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Hospice — A provider that renders a health care program which provides an integrated set of services designed to provide comfort, pain relief and supportive care for terminally ill or terminally injured people under a hospice care program.

Hospital — An approved institution that meets the tests of 1, 2, 3, 4, or 5, listed below:

1. It is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Hospitals and Medicare approved.

2. It (a) is legally operated, (b) is supervised by a staff of doctors, (c) has 24-hour-a-day nursing service by registered graduate nurses, and (d) mainly provides general inpatient medical care and treatment of sick and injured persons by the use of the medical, diagnostic, and major surgical facilities in it.

3. It is licensed as an ambulatory or separate surgical center. The center must mainly provide outpatient surgical care and treatment.


4. It is an institution for the treatment of alcoholism not meeting all the tests of (1) or (2)

but which is:

• A licensed hospital; or

• A licensed detoxification facility; or

• A residential treatment facility which is approved by a state under a program that meets standards of care equivalent to those of the Joint Commission on Accreditation of Hospitals. (Educational services provided while at an approved treatment facility is not eligible).

5. It is a birth center that is licensed, certified, or approved by a department of health or other regulatory authority in the state where it operates or meets all of the following


• It is equipped and operated mainly to provide an alternative method of childbirth.

• It is under the direction of a doctor.

• It allows only doctors to perform surgery.

• It requires an exam by an obstetrician at least once before delivery.

• It offers prenatal and postpartum care.

• It has at least two birthing rooms.

• It has the necessary equipment and trained people to handle foreseeable emergencies. The equipment must include a fetal monitor, incubator, and resuscitator.

• It has the services of registered graduate nurses.

• It does not allow patients to stay more than 24 hours.

• It has written agreements with one or more hospitals in the area that meet the tests listed above in (1) or (2) and will immediately accept patients who develop complications or require post-delivery confinement.

• It provides for periodic review by an outside agency.

• It maintains proper medical records for each patient.

“Hospital” does not include a nursing home. Neither does it include an institution, or

part of one, that:

• Is used mainly as a place for convalescence, rest, nursing care, or for the aged or drug addicts.

• Is used mainly as a center for the treatment and education of children with mental disorders or learning disabilities.

• Provides home-like or custodial care.


Illness — Any disorder of the body or mind.

Independent Review Organization (IRO) — An independent organization commissioned by the New Jersey Department of Banking and Insurance to review utilization management appeals that have already gone through the internal Horizon HMO appeals process.

In network — The physicians, other health care professionals and facilities that the Horizon HMO has selected and contracted with to care for it members. In-network care occurs when: your receive care from your Primary Care Physician (PCP), you received care from a participating OB/GYN, you received care at a participating facility; or your specialty care is coordinated by your PCP.

Injury — Damage to the body.

Local Employee — For purposes of health benefits coverage, a local employee is a full-time employee receiving a salary and working for a Participating Local Employer.

Full-time shall mean employment of an eligible employee who appears on a regular payroll and who receives salary or wages for an average number of hours specified by the employer, but not to be less than 25 hours per week. It also means employment in all 12 months of the year except in the case of those employees engaged in activities where the normal work schedule is 10 months. In addition, for local coverage, employee shall also mean an appointed or elected officer of the local employer, including an employee who is compensated on a fee basis as a convenient method of payment of wages or salary but who is not a self-employed independent contractor compensated in a like manner. To qualify for coverage as an appointed officer, a person must be appointed to an office specifically established by law, ordinance, resolution, or such other official action required by law for establishment of a public office by an appointing authority. A person appointed under a general authorization, such as to appoint officers or to appoint such other officers or similar language is not eligible to participate in the program as an appointed officer.

An officer appointed under a general authorization must qualify for participation as a full-time employee.

Local Employer — Government employers in New Jersey, including counties, municipalities, townships, school districts, community colleges, and various public agencies or organizations.

Maintenance Care — Care that does not substantially improve the condition. When care is provided for a condition that has reached maximum improvement and further services will not appreciably improve the condition, care will be deemed to be maintenance care and no longer eligible for reimbursement. Maintenance care services, even those that are considered to be medically needed, are not eligible for coverage under Horizon HMO.

92 — HORIZON HMO MEMBER HANDBOOK Medical Emergency — A medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance abuse such that a prudent layperson, 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 woman, the health of the woman or her unborn child) in serious jeopardy;

• serious impairment to bodily functions; or

• serious dysfunction of a bodily organ or part.

With respect to a pregnant woman who is having contractions, an emergency exists where there is not adequate time to affect a safe transfer to another hospital before delivery, or the transfer may pose a threat to the health or safety of the woman or the unborn child.

Medical Emergency Screening Examination — An examination and evaluation within the capability of the hospital’s emergency department including ancillary services routinely available to the emergency department, and performed by qualified personnel.

Medical Need and Appropriate Level of Care — A service or supply that Horizon HMO

determines meets each of these requirements:

• It is ordered by a doctor for the diagnosis or the treatment of an illness or injury.

• The prevailing opinion within the appropriate specialty of the United States medical profession is that it is safe and effective for its intended use, and that its omission would adversely affect the person's medical condition.

• That it is the most appropriate level of service or supply considering the potential benefits and harm to the patient.

• It is known to be effective in improving health outcomes (for new interventions, effectiveness is determined by scientific evidence; then, if necessary, by professional standards; then, if necessary, by expert opinion).

Medicare — The federal health insurance program for people 65 or older, people of any age with permanent kidney failure, and certain disabled people under age 65. Medical coverage consists of two parts: Part A is Hospital Insurance Benefits and Part B is Medical Insurance Benefits. A Retired Group member and/or spouse who are eligible for Medicare coverage by reason of age or disability must be enrolled in Parts A and B to enroll or remain in SHBP or SEHBP Retired Group coverage.

Member — An employee, retiree, COBRA enrollee or dependent who is enrolled under Horizon HMO.


Mental or Nervous Condition — A condition which manifests symptoms which are primarily mental or nervous, whether organic or non-organic, biological or non-biological, chemical or non-chemical in origin and regardless of cause, basis or inducement, for which the primary treatment is psychotherapy or psychotherapeutic methods or psychotropic medication. Mental or nervous conditions include, but are not limited to, psychoses, neurotic and anxiety disorders, schizophrenic disorders, affective disorders, personality disorders, and psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems.

Mental or nervous condition does not include substance abuse or alcoholism.

Morbid Obesity — A body mass index (BMI) greater than 40kg/m2, or a BMI greater than 35kg/m2 with associated life-threatening or disabling co-morbidities including, but not limited to, coronary heart disease, diabetes, hypertension, or obstructive sleep apnea.

Mouth Condition — A condition involving one or more teeth, the tissue or structure around them, or the alveolar process of the gums.

Nonparticipating — Physicians, health care professionals or facilities that do not contract with the Horizon HMO to provide care to Horizon HMO members.

Nonparticipating may also be referred to as out-of-network or non-network.

Off-Label Use — A drug not approved by the FDA for treatment of the condition in question or prescribed at a different dosage than the approved dosage.

Participating Provider — A Primary Care Physician, specialty care physician or other medical services professional or organization (hospitals, laboratory facilities etc.) that contracts with the Horizon HMO: or a behavioral health and substance abuse care participating facility or participating practitioner. Participating may also be referred to as in-network.

Precertification — A process by which the eligibility and medical appropriateness of services or supplies is determined before services are rendered.

Primary Care Physician (PCP) — A duly licensed family practitioner, general practitioner, internist or pediatrician who has entered into an agreement with the Horizon HMO to participate in the Horizon Managed Care Network and is responsible for coordinating all aspects of medical care for those members who have selected him or her. These responsibilities include personally providing medical care or referring members to the appropriate source for medical care, whether that source is a specialist physician, ancillary physician or inpatient facility. In addition, other specialists or health care professionals with appropriate qualifications may serve as a member’s PCP where Horizon HMO so agrees.

Primary Health Plan — A plan which pays benefits for a member's covered charge first, ignoring what the member's secondary plan pays. A secondary health plan then pays the remaining unpaid expenses in accordance with the provisions of the member's secondary health plan.

94 — HORIZON HMO MEMBER HANDBOOK Prior authorization/preapproval — Written approval by the Horizon HMO prior to the date of service for a physician or other health care professional or facility to provide specific services or supplies.

Provider — The term is used to define a participating provider and includes medical doctors, dentists, podiatrists, acupuncturists, psychologists, psychiatrists, physician assistants, nurse midwives, licensed clinical social workers, licensed marriage and family therapists, licensed professional counselors, board certified behavior analysts – doctoral (BCBA-D), board certified behavior analysts (BCBA), ABA therapist credentialed by the National Behavior Analyst Certification Board (BACB) or working under the direct supervision of a BCBA or BCBA-D, chiropractors, certified nurse practitioners, clinical nurse specialists, Registered Nurse First Assistants (RNFA), physical therapists, occupational therapists, optometrists, and audiologists who are properly licensed and are working within the scope of their practice.

Referral — The recommendation by your PCP for you to receive care from a participating physician or facility.

Residential Treatment Facility — A health care facility licensed by the State of New Jersey for treatment of alcoholism or substance abuse or meeting the same standards, if out-of-state.

Respite Care — Short-term or temporary care provided for the hospice patient in order to provide relief, or respite to the family caregiver.

Retired Group Member — An eligible retiree of a state-administered or local public pension fund who has met the requirements for participation and has completed a form constituting written notice of election to enroll for Retired Group coverage in the SHBP or SEHBP for him/herself and, if applicable, any eligible dependents. Also includes a surviving spouse of a deceased Retired Group member who has met the requirements for and has completed a form constituting written notice of election to enroll in Retired Group coverage for him/herself and, if applicable, any eligible dependents. Also includes a surviving dependent child of a deceased Retired Group member who had parent-child(ren) coverage, providing he or she has completed a form constituting written notice of election to enroll in Retired Group coverage.

School Employees’ Health Benefits Commission — The entity created by N.J.S.A.

52:14-17.46 and charged with the responsibility of overseeing the School Employee’s Health Benefits Program.

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