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• A physician, nurse provider, or clinical nurse specialist;

• A health care professional such as a registered dietician that is recognized as a Certified Diabetes Educator by the American Association of Diabetes Educators; or

• A registered pharmacist in New Jersey qualified with regard to management education for diabetes by any institution recognized by the Board of Pharmacy of the State of New Jersey.

Benefits are provided for expenses incurred for insulin pumps for the treatment of diabetes, if recommended or prescribed by a physician or nurse provider/clinical nurse specialist.

Dialysis Dialysis is covered when the services are provided and billed by an eligible hospital, by a freestanding dialysis center, or by an eligible home health care agency. The facility must make arrangements for training, equipment rental, and supplies on behalf of the patient. Home dialysis will be considered when there is documented evidence that the services cannot be performed in an outpatient facility. Ambulance transportation/invalid coach service to and from dialysis sessions is not eligible for coverage.

Durable Medical Equipment and Supplies Charges for the rental of durable medical equipment needed for therapeutic use are covered. Horizon HMO may cover the purchase of such items when it is less costly and more practical than renting such items. The rental or purchase of any items that do not fully meet the definition of durable medical equipment is not covered. It is recommended that costly durable medical equipment be approved by Horizon HMO prior to purchase.


Horizon HMO, Horizon HMO 1525, and Horizon HMO 2030 members must satisfy a $100.00 per person per calendar year deductible for Durable Medical Equipment and Medical Appliances/Equipment (DME). A separate deductible for DME does not apply for HMO2035 members; however, these services are subject to the in-network deductible under this plan.

Horizon HMO also covers eligible supplies including surgical dressings, blood and blood plasma, artificial - limbs, larynx and eyes, casts, Inherited Metabolic Disease medical food, certain non-standard infant formula (under one year of age), splints, trusses, braces, crutches, respirator oxygen and rental of equipment for its use. Deluxe models of durable medical equipment items such as, but not limited to, wheelchairs are not eligible for benefits.

Emergency Medical Services Horizon HMO covers you for medical emergency care, 24 hours-a-day, seven days-aweek. Emergency care is 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 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:

• 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.

Less severe medical problems and chronic conditions may be more appropriately handled by your PCP in his/her office.

Medical Emergency Screening Exam Sometimes you may not be sure if your condition requires emergency care. The Horizon HMO covers a medical emergency screening exam, which is an evaluation, performed in a hospital Emergency Room (ER) by qualified health care personnel, to determine if a medical emergency exists. The cost of the medical emergency screening exam will be covered. However, if it is determined that an emergency does not exist, please follow up with your PCP for instructions.

Medical Emergency Procedures

If you reasonably believe that your medical condition is a medical emergency, please follow the steps below:

1. Go directly to the nearest ER or call 911 or your local emergency response number;


2. Call your PCP, if possible. In some situations, you may be able to call before you go to the ER. If you can’t, call your PCP as soon as reasonably possible. If you are unable to make the call, please have a family member or friend call on your behalf.

It is important that your PCP be kept aware of your condition. Without this information, your PCP cannot coordinate your care.

You do not need to call member services to notify them of a medical emergency.

If it is determined that your visit was not a medical emergency, you may be responsible for all expenses with the exception of the cost of the medical emergency screening exam.

Each time the member uses the hospital emergency room, the member must pay a copayment. If the member is admitted within 24 hours, the copayment amount is waived.

There may also be additional medical charges for out-of-network emergency rooms that may not be reimbursed in full.

Urgent and After Hours Care Urgent care is medically necessary care for an unexpected illness or injury that should be treated within 24 hours but is not life-threatening. It is medical care you can safely postpone until you can call your PCP. Examples of urgent care include fever, earache, cuts, sprains, and minor burns. In instances like these, call your PCP first for instructions. If your PCP determines your situation is a medical emergency, he or she will refer you directly to an emergency facility. If it is not a medical emergency, your PCP will tell you how to treat the problem yourself or make an appointment to see you. Your physician or a covering physician should be available 24 hours a day, every day.

Contact your PCP for after-hours care or care that is required at night or on a weekend or holiday. Your PCP will provide instructions on how to treat your problem.

Federal Government Hospitals Horizon HMO will pay for eligible charges in hospitals operated by the United States government (Veterans Administration) as if they were member hospitals, regardless of their location, for eligible charges for nonmilitary conditions.

Horizon HMO will pay hospitals operated by the United States government for nonmilitary patients (i.e., patients other than military retirees and their dependents and

dependents of active duty military personnel) for eligible charges only if:

• Services are for treatment on an emergency basis for accidental injury from an external cause; or

• Services are provided in a hospital located outside of the United States and Puerto Rico.


Gynecological Care and Examinations Gynecological care and examinations are eligible. Horizon HMO provides coverage for one routine gynecological examination per year which may include one routine Pap smear, when provided by a gynecologist. No referral is required for one routine gynecological examination per year.

Hearing Aids Coverage will be provided for medically necessary expenses incurred in the purchase of a hearing aid for covered members who are 15 years old or younger. Coverage is provided for the purchase of a hearing aid for each hearing impaired ear once in a 24 month period, when it is medically necessary and prescribed by a licensed physician or audiologist. Benefits during each 24-month period are limited to the cost of the hearing aid up to $1,000 for each hearing impaired ear. If a higher priced hearing aid is selected, the member is responsible for the amount that is greater than $1,000.

Hemophilia Treatment Hemophilia treatment is covered in an inpatient facility or outpatient facility. Home hemophilia treatment will be considered when there is documented medical evidence that these services cannot be performed in an outpatient facility.

Home Health Care Home health care services and supplies are covered only if furnished by providers on a part-time or intermittent basis, except when full-time or 24-hour service is needed on a short-term basis. Precertification is required for these services. Home health care will be covered up to a maximum of 120 days. The home health care plan must be established in writing by the member's provider within14 days after home health care starts and it must be reviewed by the member's provider at least once every 30 days.

Eligible home health services (subject to exclusions) provided by a home health care

agency include:

• Part-time skilled nursing services provided by or under the supervision of a registered professional nurse (R.N.).

• Physical therapy.

• Occupational therapy.

• Speech therapy.

• Related treatment and services eligible for hospital benefits, except drugs and administration of hemodialysis.

• Medical social services or part-time services by a home health care aide during the period when you are receiving eligible skilled nursing care, physical therapy, or speech therapy services.

38 — HORIZON HMO MEMBER HANDBOOK A prior inpatient hospital stay is not required to qualify for home health care agency benefits but the patient must be homebound and require skilled nursing care under a plan prescribed by an attending physician.

Horizon HMO does not cover:

• Services furnished to family members, other than the patient.

• Services provided by a companion.

• Services and supplies not included in the home health care plan.

• Nursing home care or care that is maintenance care, supportive care, care to treat deficiencies that are developmental in nature or are primarily custodial care in nature.

Hospice Care Benefits Benefits for hospice care must be provided according to a physician prescribed course of treatment approved by Horizon HMO with a confirmed diagnosis of terminal illness and a life expectancy of six (6) months or less.

The following hospice services are covered:

• Interim professional nursing services of an R.N. or L.P.N.

• Home health care aide services provided under the supervision of an R.N.

• Medical care rendered by a hospice care program physician and/or the patient’s PCP.

• Therapy services (including speech, physical and occupational therapies).

• Diagnostic services related to the hospice member’s condition.

• Medical and surgical supplies.

• Durable medical equipment.

• Prescribed drugs.

• Oxygen and its administration.

• Up to 7 days for respite care.

• Inpatient acute care for related conditions.

• Medical social services.

• Psychological support services to the terminally ill patient.

• Family counseling related to the eligible person's terminal condition.

• Dietician services related to the hospice member’s condition.

• Inpatient room, board and general nursing services for related conditions.


No benefit consideration will be given for any of the following hospice care benefits:

• Medical care rendered by a provider other than the hospice or the member’s PCP without certification.

• Volunteer services.

• Pastoral services.

• Homemaker services.

• Food or home-delivered meals.

• Non-authorized private-duty nursing services.

• Dialysis treatment not utilized for pain management.

• Bereavement counseling.

• Private duty nursing services

• Legal or financial counseling or services.

• Treatment not included in the Hospice Care Program.

Inpatient benefits for hospice patients are provided at the same level as those provided for non-hospice patients. For more information on hospice care, please call Horizon HMO at 1-800-414-7427.

Immunizations Immunizations provided by in-network physicians or contracted New Jersey pharmacies are covered under Horizon HMO unless they are for travel outside the country or workrelated.

Infertility Treatment Horizon HMO will follow the New Jersey State Mandate for Infertility.

Charges made for services related to diagnosis of infertility and treatment of infertility

once a condition of infertility has been diagnosed. Services include, but are not limited to:

approved surgeries and other therapeutic procedures that have been demonstrated in existing peer-reviewed, evidence-based, scientific literature to have a reasonable likelihood of resulting in pregnancy (including microsurgical sperm aspiration); laboratory tests; sperm washing or preparation; diagnostic evaluations; assisted hatching; fresh and frozen embryo transfer; ovulation induction; gamete intrafallopian transfer (GIFT); in vitro fertilization (IVF), including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate; zygote intrafallopian transfer (ZIFT); artificial insemination; intracytoplasmic sperm injection (ICSI); and the services of an embryologist. This benefit includes diagnosis and treatment of both male and female infertility.

40 — HORIZON HMO MEMBER HANDBOOK Eligibility Requirements Infertility services are covered for any abnormal function of the reproductive systems

such that you are not able to:

• Impregnate another person;

• Conceive after two years if the female partner is under 35 years old, or after one year if the female partner is 35 years old or older, or if one partner is considered medically sterile; or

• Carry a pregnancy to live birth.

In vitro fertilization, gamete transfer and zygote transfer services are covered only:

• If you have used all reasonable, less expensive and medically appropriate treatment and are still unable to become pregnant or carry a pregnancy;

• Up to four completed egg retrievals combined. Egg retrievals covered by another plan or the member (outside of the SHBP/SEHBP) will not be applied toward the SHBP/SEHBP limit for infertility services; and

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