enrollment in both Part A (Hospital Insurance) and Part B (Medical Insurance) of the federal Medicare Program. State law requires that anyone who is enrolled in the Retired Group and is eligible for Medicare must enroll in both Parts A and B of the Medicare Program in order to be covered in the State Health Benefits Program or School Employees’ Health Benefits Program.

Gestational Carrier — A woman who has become pregnant with an embryo or embryos that are not part of her genetic or biologic entity, and who intends to give the child to the biological parents after birth.

Government Hospital — A hospital which is operated by a government or any of its subdivisions or agencies. This includes any federal, military, state, county, or city hospital.

Home Health Care Agency — A provider which mainly provides skilled nursing care and therapeutic services for an ill or injured person in the home under a home health care program designed to eliminate hospital stays. To be eligible for reimbursement it must be licensed by the state in which it operates, or be certified to participate in Medicare as a home health care agency.

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