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This birthday rule regulation affects all carriers and all contracts which contain COB provisions. It applies only if both contracts being coordinated have the birthday rule provision. If only one contract has the birthday rule and the other has the gender rule (father's contract is always primary), the contract with the gender rule will prevail in determining primary coverage.

• If two or more plans cover a person as a dependent child of separated or divorced parents, benefits for the dependent child will be determined in the following order.

✔ The plan of the parent with custody is primary; followed by ✔ The plan of the spouse/partner of the parent with custody of the child; then ✔ The plan of the parent not having custody of the child.

• If it has been established by a court decree — Qualified Medical Child Support Order (QMCSO) — that one parent has responsibility for the child's health care expenses, then the plan of that parent is primary.

• If none of the rules listed above determine the order of benefits, the plan that has covered the patient for the longer period is the primary plan.

• Horizon HMO will provide its regular benefits in full when it is the primary plan.

• As a secondary plan, Horizon HMO, Horizon HMO 1525 and Horizon HMO 2030 will provide reimbursement up to its regular benefit which when added to the benefits under other group plans will not exceed 100 percent of the member’s liability.

• As a secondary plan, Horizon HMO 2035 uses a non-duplication of benefits approach to COB. When Horizon HMO 2035 is secondary to another health plan, Horizon HMO 2035 will only provide reimbursement up to the normal liability if we had been primary.

The secondary benefit payment under non-duplication COB is determined by calculating the Horizon HMO 2035 normal liability then subtracting the other (primary) health plan payment, and paying the remaining amount, if any. If the primary health plan benefit is the same as or higher than the Horizon HMO 2035 benefit, no secondary payment will be made.

Please note: The Coordination of Benefits rules described above may change if Medicare is involved. Please refer to the Medicare sections on page 14 and page 29 for more information.


This section lists the general treatments, services, and supplies that Horizon HMO will consider. Expenses for these services or supplies are subject to medical need and appropriate level of care; utilization review; the Schedule of Services and Supplies; and benefit limitations and exclusions. A “Summary Schedule of Services and Supplies” is on page 83 for your reference. Select services require prior authorization (see page 22 for details).

30 — HORIZON HMO MEMBER HANDBOOK Allergy Testing and Treatment Most commonly used methods of allergy testing are covered. However, some methods are subject to medical need at the appropriate level of care and will be reviewed before eligibility can be determined.

Ambulance Ambulance use for local emergency transport to the nearest facility equipped to treat the emergency condition is covered subject to medical need at the appropriate level of care.

If emergency air transport is needed, it must be medically necessary and approved by having your physician call Horizon HMO at 1-800-664-2583.

Chartered air flights, non-emergency air ambulance, invalid coach, transportation services, or other travel, lodging, or communication expenses of patients, providers, nurses, or family members are not covered.

Audiology Services Audiology services are covered when rendered by a physician or a licensed audiologist, when such services are determined to be medically necessary and at the appropriate level of care. See exclusions for hearing aids and hearing examinations.

Autism or Other Developmental Disability

Chapter 115, P.L. 2009, requires that the SHBP/SEHBP provide:

• Coverage for expenses incurred in screening and diagnosing autism or another developmental disability;

• Coverage for expenses incurred for medically necessary physical therapy, occupational therapy and speech therapy services for the treatment of autism or another developmental disability;

• Coverage for expenses incurred for medically necessary behavioral interventions (ABA therapy) for individuals diagnosed with autism;

• A benefit for the Family Cost Share portion of expenses incurred for certain health care services obtained through the New Jersey Early Intervention System (NJEIS).

ABA therapy is not eligible for children with developmental diagnoses.

Horizon Behavioral Health must be contacted to precertify ABA services for autistic children.

Horizon HMO Utilization Management must be contacted for precertification by the provider requesting occupational therapy, speech, and physical therapy services.


Automobile-Related Injuries Horizon HMO will provide secondary coverage to your mandatory New Jersey Personal Injury Protection (PIP) unless Horizon HMO has been elected as the primary coverage by or for the employee covered under Horizon HMO. This election is made by the named insured under the PIP program and affects that member's family members who are not themselves the named insured under another auto policy. Horizon HMO may be primary for one member, but not for another if the individuals have separate auto policies and have made different selections regarding primacy of health coverage.

If Horizon HMO is primary to PIP or other automobile insurance coverage, benefits are paid in accordance with the terms, conditions, and limits set forth in your contract and only for those services normally covered under the HMO.

Please note: If you elect to have the Horizon HMO as primary to PIP, prior notification to Horizon HMO is not required. Upon receipt of an auto-related claim, the Horizon HMO will request the submission of written documentation, such as a copy of your policy declaration page, for verification of your selection.

The Horizon HMO is one of several health insurance plans which provide benefits for automobile-related injuries. If the covered employee has elected health coverage as primary, these plans may coordinate benefits as they normally would in the absence of this provision.

If the Horizon HMO is secondary to PIP, the actual benefits payable will be the lesser of:

• The remaining uncovered allowable expenses after PIP has provided coverage, subject to medical need at the appropriate level of care and other provisions, after application of deductibles and coinsurance, or

• The actual benefits that would have been payable had Horizon HMO been primary.

Behavioral Health and Substance Abuse Care Horizon Behavioral Health is responsible for the management of your behavioral health benefit. No referral is required to access treatment. This benefit includes treatment for both mental health conditions and alcohol/substance abuse provided by an eligible behavioral health provider and include in-patient, partial hospital, residential, intensive out-patient, out-patient, and group treatment. Eligible providers of behavioral health are Psychiatrists (MD), Licensed Psychologists (PhD), Licensed Clinical Social Workers (LCSW), Licensed Marriage and Family Therapists (LMFT), Licensed Professional Counselors (LPC), and Certified (Psychiatric), Nurse Practitioners working within the scope of their practice.

Precertification (prior to treatment) is required by Horizon Behavioral Health for all admissions. The Precertification process will determine if the treatment to be provided is medically appropriate and if it will be provided at the most appropriate level of care to fit 32 — HORIZON HMO MEMBER HANDBOOK your behavioral health needs. Horizon Behavioral Health medical necessity determinations for mental health services are supported by Horizon Medical Necessity criteria. Substance abuse determinations are supported by the American Society of Addictions Medicine (ASAM) guidelines. The precertification process through Horizon Behavioral Health is available 24 hours a day, 7 days a week.

To receive mental health or substance abuse treatment benefits, a participating provider must provide your care. Outpatient mental health and substance abuse care will generally be covered without the need for authorization by Horizon; for coverage of electroconvulsive therapy, biofeedback, psychological testing, and intensive outpatient treatment, you will need to follow the precertification process outlined above. In addition, authorization is required for coverage of any treatment that Horizon determines is not consistent with usual treatment practice for your condition (for example, frequency of sessions, duration of treatment, and other factors). Horizon will contact your provider to discuss your treatment and the authorization requirement that will be applied.

If the services that require precertification are provided before precertification is received, this may result in the denial of payment for services.

In addition to the precertification process, Horizon Behavioral Health will support your treatment and manage the services you are receiving to ensure that they are the most appropriate for your behavioral health needs and ensure that your treatment is supported by Horizon Behavioral Health Medical Necessity criteria and/or the American Society of Addictions Medicine (ASAM) criteria.

Call Horizon at 1-800-991-5579 and get assistance from a Member Advocate when you need help understanding your Behavioral Health benefits or navigating the range of services available. The Member Advocate will help you prioritize appropriate use of such services according to your need. Educational materials including information packets, articles, and screening tools are also available to you and providers online at www.horizonblue.com/shbp

Birthing Centers

As an alternative to conventional hospital delivery room care for low-risk maternity patients, Horizon HMO allows benefits for care in participating birthing centers. Services routinely provided by the birthing centers including prenatal, delivery, and postnatal care will be covered in full if the delivery takes place at the center. If complications occur and delivery occurs in an approved hospital because of the need for emergency or inpatient care, this care will also be covered in full.

Blood Blood, blood products, blood transfusions, and the cost of testing and processing blood are covered. Horizon HMO does not pay for blood which has been donated or replaced on behalf of the patient.


Breast Reconstruction If you are receiving benefits in connection with a mastectomy and elect to have breast reconstruction along with that mastectomy, Horizon HMO will provide coverage for the


• Reconstruction of the breast on which the mastectomy was performed.

• Prosthesis(es).

• Surgery and reconstruction of the other breast to produce a symmetrical appearance.

• Physical complications at all stages of the mastectomy, including lymphedemas.

Chiropractic Services There is a 20-visit per calendar year benefit maximum for chiropractic services. The chiropractor must be licensed, the services must be appropriate for the diagnosed condition(s), and must fall within the scope of practice of a chiropractor in the state in which he or she is practicing. No referral is needed to use the services of a chiropractor.

Chiropractic services are subject to a medical necessity review process.

Dental Care Horizon HMO provides benefits for the removal of bony impacted molars, and will pay for the treatment of accidental injuries, and treatment for mouth tumors if medically necessary.

Horizon HMO may provide coverage for the treatment of accidental dental injuries. You must have been covered by Horizon HMO at the time the injury occurred. An accidental dental injury is considered an injury to teeth (must be sound natural teeth) which is caused by an external factor such as damage caused by being hit by a hockey puck or having teeth broken in a fall on the ice.

The treatment and replacement must occur within 12 months of the accident. A treatment plan must be submitted. If it is determined that treatment cannot be reasonably completed within 12 months, this time limit may be extended. Breaking a tooth while chewing on food is not considered an accidental dental injury. Stress fractures in teeth are very common and generally undetectable by X-ray. Stress fractures are often the cause of tooth breakage. Treatment for this type of tooth breakage is considered a dental service and not eligible for reimbursement.

Dental services required as the result of medical conditions or medical services rendered such as: radiation, chemotherapy and long term use of prescription drugs are not eligible.

These dental services should be submitted to your Dental Plan.

Hospital and anesthesia charges incurred for dental services that are medically needed and at the appropriate level of care are covered for severely disabled members and children when convincing documentation is submitted in advance for the medical need for the hospitalization/anesthesia services. Charges for the actual dental procedures would not be eligible for benefits.

Orthodontia is not covered.

34 — HORIZON HMO MEMBER HANDBOOK Diabetic Self-Management Education Benefits, limited to four visits per year, are included for expenses incurred for diabetes self-management education to ensure that a person with diabetes is educated as to the proper self-management and treatment of the member's condition.

Benefits for self-management education and education relating to diet shall be limited to

medically necessary visits upon:

• The diagnosis of diabetes;

• The diagnosis by a physician or nurse provider/clinical nurse specialist of a significant change in your symptoms or conditions which necessitate changes in your self-management; and

• Determination by a physician or nurse provider/clinical nurse specialist that reeducation or refresher education is necessary.

Diabetes self-management education is covered when provided by:

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