«STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS Horizon HMO MEMBER HANDBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN ...»
As of January 1, 2000, where the member becomes eligible for Medicare solely on the basis of ESRD, the Medicare eligibility can be segmented into three parts: (1) an initial three-month waiting period; (2) a "coordination of benefits" period; and (3) a period where Medicare is primary.
Three-month waiting period Once a person has begun a regular course of renal dialysis for treatment of ESRD, there is a three-month waiting period before the individual becomes entitled to Medicare Parts A and B benefits. During the initial three-month period, the group health plan is primary.
Coordination of benefits period During the "coordination of benefits" period, Medicare is secondary to the group health plan coverage. Claims are processed first under the health plan. Medicare considers the claims as a secondary payer. For members who became eligible for Medicare due solely to ESRD, the coordination of benefits period is 30 months.
When Medicare is primary After the coordination of benefits period ends, Medicare is considered the primary payer and the group health plan is secondary. If you are eligible for Medicare by reason of ESRD and Medicare is primary, you must enroll in Medicare A and B and submit proof of enrollment to the SHBP/SEHBP. If you do not enroll in Medicare A and B before the end of the coordination of benefits period, your SHBP/SEHBP coverage will be terminated. It is your responsibility to ensure that you file your application for Medicare so that the Medicare effective date is on or before the date that the coordination of benefits period ends.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —
• Dual Medicare Eligibility When the member is eligible for Medicare because of age or disability and then
becomes eligible for Medicare because of ESRD:
✓ If the health plan is primary because the member has active employment status, then the group health plan continues to be primary for 30- months from the date of dual Medicare entitlement.
✓ If the health plan is secondary because the member is not actively employed, then the health plan continues to be the secondary payer. There is no 30- month coordination period.
GENERAL CONDITIONS OF THE PLANAll benefits listed in this handbook may be subject to limitations and exclusions as described in subsequent sections. All pertinent parts of this handbook should be consulted regarding a specific benefit.
Even though a service or supply may not be described or listed in this handbook, that does not mean the service or supply is eligible for benefits under the Horizon HMO.
Horizon HMO will pay only for eligible services or supplies that meet the following conditions:
• Are medically needed at the appropriate level of care (see below) for the medical condition. (When there is a question as to medical need, the decision on whether the treatment is eligible for coverage will be made by Horizon HMO.)
• Are listed in the “Eligible Services and Supplies” section on page 83.
• Are ordered by an eligible provider for treatment of illness or injury.
• Were provided while you or your eligible covered dependents were covered by the HMO.
• Are not specifically excluded (listed in the “Charges Not Covered by Horizon HMO” section on page 49).
Medical Need and Appropriate Level of Care The medical need and appropriate level of care for any service or supply is determined
by Horizon HMO and must meet each of these requirements:
• It is ordered by an eligible provider 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.
• That it is the most appropriate level of service or supply considering the potential benefits and possible harm to the patient.
See also “Experimental or Investigational Treatments” on page 23.
16 — HORIZON HMO MEMBER HANDBOOK Health Care Fraud Health care fraud is an intentional deception or misrepresentation that results in an unauthorized benefit to a member or to some other person. Any individual who willfully and knowingly engages in an activity intended to defraud the SHBP or SEHBP will face disciplinary action that could include termination of employment and may result in prosecution. Any member who receives monies fraudulently from a health plan will be required to fully reimburse the plan.
Your Primary Care Physician (PCP) When you enroll with the Horizon HMO, you must select a Primary Care Physician (PCP), PCP's are licensed family practitioners, general practitioners, internists or pediatricians who have passed the Horizon Managed Care Network credentialing process. They have agreements with Horizon Managed Care Network to participate in their network.
As your personally selected physician, your PCP provides medical care or refers you to the appropriate source for medical care, whether that source is a specialty physician or other health care professional or facility. Your PCP also coordinates your health care services.
• Handles most of your medical care in his/her office.
• Performs annual well care and preventive health exams or refers you to a specialty care physician or facility, as applicable.
• Coordinates your specialty care and helps you with prior authorizations for medically necessary services.
• Is on call or has an appointed, covering physician available 24 hours a day, seven days a week.
To verify that the PCP you select is participating in the Horizon Managed Care Network, visit the Provider Directory at www.HorizonBlue.com/SHBP You may also call the SHBP/SEHBP Member Services at 1-800-414-7427 (SHBP).
Changing Your PCP You may change your PCP at any time. To do so, follow these simple steps.
1. Visit the online provider directory at www.HorizonBlue.com/SHBP to find a new participating PCP. By answering a few short questions, you can create a list of participating physicians near you, or check to see if a specific physician is participating in the Horizon BCBSNJ network.
2. There are three ways to notify the Horizon HMO of your request to change your
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —
• If you’re registered for Member Online Services, you may change your PCP online. Just visit www.HorizonBlue.com/SHBP, log in to Member Online Services and click Change Your Doctor.
• You may call Horizon HMO at 1-800-414-7427 (SHBP) to change your PCP through the interactive voice response (IVR) system.
• You may call the SHBP/SEHBP member services at 1-800-414-7427 (SHBP) and speak with a Member Services Representative.
Horizon BCBSNJ will send a letter to you confirming your new PCP selection. You may see your new PCP 14 days after notifying Horizon HMO.
3. Have your medical records transferred to your newly selected PCP. There may be a nominal cost from your physician to transfer your records.
Making Appointments Call your PCP when you need an appointment for periodic physical exams. This helps ensure that you receive proper preventive care services. Contact your PCP whenever you have medical concerns or questions.
18 — HORIZON HMO MEMBER HANDBOOK Physician Access Standards It is important for you to receive a timely appointment. To help make sure you have access to the medical care you need, when you need it, Horizon HMO developed Physician Access Standards when scheduling appointments with you.
Routine Care — includes any condition An appointment as soon as possible not or illness that does not require urgent to exceed two weeks from your call.
attention or is not life-threatening, as well as routine gynecological care.
Routine Physical Exam — includes an An appointment within four months of annual health assessment, as well as your call.
routine gynecological exams, for new and established patients.
Urgent Care — includes medically nec- An appointment within 24 hours of your essary care for an unexpected illness or call.
Emergency Care — includes a medical To be seen immediately or directed to condition of such severity that a prudent an emergency care facility.
layperson would call for immediate medical attention and care. For a complete definition, please refer to the Glossary.
Physician Compensation You have a right to know how Horizon HMO pays the physicians and facilities in their managed care network so you will know if there are any financial incentives or disincentives tied to medical decisions. You also have the right to ask physicians and other health care professionals how they are compensated for their services.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —Physicians and other health care professionals in the Horizon HMO network have agreed to be paid in different ways. Your participating physician may be paid each time he/she treats you (fee for service), or he/she may be paid a set fee each month for each member whether or not the member actually receives services (capitation).
These payment methods may include financial incentive agreements to pay some physicians more (bonuses) or less (withholds) based on many factors, including member satisfaction, quality of care and the control of costs and use of services.
The laws of the state of New Jersey at N.J.S.A. 45.9-22.4 et seq., require that a physician, chiropractor, or podiatrist, who is permitted to make referrals to other health care professionals or facilities in which he/she has a significant interest, inform his/her patients of that financial interest when making such a referral.
For more information about this, contact your physician, chiropractor or podiatrist. If you believe that you are not receiving the information to which you are entitled, call the New Jersey Division of Consumer Affairs at 1-800-242-5846 or 1-973-504-6200.
Specialty Care At times your PCP may feel it is appropriate to refer you for specialty care services. If specialty care services are required, your PCP will give you a referral. Your PCP will find the appropriate specialist to provide the specialty care you need. You do not need a referral for routine obstetrical or gynecological-related visits to participating OB/GYNs.
Referrals Your PCP will give you a referral if he/she determines that you need specialty medical care or services. Take this referral confirmation and your Horizon HMO ID card to the participating specialty care physician at the time of service.
If you are referred for specialty care, please review your referral with your PCP. It is a good idea to write down any questions you have about your condition and your need for specialty care and discuss these questions with your PCP.
How Long are Referrals Valid?
Referrals are valid for the number of visits and type(s) of services specified by your PCP.
Your PCP can refer you for as many as 12 visits within 180 days if it is medically necessary and appropriate.
Extended Referrals If you have a chronic condition, your PCP may contact Horizon HMO to request an extended referral. Extended referrals may also be called special referrals.
20 — HORIZON HMO MEMBER HANDBOOK What to do if Referred for Care If you need specialty care services, call the participating specialist your PCP has referred you to and schedule an appointment. You may also access your referral by visiting www.horizonblue.com/shbp and selecting the Member Portal. Take our referral confirmation and your ID card to your visit. If you do not have these items, the specialist may not be able to see you.
The Horizon Hospital Network includes many hospitals throughout New Jersey and nearby in Pennsylvania, Delaware and New York. For eligible charges to be covered:
You must receive care, or be admitted to, a network hospital. Your PCP or participating health care professional must follow the Horizon HMO prior authorization procedures.
To find a participating hospital or facility, use our Provider Directory at:
www.HorizonBlue.com/shbp or call Member Services at 1-800-414-7427. You can also use a web-enabled device to access the Provider Directory from Mobile.HorizonBlue.com Hospital Stays and Prior Authorization If you need to be hospitalized, your PCP or other participating health care professional must contact the Horizon HMO for prior authorization. Once your hospital stay has been authorized, they will give your physician a prior authorization number. If you need emergency care, go directly to the nearest hospital or emergency facility without worrying about finding a participating facility. If you are admitted into the hospital, you or the hospital’s admitting staff need to call Horizon HMO to let them know.
Behavioral Health and Substance Abuse Care Horizon Behavioral Health is responsible for the management of your behavioral health benefit. This benefit includes treatment for mental health conditions and alcohol/substance abuse. An extensive network of participating providers will provide behavioral health and substance abuse services (including treatment of alcoholism). A referral is not required to access behavioral health and substance abuse treatment. Please refer to page 32 for details.
Accessing Behavioral Health and Substance Abuse Care For assistance with behavioral health or alcohol/substance abuse care, please call Horizon Behavioral Health at 1-800-991-5579. The phone number is on the back of your Horizon HMO ID card. Behavioral health and substance abuse care is available 24 hours a day, seven days a week. All calls are confidential.