«STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS Horizon HMO MEMBER HANDBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN ...»
• If you are 45 years old or younger.
• Where a live donor is used in the egg retrieval, the medical costs of the donor shall be covered until the donor is released from treatment by the reproductive endocrinologist.
• Intracytoplasmic sperm injections.
• In vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate.
• Prescription medications, including injectable infertility medications, are covered under the SHBP/SEHBP’s Prescription Drug Plans. Private freestanding prescription drug plans arranged by local employer groups are required to be comparable to the SHBP/SEHBP Prescription Drug Plans and must provide coverage for infertility medications for covered members and donors.
• Ovulation induction.
• Surgery, including microsurgical sperm aspiration.
• Artificial Insemination.
• Assisted Hatching.
• Diagnosis and diagnostic testing.
• Fresh and frozen embryo transfers
• Reversal of male and female voluntary sterilization.
• Infertility services when the infertility is caused by or related to voluntary sterilization.
• Non-medical costs of an egg or sperm donor. Medical costs of donors, including office visits, medications, laboratory and radiological procedures and retrieval, shall be covered until the donor is released from treatment by the reproductive endocrinologist.
• Cryopreservation is not a covered benefit.
• Any experimental, investigational, or unproven infertility procedures or therapies.
• Payment for medical services rendered to a surrogate for purposes of childbearing where the surrogate is not covered by the carrier’s policy or contract.
• Ovulation kits and sperm testing kits and supplies.
• In vitro fertilization, gamete intrafallopian tube transfer, and zygote intrafallopian tube transfer for persons who have not used all reasonable less expensive and medically appropriate treatments for infertility, who have exceeded the limit of four covered completed egg retrievals, or are 46 years of age or older. 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.
• Costs associated with egg or sperm retrieval not related to an authorized IVF procedure.
Laboratory Testing You must use LabCorp or AtlantiCare Clinical Laboratories for laboratory work. Your PCP may draw blood for the test in his/her office or send you to a participating laboratory for testing.
Your PCP may refer you directly to a LabCorp Patient Service Center. If so, he/she will give you a LabCorp Requisition Form to take with you. You may also use this form at AtlantiCare Clinical Laboratories. Please present the requisition form and your Horizon HMO ID card at the participating laboratory facility.
To find a LabCorp Patient Service Center near you, visit www.labcorp.com/psc or call 1-888- LAB-CORP (522-2677). You may also use the website to schedule an appointment.
AtlantiCare Clinical Laboratories has a special relationship with Horizon HMO and LabCorp. Horizon HMO members may use AtlantiCare Clinical Laboratories to draw laboratory specimens on behalf of LabCorp on an in-network basis. For more information and to locate the most convenient AtlantiCare testing center, visit our online Provider Directory at www.HorizonBlue.com or visit www.AtlantiCare.org — click Locations and then click Clinical Laboratories. Remember, if you do not use LabCorp or AtlantiCare 42 — HORIZON HMO MEMBER HANDBOOK Clinical Labs, you will not be covered. If you receive a bill for lab work from LabCorp or AtlantiCare Clinical Labs, please call Member Services at 1-800-414-7427 (SHBP).
Lead Poisoning Screening and Treatment No copayment applies to in-network screenings.
Lithotripsy Centers Lithotripsy services are covered when they are performed in an approved hospital or lithotripsy center.
Lyme Disease Intravenous Antibiotic Therapy All intravenous antibiotic therapy for the treatment of Lyme Disease requires precertification. When intravenous therapy is determined to be medically appropriate, the supplies, cost of the drug, and skilled nursing visits will be covered services. If services are not precertified and are determined not to be medically necessary, the services will not be covered.
Covers mammograms provided to a female member. Coverage is provided as follows:
• One baseline mammography at any age.
• Age forty and older, one screening mammography per year.
Mastectomy Benefits A hospital stay of at least 72 hours following a modified radical mastectomy and a hospital stay of at least 48 hours is covered following a simple mastectomy unless the patient, in consultation with the physician, determines that a shorter length of stay is medically needed and at the appropriate level of care.
Maternity/Obstetrical Care Medical care related to childbirth includes the hospital delivery and hospital stay for at least 48 hours after a vaginal delivery or 96 hours after a cesarean section if the attending provider determines that inpatient care is medically needed and at the appropriate level of care.
Services and supplies provided by a hospital to a newborn child during the initial covered hospital stay of the mother and child are covered as part of the obstetrical care benefits.
Horizon HMO also covers birthing center charges made by a provider for pre-natal care, delivery, and post-partum care in connection with a member's pregnancy.
Professional charges, billed by an eligible provider, related to the prenatal care, delivery and postnatal care for home birth are covered.
Note: Providers do not routinely perform home births. The availability of a provider who performs home births is not guaranteed.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —Maternity/Obstetrical Care for Child Dependents In some instances, Horizon HMO will pay bills related to the birth of a grandchild. In order for benefits to be available, the mother must be enrolled as a covered child.
Coverage for the grandchild ends when the mother is discharged from the hospital. The grandparent may apply for dependent coverage of the grandchild only if he or she obtains legal custody of the child.
Nutritional Counseling The HMO allows three visits per year for nutritional counseling that is medically needed and at the appropriate level of care.
Occupational Therapy (See Therapy Services) Organ Transplant Benefits
Pre-approved services and supplies for the following types of transplants are covered:
• Bone marrow/stem cell (autologous and allogeneic)
• Combination liver/kidney
• Combination heart/bilateral lung
• Kidney If you need a transplant, the Horizon HMO dedicated case management team is available to assist you and your physician. For more information on Horizon HMO’s participating local and national transplant facilities, call 1-888-621-5894 extension 46404.
Benefits only include surgical, storage and transportation services of the organ which are directly related to the donation and billed for by the hospital.
Pain Management Pain management services are subject to current medical guidelines and policies. Pain management therapy administered by a licensed physician must be supported by a comprehensive evaluation of the patient and documentation of the rationale for treatment. The treatment of pain is multifaceted and may include therapeutic exercises, activity modification, physical therapy, occupational therapy, pharmacological interventions, behavioral health interventions, therapeutic and/or surgical interventions.
Treatment may not achieve complete elimination of a patient’s pain. In such cases, an increase in a patients’ level of function and teaching the patient strategies to cope with residual pain will be the goal. If treatment offers no appreciable improvement in the patient’s condition, further services may be considered maintenance and/or supportive care and will not be eligible for reimbursement.
44 — HORIZON HMO MEMBER HANDBOOK Horizon HMO contracts with CareCore National LLC to review and authorize pain management services. Monitored anesthesia rendered as part of pain management services must also be authorized. Your network physician will obtain prior authorization on your behalf. Your physician can contact CareCore at 1-866-241-6603 to request authorization.
If you or your physician do not obtain prior authorization for pain management services, those services will not be eligible for reimbursement. If services are rendered without the proper authorization, benefits will be denied. A retroactive benefit review will not be conducted.
Pap Smears Annual Pap smears provided by your participating OB/GYN are covered at the in-network level of benefits. This benefit is limited to one Pap smear per year unless additional tests are medically needed and at the appropriate level of care for diagnostic purposes.
Patient Controlled Analgesia (PCA)
Patient Controlled Analgesia (PCA) is covered when it is medically appropriate, prescribed by a medical doctor, and provided under the guidance of one of the following:
• Anesthesiologist; or
• Approved home care agency.
Physical Therapy (See Therapy Services) Physicals One routine physical examination for you and your eligible dependents is covered per year. No copayment applies if the sole reason for the visit is to receive preventive services as noted by the procedure and diagnosis code reported by the provider.
Physicals for work-related purposes — other than employer mandated physical examinations that are a prerequisite for participation in an employer mandated physical fitness test required as a condition of continuing employment — sports, or other similar reasons are not covered.
Pre-Admission Hospital Review All non-emergency hospital and other facility admissions must be reviewed by Horizon HMO before they occur. You or the network hospital or your provider must notify Horizon HMO and request a Pre-Admission Review by phone or facsimile. Horizon HMO must receive the notice and request at least 5 business days or as soon as reasonably possible before the admission is scheduled to occur. For a maternity admission, such notice must be given to Horizon HMO at least 60 days before the expected date of delivery, or as soon as reasonably possible, to obtain in-network benefits.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —Pre-Admission Testing Charges Pre-admission diagnostic X-ray and laboratory tests needed for a planned hospital admission or surgery are covered. Horizon HMO only covers these tests if the tests are done on an outpatient or out-of-hospital basis within seven days of the planned admission or surgery.
However, Horizon HMO does not cover tests that are repeated after admission or before surgery, unless the admission or surgery is deferred solely due to a change in the member's health.
Prostate Cancer Screening One routine office visit per year is covered for adult members, including a digital rectal examination and a prostate-specific antigen test for adult male members over the age of 40.
Radiology/Diagnostic Imaging Services CareCore National, LLC provides you with access to nonemergency outpatient radiology/ diagnostic imaging services. CareCore, a physician-owned radiology management service company, will help schedule and manage your outpatient radiology/diagnostic imaging services, including determining whether a service is medically necessary. Your ordering physician must call CareCore at 1-866-496-6200, before you receive any of the
Advanced Imaging Services listed below:
� CT/CTA scans � Diagnostic left heart catheterization � Echocardiogram � Echo stress � MRIs/MRAs � PET scans � Nuclear medicine studies (including Nuclear Cardiology) Once the test is approved, CareCore will contact you to schedule the procedure at a participating rendering location. When possible, CareCore will conduct a three-way call with you and the rendering location to coordinate the scheduling process. You may call CareCore directly at 1-866-969-1234 to schedule the approved procedure. You will also receive a letter from CareCore confirming the scheduled appointment.
You may schedule all other radiology services through CareCore’s easy-to-use Scheduling Line. The Scheduling Line replaces the referral process. The scheduling staff will coordinate with the participating radiology/diagnostic imaging center of your choice to schedule your exam and provide you with a confirmation number. To make an appointment and get a confirmation number, please call the Scheduling Line toll free at 1-866-969-1234, Monday through Friday, between 7 a.m. and 7 p.m., Eastern Time (ET).
For more information, please call your dedicated SHBP/SEHBP customer service area Member Services at 1-800-414-7427.
46 — HORIZON HMO MEMBER HANDBOOK Scalp Hair Prostheses A benefit maximum of $500 in a 24-month period subject to the annual $100 deductible, per person, is covered for scalp hair prostheses (wig) prescribed by a doctor, only if they are furnished in connection with hair loss resulting from the treatment of disease by radiation or chemicals.
Second Surgical Opinion Horizon HMO provides coverage for a second physician's personal examination of a patient following a recommendation for any eligible surgical procedure. Horizon HMO will pay for one consultation by a qualified specialist physician.
If the second opinion specialist does not confirm the need for surgery, Horizon HMO will provide coverage for one additional consultation if requested by the patient. Horizon HMO also will provide coverage for any diagnostic X-rays, laboratory tests, or diagnostic surgical procedures required by the physicians performing the consultations.