«STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS Horizon HMO MEMBER HANDBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN ...»
Shock Therapy Benefits Horizon HMO provides benefits for electroshock treatments, insulin shock treatments, and other similar treatments. Benefits are also payable for anesthesia in connection with the shock treatment and for all other eligible services performed on that day for the disorder.
Skilled Nursing Facility Charges Room and board, including diets, drugs, medicines and dressings, and general nursing services in a skilled nursing facility are covered.
For Medicare Primary Members — the eligible benefit days run concurrently with Medicare eligible days. Once Medicare days are exhausted and Horizon HMO becomes primary, Horizon HMO will review continuing services for medical appropriateness and eligibility. Precertification is required after Medicare benefits are exhausted or if Medicare does not allow benefits.
Speech Therapy Benefit (see Therapy Services) Surgery Surgical procedures performed by a network physician with the appropriate referral from your PCP are covered under the Horizon HMO.
Therapy Services Therapy Services are covered when ordered by a network provider and performed by a network practitioner. The services must be medically necessary and appropriate for the treatment of the member’s illness or injury.
Therapy Services means the following services and supplies:
• Chelation Therapy — the administration of drugs or chemicals to remove toxic concentrations of metals from the body.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —
• Chemotherapy — the treatment of malignant disease by chemical or biological antineoplastic agents.
• Cognitive Rehabilitation Therapy — retraining the brain to perform intellectual skills which it was able to perform prior to disease, trauma, Surgery, congenital anomaly or previous therapeutic process.
• Dialysis Treatment — the treatment of an acute renal failure or chronic irreversible renal insufficiency by removing waste products from the body. This includes hemodialysis and peritoneal dialysis.
• Infusion Therapy — the administration of antibiotic, nutrient, or other therapeutic agents by direct infusion.
• Occupational Therapy* — treatment to restore a physically disabled person's ability to perform the ordinary tasks of daily living.
• Physical Therapy* — the treatment by physical means to relieve pain, restore maximum function, and prevent disability following disease, injury, or loss of limb.
*See note at bottom of page.
• Radiation Therapy — the treatment of disease by x-ray, radium, cobalt, or high energy particle sources. Radiation Therapy includes rental or cost of radioactive materials.
Diagnostic Services requiring the use of radioactive materials are not Radiation Therapy.
• Respiration Therapy — the introduction of dry or moist gases into the lungs.
• Speech Therapy* — therapy that is rendered by a qualified speech therapist and is
✓ Restore speech after a loss or impairment of a demonstrated previous ability to speak. Two examples of speech therapy that will not be covered are: (a) therapy to correct pre-speech deficiencies; and (b) therapy to improve speech skills that have not fully developed.
✓ Develop or improve speech to correct a defect that both (a) existed at birth and (b) impaired or would have impaired the ability to speak.
Speech therapy to correct pre-speech deficiencies or to improve speech skills that have not fully developed are not covered except for Autism and Pervasive Development Disorder (PDD).
*Note: Coverage for physical therapy, speech therapy and occupational therapy is limited to 60 visits per calendar year for all three therapies combined, except that therapy services rendered for a diagnosis of autism or developmental disability will have no limit to the number of visits.
Vision Care Benefits Horizon HMO covers an annual routine eye examination by a network ophthalmologist or optometrist. There are no benefits available for frames, lenses, or contact lenses. Contact lens fitting examinations are also not covered. No referral is needed for an annual routine vision examination.
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CHARGES NOT COVERED BY HORIZON HMOEven though a service or supply may not be described or listed in this handbook, that does not make the service or supply eligible for a benefit under this plan.
The following services and supplies are not covered:
• Automobile accident-related injuries or conditions: Unless Horizon HMO has been chosen by the member as primary, Horizon HMO does not pay for the treatment of injuries or conditions related to an automobile accident if automobile insurance could have or should have covered the treatment. This exclusion applies to, but is not limited
✔ Existing motor vehicle insurance contracts;
✔ Motor vehicle contracts that were purchased but have since lapsed;
✔ Motor vehicle insurance coverage that should have been purchased; and ✔ Failure to make timely claims under a motor vehicle insurance policy.
• Any therapy not included in the definition of Therapy Services.
• Blood or blood plasma or other blood derivatives or components which are replaced by a Member.
• Broken appointments.
• Car Seats.
• Chair and stair lifts.
• Charges that exceed the Plan allowance. This includes all charges for chiropractic services beyond the 20 visit maximum benefit per calendar year.
• Charges billed by an Assisted Living Facility.
• Charges for services or supplies not specifically covered under the plan.
• Charges for services rendered by a member of the patient’s immediate family (including you, your spouse/domestic partner, your child, brother, sister, or parent or grandparent of you or your spouse/domestic partner).
• Charges for services rendered by a Birth Doula.
• Charges for the completion of a claim form, photocopies of pertinent medical information, medical records or report preparation.
• Charges the Member or his Dependent is not legally obligated to pay.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —
• Charges in connection with an external review of an appeal or complaint.
• Charges incurred prior to or in the course of a legal adoption.
• Charges that should have been paid by Medicare, if Medicare coverage had been in effect.
• Christian Science.
• Cosmetic Surgery, unless it is required as a result of an injury or to correct a functional defect resulting from a congenital abnormality or developmental anomaly; complications of cosmetic surgery; drugs prescribed for cosmetic purposes.
• Cosmetic procedures — charges connected with curing a condition by cosmetic procedures. This provision does not apply if the condition is due to an accidental injury
that occurred while the injured person is enrolled in Horizon HMO. Among the services that are not covered are:
✔ Removal of warts, with the exception of plantar warts;
✔ Spider vein treatment; and ✔ Plastic surgery when performed primarily to improve the person's appearance.
• Costs beyond the embryo transfer for a surrogate are not eligible.
• Court ordered services or treatments.
• Custodial care or domiciliary care.
• Deluxe models of wheelchairs and other durable medical equipment.
• Dental care or treatment and appliances (other than accidental injury as described on
page 34), including but not limited to the following:
✔ Dental prosthesis;
✔ Operative restorations;
✔ Medical or surgical treatment of dental caries;
✔ Outpatient and Out-of-Hospital dental treatment;
✔ Radicular or dentigerous cysts;
✔ Extractions of teeth; and ✔ Dental implants.
50 — HORIZON HMO MEMBER HANDBOOK
• Durable medical equipment or supplies which are specifically excluded from coverage.
• Education or training while a Member is confined in an institution that is primarily an institution for learning or training.
• Educational or developmental services or supplies, or educational testing. This includes services or supplies that are rendered with the primary purpose being to
provide the person with any of the following:
✔ Training in the activities of daily living. This does not include training directly related to the treatment of an illness or injury that resulted in a loss of a previously demonstrated ability to perform those activities.
✔ Instruction in scholastic skills such as reading and writing.
✔ Preparation for an occupation.
✔ Treatment for learning disabilities.
✔ To promote development beyond any level of function previously demonstrated.
✔ Assessments/testing of academic function.
✔ Services and supplies are not covered to the extent that they are determined to be allocated to the scholastic education or vocational training of the patient regardless of where services are rendered. Rehabilitation programs that are primarily educational or behavioral in nature.
• Expenses for wilderness rehabilitation programs, diabetic camps, or other similar camps or programs.
• Experimental or investigational treatments, procedures, hospitalizations, drugs, biological products or medical devices and charges in connection with such treatment, services or supplies (see page 23).
• Eye care including:
✔ Lenses of any type except initial lens replacement for loss of the natural lens after cataract surgery.
✔ Eyeglasses and contact lenses regardless of the diagnosis, including but not limit to Kerataconus.
✔ Low vision aids.
✔ Orthoptics-exercises designed to improve eye movement disorders including, but not limited to, strabismus (squint) and amblyopia (lazy eye).
• Eye surgery, such as radial keratotomy, Lasik procedures, or other refractive procedures performed for any reason.
• Facility charges, e.g., operating room, recovery room and use of equipment, when billed for by a Provider that is not an Eligible Facility.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —
• Food products (including externally administered food products, except when used as the sole source of nutrition). This exclusion does not apply to the foods, food products and specialized non-standard infant formulas that are eligible for coverage in accordance with the treatment of Inherited Metabolic Diseases and Specialized NonStandard Infant Formulas.
• Routine foot care including treatment for bunions, corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, subluxations of the foot, symptomatic complaints of the feet, orthopedic shoes, the casting for orthotics and any appliances except orthotics. This exclusion does not apply to capsular or bone surgery.
• Government plan charges including a charge for a service or supplies:
✔ Furnished by or for the United States government.
✔ Furnished by or for any government, unless payment is required by law; or ✔ To the extent that the service or supply, or any benefit for the charge, is provided by any law or government under which the member is or could be covered. This applies to Medicare and “no-fault” medical and dental coverage when required in contracts by a motor vehicle or similar law.
• Health clubs and gym memberships.
• Hearing aids of any type (except as described under “Hearing Aids” on page 38).
• Hearing examinations - to determine the need for hearing aids, the purchase, repair and maintenance of hearing aids, and the need to adjust them, except as otherwise provided in Grace's Law/Hearing Aids and Related Services and Newborn Hearing Screening.
• Herbal, Alternative or Complementary medicine and treatments.
• Incidental Procedures — certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is considered part of the primary procedure in order to successfully complete service.
• Infertility enhancement treatments, except as stated on page 41.
• Legal fees.
• Local anesthesia charges billed separately by a Practitioner for surgery performed on an outpatient basis.
• Maintenance care — care that has reached a level where additional services will not appreciably improve the condition.
• Maintenance therapy for:
52 — HORIZON HMO MEMBER HANDBOOK ✔ Physical Therapy;
✔ Therapeutic Manipulation;
✔ Occupational Therapy; and ✔ Speech Therapy.
• Marriage, career or financial counseling, and sex therapy.
• Medical Emergency services when not rendered by a physician, and related supplies.
• Medicare services rendered by providers who are not registered with or who opt-out of Medicare.
• Membership costs for health clubs, weight loss clinics and similar programs.
• Methadone maintenance treatment or programs.
• Milieu Therapy: Inpatient services and supplies which are primarily for milieu therapy, even though eligible treatment may also be provided. This means that Horizon HMO has determined that the purpose of an entire or portion of an inpatient stay is chiefly to change or control a patient’s environment; and an inpatient setting is not medically necessary and appropriate for the treatment provided, if any.
• Modifications to an auto to make it accessible and/or drivable.
• Modifications to a home to make it accessible for a disabled/injured person.