Annual Material Updates

Your updated member materials are available!

Thank you for being a member of Horizon NJ Health. With more than 85 years of experience, you can count on us to help you on your journey to better health.

We have quick and easy access to your updated plan information:

To request a hard copy of any of these materials, call us at 1-800-682-9090 (TTY 711).

Sign in to horizonNJhealth.com:

  • Change your Primary Care Provider (PCP)
  • Enroll in the Mom’s GEMS prenatal program
  • Request a new member ID card
Tikka Attach

1. How do I know if a doctor or dentist
is a Horizon NJ Health provider?

Answer: A copy of the Provider Directory for your
area is included in your Welcome Kit. A Provider
Directory is a list of Horizon NJ Health providers,
dentists, hospitals and specialists. We will send
you a new directory every year. Member Services
will also mail you a copy whenever you wish.
A searchable Provider Directory is also available
on our website at horizonNJhealth.com.

2. Can I go to a doctor or dentist who
is not a part of Horizon NJ Health?

Answer: You must use a provider who is
contracted with Horizon NJ Health. Each member
chooses or is assigned a Primary Care Provider
(PCP). Your assigned PCP will coordinate all of
your health care needs. If you receive care from
a provider who does not participate with Horizon
NJ Health without our approval, you may be
responsible for the cost of the care.

3. Can I change my PCP?
Answer: Call Member Services at 1-800-682-9090
(TTY 711) and they will help you choose a new
PCP. You will get a new member ID card with the
updated information. If you need to visit your PCP
before you receive your new card, let Member
Services know, and they will help you.

4. Do I need a referral to see a specialist?
Answer: Yes. All visits to a specialist must be
coordinated with your PCP. Your PCP can send
an electronic referral to the specialist or give
you one to bring with you. You do not need
a referral to visit a dentist, Ob/Gyn, to have
routine eye care or to get a mammogram.

5. Do I have dental coverage?
Answer: Yes. Your dental coverage is shown on
your Horizon NJ Health member ID card.

6. If I have an emergency and the nearest
hospital is not a part of Horizon NJ Health,
will I have to pay the bill?

Answer: No. In case of an emergency, always
go to the nearest hospital for care. You do not
need to get approval from Horizon NJ Health
to go to the Emergency Room (ER).

7. What do I do if I get a bill from a doctor?
Answer: You should not receive bills for
services covered by your plan. If you do get
a bill, call Member Services at 1-800-682-9090
(TTY 711). They will give you instructions
on what to do.

Member Services is available 24 hours a day, seven days a week, to help answer any
questions about your Horizon NJ Health benefits. Call toll free at 1-800-682-9090
(TTY 711) to speak with a representative today.

Top 10 Questions
Asked by New Members

(continued on reverse)



8. How do I keep my coverage?
Answer: NJ FamilyCare members need to renew
their eligibility every year. Failure to renew in
a timely manner may result in termination of
eligibility. Contact your county caseworker or
the NJ FamilyCare Health Benefits Coordinator
at 1-800-701-0710 (TTY 1-800-701-0720) for
your renewal dates.

9. How do I enroll my newborn?
Answer: To enroll your newborn baby,
call NJ FamilyCare at 1-800-701-0710
(TTY 1-800-701-0720). Your child must
be enrolled in NJ FamilyCare to be enrolled
in Horizon NJ Health.

10. What is the phone number
for NJ FamilyCare?

Answer: The State?s Health Benefits Coordinator
for NJ FamilyCare can be reached toll free at
1-800-701-0710. Hearing impaired members can
call the TTY number at 1-800-701-0720.

horizonNJhealth.com

Products are provided by Horizon NJ Health. Communications are
issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity
as administrator of programs and provider relations for all its companies.
Both are independent licensees of the Blue Cross and Blue Shield
Association. The Blue Cross? and Blue Shield? names and symbols are
registered marks of the Blue Cross and Blue Shield Association. The
Horizon? name and symbols are registered marks of Horizon Blue Cross
Blue Shield of New Jersey. ?2019 Horizon Blue Cross Blue Shield
of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105.

ATTENTION: If you speak a language other than English,
language assistance services, free of charge, are available to you.
Call 1-800-682-9090 (TTY 711). This document is also available in other
languages, as well as other formats, such as large print and Braille.
Horizon NJ Health complies with applicable Federal civil rights laws and does not discriminate on the basis
of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or
health status in the administration of the plan, including enrollment and benefit determinations.
Spanish (Espa?ol): Para ayuda en espa?ol, llame al 1-800-682-9090 (TTY 711).
Chinese (??)??????????? 1-800-682-9090 (TTY 711)?

Member Services 1-800-682-9090 (TTY 711)



2019
Member Handbook

horizonNJhealth.com



horizonNJhealth.comMember Services: 1-800-682-90901

Welcome What?s Inside
You and your family deserve quality health care
coverage. With Horizon NJ Health, you can count
on it. Horizon NJ Health covers NJ FamilyCare
program benefits plus additional benefits, special
health programs and your personal doctor. You
also get the special comfort of knowing that you
are with the plan backed by Horizon Blue Cross
Blue Shield of New Jersey. And the best part is
that all of this is covered at little or no cost to you.

Thank you for joining Horizon NJ Health. You
made a great health plan choice for you and
your family. Please look through this Member
Handbook and keep it in case you need it
at a later date. This handbook will help you

understand all the benefits that are available to
you and your family.

Remember, if you have questions any time ? day
or night ? call our Member Services department
toll free at 1-800-682-9090 (TTY 711). Someone
is ready to help you 24 hours a day, seven days
a week.

You may also write to Horizon NJ Health at:

Horizon NJ Health
Member Outreach Department
250 Century Parkway
Mt. Laurel, NJ 08054

We are here to help you.

Important Phone Numbers
Member Services

A knowledgeable representative is available 24 hours a day, seven days a week to help you:
1-800-682-9090

Horizon NJ Health
Enrollment Hotline

If you, a friend or a family member need help enrolling or making any changes to a provider:
1-800-637-2997

Horizon NJ Health
Care Manager

To speak with one of our experienced and compassionate Care Managers or to learn about our
health management programs: 1-800-682-9094, and then enter the phone extension 89634

24/7 Nurse Line
If you have questions about your health, preventive screenings, medications or test results, or
just need peace of mind, you?ll get reliable, expert advice you can count on: 1-800-711-5952

NJ FamilyCare
Health Benefits
Coordinator (HBC)

For questions about the status of your NJ FamilyCare application or renewal date:
1-800-701-0710 (TTY 1-800-701-0720 for hearing- and speech-impaired)

Behavioral Health
Services

Members enrolled with Division of Developmental Disabilities (DDD), call Horizon Behavioral
Health toll free at: 1-800-356-1561

Choice Counseling
Services

Members who would like help understanding the information given in printed materials can
call NJ FamilyCare at 1-800-701-0710 (TTY 1-800-701-0720).

Printed Member
Materials

If you need additional materials, like a member handbook or provider directory, please call
1-800-682-9090. There is no charge for printed materials, and the request will be processed
within five (5) business days.

TTY/TDD Services For people with hearing or speech difficulties: 711
Members not enrolled with DDD or the Managed Long Term Services & Supports Program (MLTSS) may also call their local
Medical Assistance Customer Center (MACC) for mental health services. To find the number of a local MACC, call the
NJ FamilyCare hotline toll free at 1-800-356-1561 (TTY 711). For community-based substance use services and referrals,
call the New Jersey Addiction Services Hotline at 1-844-276-2777 (TTY 711).

2

Words to Know
We?ve highlighted some key words throughout this handbook. Look
for these boxes for definitions that will help you understand your
Horizon NJ Health benefits and services.

Becoming a Member ???????????????????????????????????????????? 3

Premiums and Copayments ?????????????????????????????????????? 5

Member Services ??????????????????????????????????????????????? 6

Your Horizon NJ Health ID Card ?????????????????????????????????? 7

Your Personal Doctor ???????????????????????????????????????????? 9

Emergencies ???????????????????????????????????????????????????13

Your Benefits and Services ??????????????????????????????????????15

Programs for You and Your Family ???????????????????????????????29

Keeping You Healthy ???????????????????????????????????????????35

Your Rights and Responsibilities ?????????????????????????????????37

More about Horizon NJ Health ??????????????????????????????????42

Other Health Insurance ?????????????????????????????????????????43

Bills ???????????????????????????????????????????????????????????44

Ending your Membership ???????????????????????????????????????45

Fraud, Waste and Abuse ????????????????????????????????????????47

Grievance and Appeal Procedures ???????????????????????????????48



4horizonNJhealth.com3 Member Services: 1-800-682-9090

Who Can Join?
Many people can join NJ FamilyCare including
children, pregnant women, legal guardians,
single adults and childless couples. Eligibility is
based on the number of people in your family
and your family?s monthly income. You, your
spouse and/or your family members must be
New Jersey residents and, in most cases, you
must have been without medical insurance for at
least three months. There are some exceptions
to this rule, so please call the NJ FamilyCare
Health Benefits Coordinator toll free at
1-800-701-0710 (TTY 1-800-701-0720).

Signing Up and Getting Started
To become a Horizon NJ Health member, call
a NJ FamilyCare Health Benefits Coordinator
toll free at 1-800-701-0710. People with
hearing difficulties may call the NJ FamilyCare
TTY number toll free at 1-800-701-0720. Your
membership must be verified and approved by
the Division of Medical Assistance and Health
Services (DMAHS).

It will take about 30 to 45 days for your
membership in Horizon NJ Health to start. Until
your membership is approved, your current
health insurer ? if you have insurance ? will
continue to provide your health care services.
Horizon NJ Health will coordinate your care with
your previous insurer once your membership
starts.

The Health Benefits Coordinator will share your
enrollment information with Horizon NJ Health.
By signing your plan selection form, or having
an authorized person sign for you, you are
allowing the release of your medical records to
Horizon NJ Health.

When you sign up with Horizon NJ Health, it
is important that you tell the Health Benefits
Coordinator and Horizon NJ Health about any
doctors you are currently seeing.

Keeping Your Membership
Most members must confirm that they are still
eligible for membership every year. Aid to
Families with Dependent Children (AFDC) and
Temporary Assistance for Needy Families (TANF)
members are checked for eligibility every
six months.

If your application was processed at your local
County Welfare Agency (CWA), they will contact
you when it is time for a renewal.

If your NJ FamilyCare application was not
processed at your local CWA, you may call a
Health Benefits Coordinator toll free at
1-800-701-0710 to find out your renewal date
or to ask for a renewal form. People with
hearing or speech difficulties may use
TTY 1-800-701-0720.
It is very important that you contact your
caseworker at the CWA or Health Benefits
Coordinator at NJ FamilyCare when you move
or change your phone number. Call a Health
Benefits Coordinator to update your address
and phone number so that you always receive
information and updates about your Horizon
NJ Health membership.

Renewal Process ? Renew It or Lose It!
If you have NJ FamilyCare, you must renew your
eligibility every year. If you don?t renew your
NJ FamilyCare eligibility on time, you might
have to start over as a new applicant, and this
approval process will take longer.

You can call the NJ FamilyCare Health Benefits
Coordinator (HBC) at 1-800-701-0710 (TTY
1-800-701-0720) to find out your renewal
date or to ask for a renewal form. You can also
contact your caseworker at your County Welfare
Agency (CWA). To find the location and phone
number of your local CWA, you can call the NJ
FamilyCare hotline toll free at 1-800-356-1561
(TTY 711).
Please be sure to pay your premium on time
if you have one.

If the state is able to verify your household
information from other sources available to
them, you will not get a paper renewal packet.
These sources include the Department of
Labor Wage Report, Unemployment Insurance
Benefits, Temporary Disability Insurance Benefits,
Internal Revenue Services and Social Security
Benefits systems. If they cannot verify your
household information, you will get a paper
renewal packet with a renewal application.

Return the completed renewal application in
the self-addressed envelope that came with it
at least 30 days before your renewal date. If you
have questions or need help completing the
renewal application, call the NJ FamilyCare HBC
at 1-800-701-0710 (TTY 1-800-701-0720), or
your local CWA.

Provider Directory
Horizon NJ Health has a large network of doctors
and other health care professionals that provide
quality health care services to our members. This
list is called the Provider Directory. All types of
providers are listed, including doctors, hospitals,
laboratory services, pharmacies, general dentists,
dental specialists and more. There are three
different ways to view the Provider Directory:

1. Online at horizonNJhealth.com ?
updated daily, this web-based directory
lets you search for a provider by location,
specialty, name and other fields. All types
of providers are listed, including doctors,
hospitals, laboratory services, pharmacies,
general dentists and dental specialists
and more. Members can also find a
detailed list of dentists who treat children
6 years of age or younger in Horizon
NJ Health?s ?NJ Smiles Directory.? This

separate list of dentists is located on
horizonNJhealth.com under the Member
Support tab, select Resources from the
dropdown menu.

2. County-Specific Provider Directory ?
updated monthly, this directory is mailed
to new members. It lists Primary Care
Providers, dentists, hospitals, pharmacists
and other commonly needed providers in
and around a member?s county.

3. The Provider and Health Care Directory ?
updated twice a year, this book lists all
specialists, hospitals, pharmacists and
other providers.

All versions of the Provider Directory include
information such as office hours, languages
spoken and local public transportation services.
To get a copy of a printed directory, call
Member Services.

Selecting Your Horizon NJ Health Doctor
You and each of your family members can
choose a personal Horizon NJ Health doctor,
known as a Primary Care Provider (PCP). You can
have a different PCP for each family member. For
example, you can choose a pediatrician for your
child and a general family doctor for yourself.

Use the Horizon NJ Health Provider Directory to
find a doctor near you.

An authorized person acting for you may help
you choose a doctor. If you did not select a
PCP on your enrollment form, we selected one
for you based on where you live and your age.
Member Services can also help you find a doctor
in your area. You can change your PCP at any
time. To change your PCP, log on to Member
Online Services or call Member Services.

Becoming a Member

Words to Know
Provider: A person or location (such as your Primary Care Provider, hospital

or dentist) that gives medical or dental care.



6horizonNJhealth.com5 Member Services: 1-800-682-9090

Families in the NJ FamilyCare program may be
required by the State of New Jersey to pay a
premium or copayment for service.
Premiums for NJ FamilyCare D members range
from $44.50 to $151.50 each month. The amount
is based on the family?s income. If you do not
pay your monthly premium on time, you may be
disenrolled from the program. NJ FamilyCare
collects all premiums.

Your copayment amount is on your
member ID card.
The family limit on all annual copayments for
members may not be more than 5 percent of
their annual family income. For example, if a
NJ FamilyCare D family of four earns $89,105 a
year, the maximum amount of their copayments
is $4,455.25. To keep track of copayments,
members should ask for and keep receipts for
all copayments made during the year. If you
reach the maximum amount, call NJ FamilyCare
at 1-800-701-0710 for help. For people
with hearing or speech difficulties use
TTY 1-800-701-0720.

Our multilingual Member Services staff is ready
to help you get the most out of your Horizon
NJ Health membership, 24 hours a day, seven
days a week, including holidays. Any time
you have a question about your benefits, how
Horizon NJ Health works or how to get the care
you need, give us a call. Our toll-free number is
printed on your member ID card and is on our
website at horizonNJhealth.com.
To help you learn how Horizon NJ Health works
and how to get the most out of your benefits,
a Member Services representative will call you
when your membership begins. This is the
perfect time to ask any questions you may have.

We also offer educational and outreach activities
throughout the year. Member Services can give
you details about times and locations of outreach
events. Call 1-800-682-9090 (TTY 711).

Horizon NJ Health Online
Member Support
As a Horizon NJ Health member, you have
access to our secure online member support
services. The following features will be available
to you once you sign up:

? Request an ID card ? if you need a new
ID card, you can easily request one to be
sent to you.

? View your covered benefits ? learn about
your benefit level, what is covered under
your plan, and whether or not you have
copayments for certain services.

? Complete a health assessment ? complete
a Health Needs Survey, learn about your
risks, and see how you can make changes
to your lifestyle to improve your health.

? Change your PCP ? if you need to change
your doctor, you can easily do this online.

? Wellness Topics ? get personalized health
news articles from WebMD based on the
information you provide in your health
assessment.

? Enroll in a disease management
program ? if you have a chronic condition,
like asthma or diabetes, you can enroll in a
specific disease management program to
help manage your health issue(s).

? Enroll in Mom?s Getting Early Maternity
Services ?GEMS? program ? if you are
pregnant, you can enroll in the Mom?s
GEMS program to get information for a
healthy pregnancy and healthy baby.

To register for online member support services,
visit horizonNJhealth.com and click Member
Sign In.

We encourage you to sign up as soon as
possible. You will find this self-service tool to be
a useful resource for managing your health plan!

Translation Services and
Audio/Visual Information
We have staff members who can speak many
languages. If we do not speak your language,
we will find someone who does. We can arrange
for a translator to talk over the phone with you
and your doctor to help during your doctor?s
visit. Horizon NJ Health can coordinate a sign
language interpreter to be with you at the
doctor?s office.

Translators will make sure that your doctor knows
what you are saying and you know what the
doctor is saying. With the translator?s help, you
can get answers to all of your questions.

There is no cost to you to use our translation or
sign language interpreter services. To schedule
this service, just call Member Services toll free at
1-800-682-9090 (TTY 711).
All Horizon NJ Health information for members
is available in Spanish. If you need information
printed in another language, call Member
Services. Materials for the visually and hearing
impaired are also available through Member
Services, including Braille, large print and
listening systems.

Premiums and Copayments Member Services

Words to Know
Premium: The monthly cost of health insurance paid by the member.
Copayment: The amount a person must pay for a health care service at

the time the service is given.

Benefit: Service given to a person that is paid for by the health plan.



8horizonNJhealth.com7 Member Services: 1-800-682-9090

Emergencies

Member Services

Always Carry it With You
Before your membership begins, a Horizon
NJ Health ID card is mailed to you. Everyone in
your family who is a Horizon NJ Health member
will get his or her own card. Always carry your
Horizon NJ Health ID card with you. It is one of
the most important cards you have.

Show your card every time you get health care ?
when you see your personal Horizon NJ Health
doctor or dentist, when you are referred to a
specialist, when you fill a prescription, when you
have lab work done, and if you go to a hospital
Emergency Room (ER). You can use your card as
long as you are a member.

Please keep your Horizon NJ Health member
ID card safe and never let anyone else use or
borrow it. It is illegal to lend your member ID
card or number to anyone. You could lose your
NJ FamilyCare benefits and may even go to jail.

What is on the Card
? Name of the member

? Effective date ? the date your Horizon
NJ Health benefits begin

? Your doctor?s name and phone number

? A phone number to help you access
information on your dental benefits

? Your copayment amount for visiting
your doctor, dentist or the ER or filling a
prescription (if any)

? Our toll-free Member Services phone
number is on the back of the card

? Information on what to do in an emergency
is on the back of the card

If it is Lost or Stolen
If your ID card is lost or stolen, call Member
Services right away. We will cancel your old card
and send you a new one.

Other ID Cards
You should carry your Health Benefits
Identification (HBID) card sent to you by the
State of New Jersey, your Horizon NJ Health
ID card and cards for any other health insurance
you may have, including Medicare. Show all
your cards any time you visit a doctor, dentist,
hospital, pharmacy, lab or other provider. This
will help make sure that all your providers
know how to bill for that service, supply or
prescription.

You will need to show your doctor the HBID card
to get NJ FamilyCare Fee-for-Service benefits
not covered by Horizon NJ Health (see the Your
Benefits and Services section on page 15).

Your Horizon NJ Health ID Card

Issue date
Effective date

Member ID number
Member name

Primary Care Provider
Primary Care Provider phone

Dental benefit indication

Copayment
amount

!Do you know what benefit level you have? Look on your Horizon NJ Health member ID card to identify
your benefit level. Each level has different benefits and
copayments. Your level is determined by your health, income
and the number of people in your family and is set by the
NJ FamilyCare program.



10horizonNJhealth.com9 Member Services: 1-800-682-9090

?

Your Primary Care Provider (PCP)
Arranges All of Your Care
Call your doctor?s office first ? at any time,
24 hours a day, seven days a week ?
whenever you need medical care. Your doctor
will know how to help. Most non-emergency
health care services must be planned through
your Horizon NJ Health PCP.

Your health services are covered 24 hours a day,
seven days a week. Horizon NJ Health covers
services by PCPs, dentists, specialists, certified
nurse midwives, certified nurse practitioners,
clinical nurse specialists, physician assistants
and independent clinics in Horizon NJ Health?s
network. Your PCP may sometimes ask other
health care providers to help give timely care to
you and your family.

If you are a member with a special medical
need, you may ask to have a Horizon NJ Health
participating specialist as your PCP. You may
also request a referral to certain care facilities
for highly specialized care or to continue care
with a non-participating doctor. These requests
must be made through Horizon NJ Health?s Care
Management Department. Call Member Services
to be put in touch with a Care Manager.

What if I cannot reach my
doctor or dentist right away?

There could be times ? maybe at night or on
weekends ? when your doctor or dentist is not
in the office. You should still call your doctor?s
or dentist?s office. Your doctor or dentist has
made arrangements to help you even if the
office is closed.

* Unless the panel is full or you are in a Provider
Lock-in Program.

Questions and Answers About Your
Doctor and Dentist
Q. If I have Medicare and NJ FamilyCare, do I

need to see my Horizon NJ Health PCP?
A. For most health services, you can see your

Medicare doctors as long as they accept
patients who have Medicare. There are health
services that Medicare does not cover, but
NJ FamilyCare does. These include:

? Dental services

? Vision services

? Hearing services

? Incontinence supplies

? Personal care assistant services
(for certain members)

? Medical day care (for certain members)

? Personal Preference Program
(for certain members)

For these services, you should only see a
doctor in the Horizon NJ Health network.

Q. What if I want to change my doctor?
A. You can change your PCP at any time.*

Member Services can help you choose a
new doctor and will send you a new Horizon
NJ Health ID card with the new doctor?s
name and phone number. You can also
request to change your PCP through
Horizon NJ Health Member Online Services.

Sometimes, Horizon NJ Health reserves the
right to deny a request to change to a new
doctor. Situations where Horizon NJ Health
may deny a request include:

? If a PCP asks that a member not be
included on his or her list of patients

? If a PCP has too many patients to take any
more

Creating a positive, healthy relationship with
your doctor is important. If your PCP believes
that he or she cannot do this with a member,
they may ask that the member be changed to

another PCP. Other times in which a PCP may
ask that a member be changed to another
doctor include:

? If they cannot solve conflicts with the member

? If a member does not follow health care
instructions, which stops the doctor from
safely or ethically proceeding with the
member?s health care services

? If a member has taken legal action against
the PCP

Q. What if I want to change my dentist?
A. If you want to change your dentist, you

may select one from our list of participating
providers at horizonnjhealth.com. Simply
click Find a Doctor and select Dentist, or
call Member Services for assistance at
1-800-682-9090 (TTY 711).

You can also change your dentist through
Horizon NJ Health Member Online Services.

Q. How do I know if I should go to a doctor or
dentist for care?

A. To help choose between going to your
medical doctor or a dentist, use the following
as a guide:

? Dental treatment usually involves services
performed on the teeth or performed
to fix or replace teeth, such as fillings,
extractions (removing teeth), dentures and
crowns (caps). Treatment of the oral cavity
and supporting structures may require
seeing a dental specialist, oral surgeon or
maxillofacial surgeon.

? Medical treatment most often involves
services not directly involving the teeth,
such as treatment for broken jaws or
removal of cysts and benign or malignant
tumors in the mouth, and maxillofacial
prosthetics (replacement of facial structures
lost to disease or trauma).

You can also call Member Services for help
at 1-800-682-9090 (TTY 711).

Q. What if I need to see a specialist?
A. Your PCP will make the decision to send you

to a participating specialist. You must have
a referral to see a participating specialist.
An eye doctor (for a medical problem such
as cataracts or an eye infection) or a heart
specialist, are types of doctors you need
a referral to see. Your PCP will send an
electronic referral to the specialist.

You do not need a referral for:

? Routine gynecological/obstetrical
(Ob/Gyn) care

? Family planning services

? Mammograms

? Routine eye examinations by an optometrist
or eye doctor

? Dental care, including care from dental
specialists

? Mental health or substance use services

? Services at a Federally Qualified Health
Center (FQHC)

? Emergency Room (ER) visits

? Medicare-covered services for members
enrolled in Medicare

Your Personal Doctor

Words to Know
Specialist: A doctor or dentist who has been specially trained in a certain

field of medicine, like a cardiologist, Ob/Gyn or orthodontist.

Referral: Approval from a PCP to visit a specialist. The doctor will send an
electronic referral to the specialist you need to see.



12horizonNJhealth.com11 Member Services: 1-800-682-9090

!

!

If you have a condition that needs ongoing
care from a participating specialist (such
as kidney disease or HIV) or you have a
life-threatening or disabling condition or
disease, you can ask your PCP for a ?standing
referral.? A standing referral lets you to go to
your specialist as often as the specialist needs
to see you to treat your medical condition.
The specialist may be able to act as your PCP
and specialty care provider.

Q. What if my condition requires care from a
doctor or dentist who does not participate
with Horizon NJ Health?

A. Horizon NJ Health has thousands of doctors,
general dentists and medical and dental
specialists throughout New Jersey in our
network. If we do not have a doctor to care
for your condition, we will work with your
PCP or dentist to make sure you get the
care you need. You may also get special
approval from Horizon NJ Health for an out-
of-network doctor if your medical condition
requires. Your doctor or dentist will need
to contact Horizon NJ Health and talk to
our Authorization unit. If you use an out-
of-network doctor without approval from
Horizon NJ Health, you will have to pay for
those services on your own.

Q. What if I want a second opinion?
A. You can ask for another doctor?s or dentist?s

opinion for any medical, dental or surgical
diagnosis. Talk to your PCP or dentist about
a second opinion. He or she will make all of
the arrangements, or you may call Member
Services for help finding another doctor.

Make an Appointment Right Away
After you become a member of Horizon
NJ Health, we will call you or your authorized
personal representative to welcome you to the
plan, explain our benefits and services, and give
you information about being a member.

Soon after becoming a member, you should
see your PCP. A baseline physical will let your
doctor measure your health, review your health
history and help prevent future health problems.
We will encourage your PCP?s office to contact
you to schedule the appointment if you do not
schedule one. Your PCP?s office should schedule
appointments for routine visits within 28 days of
your request.

Regular Checkups Are Important

Regular medical and dental exams and
tests can help find problems before they
start. They can also help find problems early,
when your chances for treatment and a cure
are better, helping your chances for a lon-
ger, healthier life. Your age, health and fami-
ly history, lifestyle choices (like what you eat,
how active you are and whether you smoke)
and other factors impact what services and
screenings you need and how often you
need them.

Now would also be a good time to schedule a
dental exam. Children and adults should have a
dental exam and have their teeth cleaned twice
a year.

If your effective date of enrollment is different
from that given to you by your Health Benefits
Coordinator, Horizon NJ Health will notify you
(or an authorized person when applicable) of the
new date of enrollment.

If you need to see your PCP before you get your
ID card, call Member Services. A representative
will help make arrangements for you to see your
PCP.

Very important:
Keep your appointments!
When you are sick or injured and need care,
call your doctor or dentist right away for an
appointment. Sometimes, it can take a while to
get an appointment, so do not delay in calling
to schedule one.

Showing up for every doctor?s appointment is the
only way your doctor and dentist can make sure
that you and your family are getting the quality
care you deserve. Your doctor has saved time to
see you. If you cannot keep an appointment, call
and let your doctor or dentist know right away, at
least 24 hours before the appointment. That way,
your doctor can use the time to help another
patient. You should make every effort to be on
time to your appointment.

Appointment Availability
Emergency services: Immediately when you
show up at an emergency care site.

Urgent care: Within 24 hours of calling, your
doctor will see you. Urgent care is when you
need immediate medical attention but your
concern is not life-threatening.

Symptomatic acute care: You will be seen
within 72 hours. Having the flu is an example
of this type of care.

Routine care: Checkups for illness, such as
diabetes or high blood pressure, are available
within 28 days.

Specialist care: Care can be received within four
weeks, or within 24 hours if it is an emergency.

New member physicals: Appointments should
be made within 90 days of initial enrollment for
children and adult clients of DDD, and 180 days
of initial enrollment for adults.

Routine physicals: Physicals needed for school,
camp, work, etc. are scheduled within four weeks.

Prenatal care: If you have a positive pregnancy
test, your first appointment will be scheduled
within three weeks. Your appointment should
be scheduled within your first trimester. If you
are identified as having a ?high-risk? pregnancy,
your appointment will be within three days.
During a woman?s first and second trimester,
appointments are available within seven days
of the request. Appointments are available
within three days during the last three months
of pregnancy.

Lab and radiology services: Appointments
are available within three weeks for routine care
and 48 hours for urgent care. Your results will be
available within ten business days of receipt, or
24 hours for urgent care.

Dental care: Emergency care is available within
48 hours, urgent care within three days and
routine care within 30 days.

Behavioral health care: Appointments are
available within ten days of referral for routine
care and 24 hours for urgent care. If you have an
emergency, you will be seen immediately when
you get to your behavioral health provider.

Remember:

? If you or your child is sick, your doctor
will see you the same day in most cases.

? When you get to the doctor?s office on
time for your appointment, you should not
have to wait longer than 45 minutes.

Your Personal Doctor (continued)



14horizonNJhealth.com13 Member Services: 1-800-682-9090

When should you go to the hospital Emergency
Room (ER)? ONLY go when your situation is an
emergency. An emergency medical condition
is a severe illness or injury in which not getting
immediate medical attention could put the
health of the person (and with respect to a
pregnant woman, the health of her unborn child)
in serious danger. Emergencies involve serious
injury to bodily functions or any bodily organ or
part, or potential injury (i.e. thoughts of hurting
self or others).

If an emergency exists, go to the nearest ER or
call 911, 24 hours a day, seven days a week. You
do not need approval from Horizon NJ Health
or a referral from a doctor to go to the ER.

Sometimes, it can be hard to tell if you have
a real emergency. Here are some examples of
emergency situations in which you should go to
the ER or call 911:
? Chest pain

? Broken bones

? Difficulty breathing, moving or speaking

? Poisoning

? Heavy bleeding

? Drug overdose

? Car accident

? You have thoughts of hurting yourself
or others

If you are in labor during pregnancy, follow your
Ob/Gyn?s instructions on what to do.

If it is an emergency, call your PCP if you can.
Your doctor will know how to help. He or she can
send you to the closest participating hospital
and let the hospital know you are coming. If
there is no time to call your doctor, call 911.
Go to the nearest hospital to treat your
emergency, even if the hospital or doctor does
not participate with Horizon NJ Health. All
hospitals must provide emergency care.

Dental Emergencies ? Dental Office vs.
Hospital Emergency Department
A dental emergency is when injury or serious
infection in your mouth, or the area around
your mouth, could put your life or health in
danger unless you get fast treatment. Dental
emergencies can include:

? Infection or swelling

? Pain from injuries to the mouth or jaw
(including knocked out teeth)

? Heavy, uncontrolled bleeding

? A broken or dislocated jaw

These conditions can be dangerous to your
health. If you have a dental emergency, call
your dentist first. If you are unable to reach your
dentist, you can call Horizon NJ Health Member
Services at 1-800-682-9090 (TTY 711), or if it
is after normal business hours, you can call our
24/7 Nurse Hotline at 1-800-711-5952, 24 hours
a day, seven days a week. For life-threatening
emergencies, go to the ER or call 911.

At the Emergency Room
Once at the ER, hospital staff will perform an
ER screening exam to find out if an emergency
exists. This is a covered benefit for all Horizon
NJ Health members to see if the condition can
be reasonably considered an emergency. An
emergency medical condition is a condition with
certain serious symptoms (including severe pain)
such that a layperson with an average knowledge
of medicine and health could reasonably believe
that not getting medical help could put the
health of the person (and, with respect to a
pregnant woman, the health of her unborn child)
in serious danger; serious damage to bodily
functions; or serious wound to any body part.
For a pregnant woman having contractions, an
emergency exists when there is not enough time
for a safe transfer to another hospital before
delivery or the transfer may pose a threat to the
health or safety of the woman or the unborn
child.

You are covered for emergencies 24 hours a day,
seven days a week. This includes follow-up care
in and out of the hospital.

Within 24 hours, call your Horizon NJ Health PCP
to tell him or her about the visit to the ER. If you
cannot call, ask a friend or family member to
call. You should visit your PCP for follow-up care,
not the ER. This follow-up care is sometimes
called ?post-stabilization care.? Your PCP will
coordinate your care after the emergency.

Urgent Medical and Dental Care
If you are not sure if your illness or injury is an
emergency, call your doctor or dentist first. Some
examples of illness or injury that can wait until
you talk to your doctor or dentist are:

? Cold, cough or sore throat

? Earaches

? Cramps

? Bruises, small cuts or minor burns

? Rashes or minor swelling

? Backaches from a pulled muscle

? Toothaches

? Swelling around a tooth

? Teething discomfort

? Broken natural teeth or lost fillings or crowns

? Pain or discomfort following dental treatment

? Bleeding following tooth extraction

If your situation is not an emergency, but it is
medically necessary for you to get treatment
quickly, call your doctor. This is known as urgent
care. Your doctor can make arrangements for
you to come into the office quickly for care.

Out of Town?
If you have an emergency out of town, go to
the nearest hospital and remember to show the
hospital staff your Horizon NJ Health ID card.
You do not need to get prior approval from
Horizon NJ Health for emergency services.

If you need medical attention that is not an
emergency, call your PCP right away to get
help to find medical care from a doctor in the
area. Horizon NJ Health will coordinate your
care between your PCP and the out-of-network
provider. Dental emergencies will be covered by
non-participating providers.

Horizon NJ Health will not cover care
received outside of the United States and
its territories.

Out-of-State Care for Students
If your situation is not an emergency, but it is
medically necessary for you to get care quickly,
out-of-state full-time students can visit an
out-of-town urgent care center. There are many
urgent care centers throughout the United
States open seven days a week, and you do not
need an appointment. You do not need to get
prior approval from Horizon NJ Health to visit
an urgent care center for an urgent medical
condition. Just show the staff your Horizon
NJ Health ID card. After the visit call Horizon
NJ Health?s Utilization Management Department
at 1-800-682-9094. We will need the doctor?s
information from the urgent care center to
arrange for payment.

If your situation is life-threatening, you should go
to the closest ER or call 911. If your condition is
not urgent or an emergency, it is best to call your
PCP for an appointment the next time you are
back in town. Your PCP can also give you advice
on how and when to get care if you are not sure
if your condition is urgent.

Emergencies



16horizonNJhealth.com15 Member Services: 1-800-682-9090

Your Benefits and Services

What Horizon NJ Health Covers BENEFIT PLAN TYPE

BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Abortions & Related Services Covered by Fee-for-Service

Acupuncture Covered when provided by a licensed doctor

Audiology Covered

Blood & Blood Plasma Covered

Chiropractic Services Covered Covered with a $5 copayment

Cognitive Rehabilitation Therapy Covered

Comprehensive Dental Benefits

There is no copayment for diagnostic and preventive services. The following covered services require
Prior Authorization: crowns, bridges, full dentures, partial dentures, gum treatments, root canals, surgical
extractions, complex oral surgery, implants when medically necessary to support a complete denture, and
orthodontics. Access to dental treatment in a hospital or surgical center is based on medical diagnosis.

Covered with a $5 copayment, except for diagnostic and preventive services. The following
services require Prior Authorization: crowns, bridges, full dentures, partial dentures, gum
treatments, root canals, surgical extractions, complex oral surgery, implants when medically
necessary to support a complete denture, and orthodontics. Access to dental treatment in a
hospital or surgical center is based on medical diagnosis.

Diabetic Supplies & Equipment Covered

Durable Medical Equipment
& Assistive Technology Devices Covered

Emergency Medical Care/Emergency Services Covered Covered with a $10 copayment for Emergency Room services

Covered with a $35 copayment for Emergency Room
services, except when referred by a PCP for services that
should have been provided in the PCP?s office or when
admitted to the hospital

As a member of Horizon NJ Health, you get the benefits and services you are entitled to through the
NJ FamilyCare program.

You pay little or nothing for the medical care and services you get through Horizon NJ Health. Make
sure you know how Horizon NJ Health works, especially when it comes to emergency care, seeing
your doctor and when you need a referral. Otherwise, you might be billed if you get services that are

Your Benefits and Services

not covered by Horizon NJ Health or authorized by your Primary Care Provider (PCP). Before care is
given, your doctor should tell you if a service is not covered and if you will be billed for the service.

If you are not sure whether a service is covered, call Member Services toll free at 1-800-682-9090
(TTY 711).



18horizonNJhealth.com17 Member Services: 1-800-682-9090

Your Benefits and Services

What Horizon NJ Health Covers BENEFIT PLAN TYPE

BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

EPSDT (Early and Periodic Screening,
Diagnosis & Treatment)

Covered, including medical exams, dental, vision, hearing and lead
screening services. Covered for treatment services identified through
the exam

Family Planning

Covered. Covered by Fee-for-Service when services are not given by a
Horizon NJ Health doctor. Coverage includes medical history and
physical exams (including pelvic and breast), diagnostic and lab tests,
drugs and biologicals, medical supplies and devices, counseling,
continuing medical supervision, continuity of care and genetic counseling.

Group Homes & DCPP Residential Treatment Facilities Covered

Hearing Aid Services Covered

Home Health Agency Services
Covered, including nursing services by a registered nurse and/or
licensed practical nurse; home health aide service; medical
supplies and equipment; physical, occupational and speech therapy
services; pharmaceutical services; and durable medical equipment

Hospice Services
Covered in the community as well as in institutional settings.
Room and board are included only when services are delivered
in an institutional (non-private residence) setting. Hospice care for
children under age 21 shall cover both palliative and curative care.

Hospital Services (Inpatient) Covered

Hospital Services (Outpatient) Covered Covered with a $5 copayment, except for preventive services

Intermediate Care Facilities/Intellectual Disability Covered by Fee-for-Service Not Covered

Laboratory Services Covered, including routine testing related to the administration of atypical antipsychotic drugs

Maternity Services Covered, including related newborn care and hearing screening

Medical Day Care Covered Not Covered

Medical Supplies Covered

Your Benefits and Services (continued)



20horizonNJhealth.com19 Member Services: 1-800-682-9090

Your Benefits and Services

What Horizon NJ Health Covers BENEFIT PLAN TYPE

BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Mental Health Inpatient Hospital Services
(Including Psychiatric Hospitals) Covered

Mental Health Outpatient Services Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Mental Health ? Home Health Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service .

Methadone (Maintenance and Administration) Covered

Nurse Midwife Covered Covered with a $5 copayment for each visit, except for prenatal care visits

Nurse Practitioner Covered Covered with a $5 copayment for each visit, except for preventive care services

Nursing Facility Services (Custodial Care,
Rehabilitation, Post-acute Care, Skilled Nursing Care
and Services in Special Nursing Facilities, Such as
Ventilator Facilities, Pediatric Long-term Care and
Treatment for AIDS)

Covered Covered, no Custodial Care

Optical Appliances
Covered for select eyeglasses and contact lenses as follows:
? Age 18 and under and 60 and older ? Replacement eyeglasses or

contact lenses annually if prescription changes

? Age 19 to 59 ? Replacement eyeglasses or contact lenses every two years if prescription changes

Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur.
Contact lens exams and fittings are covered only when deemed medically necessary over glasses.

Optometrist Services Covered for one routine eye exam per year Covered for one routine eye exam per year with a $5 copayment

Organ Transplants Covered for transplant-related medical costs for the donor and recipient

Orthodontic Services
Coverage is limited to members up to age 21 or loss of eligbility who
require these services due to medical need, including developmental
problems or jaw injury. Prior authorization required.

Coverage is limited to members up to age 21 or loss of eligibility who require these services due
to medical need, including developmental problems or jaw injury, with a $5 copayment. Prior
authorization required.

Orthotics Covered

Your Benefits and Services (continued)



22horizonNJhealth.com21 Member Services: 1-800-682-9090

Your Benefits and Services

What Horizon NJ Health Covers BENEFIT PLAN TYPE

BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Outpatient Diagnostic Testing Covered

Partial Care Program Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Partial Hospital Program Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Personal Care Assistant Services Covered Not Covered

Personal Preference Program Services Covered Not Covered

Podiatrist Services
Covered. Routine hygienic care of feet, including the treatment of corns
and calluses, trimming of nails and other hygienic care in the absence
of a pathological condition, is not covered.

Covered with a $5 copayment. Routine hygienic care of feet, including the treatment of corns
and calluses, trimming of nails and other hygienic care in the absence of a pathological condition,
is not covered.

Prescription Drugs (Retail Pharmacy)

Covered, including atypical antipsychotics, Suboxone and Subutex or
any other drug within this category when used for the treatment of
opioid dependence (methadone is covered for DDD clients, MLTSS and
FIDE-SNP members), and drugs that may be excluded from Medicare
Part D coverage. No coverage for erectile dysfunction drugs and drugs
not covered by a third-party Medicare Part D formulary.

Covered with a $1 copayment for generic drugs and a $5 copayment for brand-name drugs. Includes
atypical antipsychotics, Suboxone and Subutex or any other drug within this category when used for the
treatment of opioid dependence (except methadone which is covered Fee-for-Service), and drugs that may
be excluded from Medicare Part D coverage. No coverage for erectile dysfunction drugs and drugs not
covered by a third party Medicare Part D formulary.

Prescription Drugs (Medicare Part B Doctor-Administered) Covered

Primary Care, Specialty Care and
Women?s Health Services Covered

Covered with a $5 copayment for each visit. No copayment for well-child visits, lead screening/
treatment, age-appropriate immunizations, prenatal care or Pap tests.

Private Duty Nursing Covered for members under age 21, DDD Support Plus PDN and MLTSS members.

Prosthetics Covered

Radiology Services (Diagnostic & Therapeutic) Covered

Your Benefits and Services (continued)



24horizonNJhealth.com23 Member Services: 1-800-682-9090

Your Benefits and Services

What Horizon NJ Health Covers BENEFIT PLAN TYPE

BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Rehabilitation Services (Outpatient Physical Therapy,
Occupational Therapy and Speech Therapy) Covered

Sex Abuse Examinations and Related Diagnostic Testing Covered by Fee-for-Service

Social Necessity Days Covered

Specialty Foods (Medical Foods)
Coverage is limited to nutritional supplements requiring medical
supervision for members with inborn errors of metabolism and
related genetic conditions. Medical foods and special diets for all
other medical conditions are not covered.

Substance Use (Inpatient and Outpatient) Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Substance Use (Day Treatment/Partial Hospitalization) Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Substance Use (Outpatient and Intensive Outpatient) Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Substance Use (Residential and Short-term Residential) Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Sub-acute Medically Managed Detoxification and
Enhanced Medically Managed Detoxification

Covered for DDD, FIDE-SNP and MLTSS members. All other members
are covered by Fee-for-Service.

Transportation Services ? Emergency Ambulance (911) Coverage is limited to ambulance, ground and air, for medical emergencies only.

Transportation to Medically Necessary Services Covered by Fee-for-Service through LogistiCare. To schedule, call LogistiCare at 1-866-527-9933 (TTY 1-866-288-3133).

Transportation ? Livery Services (Bus and Train Fare
or Passes, Car Service, Mileage Reimbursement) to
Medically Necessary Services

Covered by Fee-for-Service through LogistiCare. To schedule, call
LogistiCare at 1-866-527-9933 (TTY 1-866-288-3133). Contact LogistiCare at 1-866-527-9933 (TTY 1-866-288-3133)

Your Benefits and Services (continued)



26horizonNJhealth.com25 Member Services: 1-800-682-9090

What Horizon NJ Health Covers
To get benefits covered by the NJ FamilyCare
program, call your NJ FamilyCare case worker,
a Medical Assistance Customer Centers office
in your area, your PCP or Horizon NJ Health
Member Services.

If any changes are made to your benefits,
Horizon NJ Heath or the State of New Jersey will
notify you of the change within 30 days.

Utilization Management
If you are very sick, Horizon NJ Health wants to
make sure you receive the right care for your
problem, in the right setting. To do this, we have
a Utilization Management (UM) process. This
process ensures that you get timely, efficient and
quality service from doctors, hospitals, dentists
and other providers.

Horizon NJ Health helps with referrals to
specialists, admissions, discharges and length-
of-stay issues when a member is admitted to a
hospital or ambulatory surgical center. We give
doctors information about our care and disease
management programs when necessary.

Most of all, we work with your PCP or specialist
to ensure that you get the continuous care you
need throughout your illness and recovery.
Horizon NJ Health has special staff who can help
you with UM questions. If you have questions
about our UM process, please call Member
Services at 1-800-682-9090 (TTY 711).

Dental Services
Good oral health is important to your body?s
overall health. You should visit your dentist
twice a year for an oral exam and cleaning,
and complete any course of treatment he or
she recommends. Dental visits should start
when a child turns 1 year old or when the first
tooth can be seen. All NJ FamilyCare members
have comprehensive dental benefits. Twice
yearly dental checkups are a covered benefit
for all members. Some services require prior
authorization (approval).

You do not need a referral from your PCP or
prior authorization from Horizon NJ Health for
routine dental care, such as cleanings, fillings
and X-rays. Members may select their dentist
or dental specialist from the Horizon NJ Health
online provider directory, which includes a
special listing of participating general dentists
and pedodontists (children?s dentists) for
members age 0-6 years old. For a list of dentists,
please visit horizonNJhealth.com and click Find
a Doctor, and select a dentist, or call Member
Services at 1-800-682-9090 (TTY 711).

Vision Services
Members are covered for routine eye exams
every one or two years based on their age and
health. You do not need a referral from your
PCP for routine eye care. If you need more
exams during the year or you need to see a
vision specialist, such as an ophthalmologist,
you will need to get a referral from your PCP.

Members with diabetes can have an eye exam
every year, which should include a dilated retinal
eye exam.

Vision services are available only from
participating Horizon NJ Health eye
doctors. For a list of eye doctors, please visit
horizonNJhealth.com and click Find a Doctor,
and select an eye doctor. You can also call
Member Services at 1-800-682-9090 (TTY 711).

Laboratory Services
LabCorp is the laboratory services provider for
Horizon NJ Health members. Your doctor will
give you a prescription for laboratory testing.
Take that prescription and your Horizon NJ Health
member ID card when you get lab work done.

You can use the Horizon NJ Health Provider
Directory to find a LabCorp location near
you. LabCorp also offers online appointment
scheduling at all New Jersey Patient Service
Centers. Visit LabCorp.com/PSC to find a
location. Walk-in patients are also welcome.

Your doctor will give you your lab test results. Or,
you can use LabCorp Patient, an online service,

to download and print your test results on your
own. Visit patient.labcorp.com to register.
Note that LabCorp will give your test results to
your doctor before posting them to your online
account.

Prescription Services
Horizon NJ Health covers many medications
that are offered to you at no cost or at a low
copayment. These approved drugs make up our
formulary. If your doctor wants to prescribe a
drug that is not included in our formulary, he or
she will need to call us to get prior authorization,
or approval in advance. It is important that the
medications you take are safe and effective. That
is why Horizon NJ Health has a committee made
up of practicing doctors and pharmacists who
review and approve our formulary. Certain over-
the-counter products are covered with a written
prescription (for example, Loratadine, Alaway,
Zaditor OTC, Omeprazole, Lansoprazole,
smoking deterrents). Some medications are not
covered under your pharmacy benefit and they
include, but are not limited to, the following:
fertility agents, weight loss drugs and erectile
dysfunction medications.

Horizon NJ Health requires the use of generic
medicine when available. If your doctor decides
that you must have a medicine that is not in the
formulary, including a brand-name medicine
exception, he or she can ask for special
permission for you to get the medicine. While
you are waiting for a response, the pharmacy can
provide a 72-hour supply of the medicine. The
Horizon NJ Health Pharmacy Department will

work with your doctor to fulfill your prescription
needs. If you have questions, call toll free at
1-800-682-9094 (TTY 711).
The Approved Drug List (formulary) is updated
annually and as changes are made or new
medications are approved. The Approved Drug
List is updated as of the date that formulary
changes are put in place. Changes to this
list are included in the member newsletters,
which are mailed to all members. Covered
pharmaceuticals, including those that require
prior authorization, are listed on our website at
horizonNJhealth.com. There is no copayment
for prescription medications for NJ FamilyCare
A, ABP and B members. For members with NJ
FamilyCare C and D, the copayment is $1 for
generic drugs and $5 for brand name drugs. In
general, Horizon NJ Health allows up to a 30-day
supply of drugs.

You can have prescriptions filled at any
participating pharmacy. For a list of pharmacies
or to find the pharmacy nearest to you, call
Member Services. Participating pharmacies
are also listed in the Provider Directory
and on the Horizon NJ Health website at
horizonNJhealth.com.
Our website also has information on
pharmaceutical management procedures,
including the formulary listing, policies and
limitations. Limitations include quantity, plan,
supply/fill, step therapy and age. Paper copies
of the pharmaceutical management procedures
are available by contacting the Pharmacy
Department at 1-800-682-9094 (TTY 711).

Your Benefits and Services (continued)

Words to Know
Ambulatory Surgical Center: A site that provides surgical care but does

not provide care overnight

Ophthalmologist: A doctor who treats people with eye problems, eye
diseases and does eye surgery

Prescription: An order written by a doctor for a drug, test or other health service
Formulary: A list of approved medicines that Horizon NJ Health covers



28horizonNJhealth.com27 Member Services: 1-800-682-9090

!

Pharmacy Lock-In
Members who see different doctors may have
many types of medicine prescribed to them.
This can be dangerous. The Pharmacy Lock-In
program coordinates a member?s care between
pharmacies and doctors. To make sure your
pharmacy care is coordinated, you should use
only one pharmacy to fill your prescriptions.
This will let the pharmacist learn about your
health and be better able to help you with
your medicine needs. Members who use many
pharmacies or doctors may be reviewed each
month to make sure that they are getting the
proper care. If it is decided that using only one
pharmacy will help the member get better
care, the member may be ?locked-in? to one
pharmacy. We will send letters to the member,
pharmacy and doctor when a lock-in is needed.

Medical Transportation
Horizon NJ Health will provide emergency
transportation for all NJ FamilyCare A, B, C, D
and ABP enrollees.

All non-emergency medical transportation
services will be provided by the NJ FamilyCare
Fee-for-Service program. If you need special
services or transportation for your medical
care, you can call the transportation broker,
LogistiCare, at 1-866-527-9933,
(TTY 1-866-288-3133). For livery service, such
as car service to a medical appointment, etc.,
you can also call LogistiCare for reservations.
There is a 20 mile limit for transportation to your
provider, unless an authorization is provided
for offices outside this radius. You should
call by noon at least two days in advance of
your transportation need. After your medical
appointment is over, if you have not scheduled
a pickup time, you or someone at the doctor?s
office can call the Where?s My Ride phone
number at 1-866-527-9934 (TTY 711) and
request that transportation be sent to pick you
up. The transportation provider will pick you up
within 90 minutes.

To report any problems with your transportation
to LogistiCare, call 1-866-333-1735. You
may also visit the LogistiCare website at
wecare.logisticare.com, where you can
complete an online form and LogistiCare will
respond to your issue.

Remember:

Do not call an ambulance for
routine transportation.

Behavioral Health Services
Horizon NJ Health provides behavioral
health benefits for members of the Division
of Developmental Disabilities (DDD). DDD
members can call Horizon Behavioral Health
toll free at 1-877-695-5612 (TTY 711) for
more information.

Most Horizon NJ Health members get mental
health and/or substance use services through
the NJ FamilyCare program. You do not need a
referral from your PCP to see a behavioral health
or substance use provider. If you need medicine
for mental health and/or substance use, your
mental health and/or substance use provider
can prescribe the medicine for you.

If you think you or a member of your family
needs help with a mental health or substance
use problem, you can contact:

? Your PCP

? Members not enrolled with DDD or MLTSS
should call their local Medical Assistance
Customer Center (MACC) for mental health
services. To find the number of a local
MACC, call the NJ FamilyCare Hotline at
1-800-356-1561 (TTY 711).

? For substance use services and referrals
for adults 18 and over, call the New Jersey
Addiction Services Hotline at
1-844-276-2777 (TTY 711), 24 hours a day,
seven days a week.

? A Horizon NJ Health Care Manager at
1-800-682-9090 (TTY 711)

? To get services for adults 18 years and
older, call your PCP or the New Jersey
Division of Mental Health Services at
1-800-382-6717 (TTY 1-877-294-4356)
during business hours.

? For mental health and/or substance use
services for youth or adults, call NJ Mental
Health Cares toll free at 1-866-202-4357
(TTY 1-877-294-4356), Monday through
Friday, from 8 a.m. to 8 p.m., Eastern TIme.

Services Not Covered by
NJ FamilyCare Fee-for-Service or
Horizon NJ Health
Services not covered by Horizon NJ Health or
the NJ FamilyCare Fee-for-Service program
include:

? All services not medically necessary, provided,
approved or arranged by a Horizon NJ Health
participating doctor (within his or her scope of
practice) except emergency services.

? Any service or items for which a provider does
not normally charge.

? Cosmetic services or surgery except when
medically necessary and approved.

? Experimental procedures or experimental
organ transplants.

? Services provided by or in an institution
run by the federal government, such as the
Veterans Administration hospitals.

? Respite care (except MLTSS members).

? Rest cures, personal comfort, convenience
items and services and supplies not directly
related to the care of the patient. Examples
include guest meals and telephone charges.
Costs incurred by an accompanying parent(s)
for an out-of-state medical intervention are
covered under EPSDT.

? Services in which health care records do not
reflect the requirements of the procedure
described or procedure code used by the
provider.

? Services provided by an immediate relative or
household member.

? Services involving the use of equipment
in facilities in which its purchase, rental or
construction has not been approved by the
State of New Jersey.

? Services resulting from any work-related
condition or accidental injury when benefits
are available from any workers? compensation
law, temporary disability benefits law,
occupational disease law or similar law.

? Services provided or started while on active
duty in the military.

? Services or items reimbursed based on
submission of a cost study in which there is
no evidence to support the costs allegedly
incurred or beneficiary income to make up
for those costs. If financial records are not
available, a provider may verify costs or
available income using other evidence that
the NJ FamilyCare program accepts.

? Services provided outside the United States
and its territories.

? Infertility diagnoses and treatment services
(including sterilization reversals and related
medical and clinic office visits, drugs,
laboratory services, radiological and
diagnostic services and surgical procedures).

? Services provided without charge. Programs
offered free of charge through public or
voluntary agencies should be used to the
fullest extent possible.

? Any service covered under any other
insurance policy or other private or
governmental health benefit system or
third-party liability.

Your Benefits and Services (continued)



30horizonNJhealth.com29 Member Services: 1-800-682-9090

Special Needs Members
Horizon NJ Health has a Care Management
Department to help members with special health
care needs. If you or a family member has a
complex or chronic medical condition, physical or
developmental disability or a catastrophic illness,
you can get care management.

New members will receive a call from Horizon
NJ Health and be asked a few questions about
their health. Your answers will help determine your
chronic care needs.

You can also ask for an evaluation to see if you
qualify for the special needs program by calling
the Care Management Department at
1-800-682-9094 x89634 (TTY 711). Your PCP,
specialist, social worker, community-based case
manager or any other concerned agency can
also ask for an evaluation for you.

A Horizon NJ Health Care Manager will complete
a comprehensive needs assessment. After the
assessment is completed, a Care Manager will let
you know what level of care management you or
your family member needs and develop a Plan of
Care. If you have a complex need, you will work
with your Care Manager and your PCP or specialist
to create a care plan that fits your needs.

Care for Special Needs
There may be times when you need more than
routine health care services. Horizon NJ Health
has a special program for members who need
extra personal care. Our Care Management unit
can help coordinate complex health care and
psychosocial needs for Horizon NJ Health
members who are identified as having special
needs.

Call us if you have questions or
concerns about:

? Baby needs ? Substance use

? Personal care ? Parenting assistance

? Housing issues ? Food

? Advocacy ? WIC

? Clothing ? Mental health

? NJ FamilyCare ? Support groups

? Domestic violence

? Attendants (home health aides or personal
care assistants)

Members with special needs may need extra
access to doctors and specialists. Horizon
NJ Health?s Care Management team will help
make sure that the member?s medical needs
are met and that they receive the education
and support they need, including access to
non-participating specialists if necessary. These
members are entitled to an additional dental
benefit of four preventive screenings per year.

If you have a condition that needs ongoing care
from a participating specialist or you have a life-
threatening or disabling condition or disease,
you can ask your PCP for a ?standing referral.?
This lets you go to your specialist as often as
needed to treat your medical condition.

Members with a special medical need may ask to
have a Horizon NJ Health participating specialist
as their PCP. You may also request a referral to
certain care facilities for highly specialized care or
to continue care with a non-participating doctor.

Call your doctor?s office first ? at any time,
24 hours a day, seven days a week ? whenever
you need medical care. If an emergency exists,
go to the nearest ER or call 911.

Care Management for the Aged
Our Care Management Department recognizes
that members 65 and older may need additional
services. Horizon NJ Health provides special
services to help with the following:

? Assessing and managing depression

? Assessing and managing cognitive
impairment

? Caregiver support

? Preventing institutionalization

? Access to preventive services, including but
not limited to:

? Immunizations against the flu and
pneumonia

? Mammograms

? Cervical cancer screening

? Colorectal health

? Prostate education

? Disease management for conditions such as:

? Asthma

? Congestive Heart Failure (CHF)

? Cardio Obstructive Pulmonary Disease
(COPD)

? Diabetes

? HIV/AIDS

? Hypertension

Call our Care Management Department at
1-800-682-9094 x89634 (TTY 711), about these
services. Licensed staff have screening tools and
educational materials and will connect you with
the right resources.

Family Planning Services
If you are interested in family planning and
contraceptive services, including genetic testing
and counseling, Horizon NJ Health can help
you find the services you need and will tell you
about doctors and clinics that are close to you.
Remember to take your Horizon NJ Health
ID card when you go to your appointment. You
can also get family planning and contraceptive
services from other clinics and doctors who
accept the NJ FamilyCare program but who are
not in the Horizon NJ Health network. Use your
Health Benefits Identification Card (HBID) if you
visit them.

Women?s Services
If you need women?s health services or you
are going to have a baby, call an Ob/Gyn or a
certified nurse midwife (CNM) who participates
in Horizon NJ Health?s network and make an
appointment. You do not need a referral from
your Horizon NJ Health PCP.

It is important that women visit an Ob/Gyn for
regular care. You should have a Pap test once
every three years if you are 20 years of age or
older or sexually active.

Programs for You and Your Family

Words to Know
Pap test: A cervical cancer test



32horizonNJhealth.com31 Member Services: 1-800-682-9090

!

Help for Pregnant Women:
Mom?s GEMS
If you think you are pregnant, call your Ob/Gyn
or CNM right away for an appointment. As a
mother-to-be, you can join the Mom?s GEMS
Program. GEMS stands for ?Getting Early
Maternity Services.? Mom?s GEMS is designed
to help you get good prenatal care, regular
checkups, nutrition advice and postpartum
information after your baby is born.

When you are pregnant, you should see
your Ob/Gyn:
? At least once during the first two months,

or once you know you are pregnant

? Every four weeks during the first six months

? Every two weeks during the seventh and
eighth month

? Every week during the last month

You should visit your Ob/Gyn as scheduled after
the birth of your baby for a postpartum visit.

If you are pregnant or have children, you may
be eligible for an extra program called WIC
(Women, Infants and Children). This program
gives you nutritional benefits, such as free milk,
eggs and cheese. To apply for WIC in
New Jersey, contact your local WIC agency to
set up an appointment.

Is Your Family Growing or Changing?
Do you have a new family member or a new
baby? Call Member Services at 1-800-682-9090
(TTY 711), and tell us right away. We will help
you get your new family member enrolled. Also,
it is very important to tell your County Board of
Social Services caseworker or Health Benefits
Coordinator. Your child must be enrolled in
the NJ FamilyCare program to be enrolled in
Horizon NJ Health.

Keeping Your Children Healthy
The Early Periodic Screening, Diagnostic and
Treatment (EPSDT) program is a government
mandate that helps keep your children healthy.
Horizon NJ Health has several programs to make
sure your children get all of the EPSDT benefits.

Horizon NJ Health?s helps maintain the health
of your children from birth until they are 21
years old. This program helps keep your child?s
immunizations and well-child visits on track and
reminds parents to have their child?s PCP screen
for medical problems early and continue to
check for problems as the child grows.

Taking your children to the doctor is very
important for their healthy growth and
development. Your children need to go to the
doctor several times a year up to age 2 and at
least once a year from 2 to 20 years old.

Babies should see their doctor at the following
ages:

? Newborn ? 3 days post hospital discharge

? Under 6 weeks

? 2 months ? 4 months

? 6 months ? 9 months

? 12 months ? 15 months

? 18 months ? 24 months

? And once a year through age 20

During well-child visits, the doctor will check
your child?s vision, teeth, hearing, nutrition,
growth and development. The doctor will also
give lead screenings to find out if your child has
been exposed to dangerous levels of lead from
paint or other sources. These visits are also a
good time to ask questions and talk about any
problems or concerns you have.

Your child?s Horizon NJ Health doctor will give
these checkups, treat problems and call in
specialists if they are needed. Horizon NJ Health
covers all of these services for members up to
the age of 21.

Horizon NJ Health also covers prescription
and non-prescription drugs, in-home ventilator
services and private-duty nursing for children,
when needed.

Remember that immunizations are safe and
effective. By making sure your child is immunized,
you can protect your child from serious illnesses,
such as:

? Mumps ? Measles

? Polio ? Meningitis

? Rubella ? Diphtheria

? Chicken pox ? Tetanus

? Influenza ? Hepatitis B

? Rotavirus ? Pertussis

? Hepatitis A ? Pneumococcal invasive
disease

Be sure your children get these immunizations
before their second birthday.

Children should have their first dental exam when
they are a year old, or when they get their first
tooth. The NJ Smiles program allows non-dental
providers to perform oral screenings, caries, risk
assessments, anticipatory guidance, fluoride
varnish applications and give dental referrals
for children through age 6. If additional care is
needed, members can find a comprehensive
list of dentists who treat children 6 years of age
or younger in Horizon NJ Health?s ?NJ Smiles
Directory.? This separate list of dentists is located
on horizonNJhealth.com under Member
Support, then select Resources.

Services for You:

Horizon NJ Health helps members
manage many health issues. Call toll
free at 1-800-682-9094 (TTY 711) for
information about these issues:
? Mom?s GEMS (prenatal care)
? Childhood Wellness

(immunizations and well-child visits)
? Lead
? Complex Case Management
? Asthma
? Diabetes
? Congestive Heart Failure (CHF)
? Hypertension
? COPD
? HIV/AIDS

Programs for You and Your Family (continued)

Words to Know
Prenatal care: Care for pregnant women
Postpartum: Care for a woman after she delivers a baby
EPSDT: Stands for Early and Periodic Screening, Diagnostic and

Treatment. This is a group of tests required for children up
to age 21 to make sure they are getting appropriate care.



34horizonNJhealth.com33 Member Services: 1-800-682-9090

!

Children with Special Health
Care Needs
Horizon NJ Health has a special program
for children who need extra care. Our Care
Management Department can help coordinate
complex health care and psychosocial needs for
children enrolled in Horizon NJ Health identified
as having special needs. Horizon NJ Health?s
Care Management team will help make sure
that the child?s medical needs are met and they
receive the support they need.

Children with special needs also have Early
Periodic Screening, Diagnostic and Treatment
(EPSDT) benefits to help keep them healthy.
Horizon NJ Health helps promote and maintain
the health of your children from birth until they
are 21 years old. This program helps keep your
child?s immunizations and well-child visits on
track and reminds parents to have their child?s
PCP screen for medical problems early and keep
checking for problems to help prevent serious
disease as the child grows. Children with special
needs have an additional dental benefit of four
preventive screenings per year.

If your child has a condition that needs ongoing
care from a participating specialist or has a life-
threatening or disabling condition or disease,
you can ask your child?s PCP for a ?standing
referral.? This lets your child go to the specialist
as often as needed to treat the condition.

Children with a special need may be able to
have a Horizon NJ Health participating specialist
as their PCP. You may also request a referral to
certain care facilities for highly specialized care
or to continue care with a non-participating
doctor when necessary.

Test Your Child for Lead Poisoning
According to New Jersey state law, your child
must be tested for lead poisoning, first between
9 and 18 months old (preferably at 12 months)
and again at 24 months. Any child who is 6
months of age or older and is exposed to a
known or suspected lead hazard, should be
screened. Children between the ages of 27
months and 6 years old should be tested if not
previously tested. Lead care management is
given to all Horizon NJ Health members up to
6 years of age who have high blood lead levels.
Lead Care Managers are nurses who work with
you to help keep your child lead free. The lead
program gives you information about keeping
your home lead free and safe. You will get
information on blood lead levels and preventive
measures, including housekeeping, hygiene,
appropriate nutrition and why it is so important
that you follow your doctor?s instructions when
dealing with lead problems.

A Horizon NJ Health nurse will work with your
child?s PCP, the Department of Health, WIC and
laboratories to make sure that any high blood
lead levels found in your child are lowered so
your child stays healthy.

Asthma Management
Horizon NJ Health has clinical staff available to
help you or your child greatly lower the risk of
asthma attacks.

You will learn what ?triggers? your asthma
attacks and how to avoid these triggers. This
has helped many children and adults. Peak
flow meters and spacers are available with a
prescription from your PCP. It is important to
take your asthma medication as prescribed by
your doctor, even if you don?t feel any symptoms.

Diabetes Disease Management
Horizon NJ Health has clinical staff available to
help any member who has been diagnosed with
diabetes. Horizon NJ Health can help members
learn to manage their diabetes. It is important
for diabetics to complete recommended
screenings such as lab tests, and seeing an
eye doctor for a retinal exam. Routine screenings
will monitor your diabetes and can be an early
indicator for worsening conditions.

Diabetic education materials about meal
planning, insulin and medication use are
available, and Horizon NJ Health will help
members find a diabetic specialist and/or
nutritionist.

You can get prescriptions for insulin and syringes
from your PCP. Diabetic testing machines and
supplies are also available with a prescription
from your PCP.

Congestive Heart Failure (CHF)
Management
Horizon NJ Health has clinical staff available to
help you improve your quality of life, reduce
hospitalizations and Emergency Room visits and
provide you with more information about CHF.

Members are given helpful tips to reduce
symptoms of CHF, such as how a proper diet and
medicine can control blood pressure. Horizon
NJ Health can help coordinate your health care
between your PCP and specialist.

Hypertension Management
Hypertension is most commonly called high
blood pressure. It is known as a ?silent killer?
because there are usually no symptoms. Horizon
NJ Health will help members learn about
high blood pressure, its signs and symptoms,
medicine and how to manage their blood
pressure and prevent stroke.

COPD Management
COPD stands for chronic obstructive pulmonary
disease. Clinical staff are available to help
members with COPD to help them learn more
about this disease and how to reduce symptoms.

HIV/AIDS Management
Horizon NJ Health has Care Managers to help
members diagnosed with HIV or AIDS. Horizon
NJ Health works closely with members and their
doctors to create and coordinate the best plan
of care.

If you are enrolled in any of
our disease management
programs and no longer wish
to be, please call our Care
Management Department
toll free at 1-800-682-9094
(TTY 711).

Programs for You and Your Family (continued)

Words to Know
Lead: Can be found in places you don?t expect. Cooking tools, toys and

candies imported from other countries may contain lead.

COPD: A lung disease that makes it hard to breathe



36horizonNJhealth.com35 Member Services: 1-800-682-9090

At Horizon NJ Health, we want to help keep the
people of our state healthy and well. Our health
representatives ? we call them ?Team NJ? ?
participate in more than 1,000 community health
events throughout New Jersey every year. Team
NJ offers fun and educational no-cost programs
and services to all New Jersey residents.

Care-A-Van
Our Care-A-Vans are like health centers on
wheels. These vans have nurses and health
educators who speak many languages. They
can teach about healthy topics and give
medical screenings. Some things we offer in the
Care-A-Van are:

? Health screenings ? Nurses give blood
pressure, cholesterol and glucose
screenings. They also check members?
skin for damage from the sun, using a skin
analysis machine. Flu shots are available
for adult members during flu season. Oral
health screenings are given by our staff
dentist.

? Nutrition and exercise ? The Care-A-Vans
have meeting areas to teach people about
being healthy, either one-on-one or in
small groups.

? Horizon NJ Health information ? Learn
more about Horizon NJ Health and find
out how to enroll.

Health Education
Horizon NJ Health?s health educators are
available to teach you about getting and staying
healthy. Horizon NJ Health holds workshops,
programs and presentations at different events
and locations in the community. Topics include
asthma, diabetes, nutrition, child obesity, cancer
screenings and prevention, dental health, lead
poisoning prevention and more.

Meet ?NJ?
?NJ? is Horizon NJ Health?s mascot. This
loveable pup shares health messages with
children in a fun, unique way, such as why
exercise and a healthy diet are important.

Dancing for Your Health?
Our Dancing for Your Health program is
nationally known for showing people of all ages
how to use dance as an easy, fun and no-cost
way to exercise. Team NJ will show you how to
do many popular dances.

Horizon Healthy Journey
Horizon NJ Health understands that it may
be difficult to remember all of the health care
recommendations and appointments for you
and your family. The Horizon Healthy Journey
program is designed to keep you on track with
reminders and educational materials relevant to
your health care needs. We will contact you by
phone with both live and automated calls. You
will also receive materials by mail. Horizon NJ
Health will work with your doctors to make sure
they are aware of the recommended services for
you and your family.

Smoking Cessation
Being smoke-free is one of the best things
you can do to improve your health. By quitting
smoking, you can improve your lung function
and circulation. You can also reduce your chance
of developing certain cancers and heart disease,
among many other benefits. It may help you add
years to your life.

New Jersey has several support options to help
you quit smoking:

? NJ Quitline: Design a program that
fits your needs and get support from
counselors. Call toll free 1-866-NJ-STOPS
(1-866-657-8677) (TTY 711), Monday
through Friday, from 8 a.m. to 8 p.m.
(except holidays) and Saturday, from
11 a.m. to 5 p.m. The program supports
26 different languages at njquitline.org.

? NJ QuitNet: Free peer support and trained
counselors, available 24 hours a day, seven
days a week at quitnet.com.

? NJ Quitcenters: Receive professional
face-to-face counseling in individual or
group sessions. Locate a center by
calling 1-866-657-8677 (TTY 711) or
visit quitnet.com.

The medicines listed below are available to
Horizon NJ Health members and can help you
quit smoking. Ask your doctor if any of these are
right for you:

? Bupropion (Zyban)

? Nicotine transdermal patches (Nicoderm)

? Nicotine polacrilex gum (Nicorette)

? Nicotine polacrilex lozenge (Commit)

Keeping You Healthy



38horizonNJhealth.com37 Member Services: 1-800-682-9090

You deserve the best health care. As a member
of Horizon NJ Health, you have a partner who
will help you get the care you need. Horizon
NJ Health will treat you with respect and there
are certain rights you can expect from Horizon
NJ Health. There are also responsibilities that
Horizon NJ Health expects from you.

Your Member Rights
You have the right to:
? Be treated with respect, dignity and a right

to privacy at all times.

? Get care no matter what your age, race,
religion, color, creed, gender, national
origin, ancestry, political beliefs, sexual or
affection preference or orientation, health
status, marital status or disability.

? Have access to care that has no
communication or access barriers, including
the assistance of a translator if needed.

? Get medical care in a timely way and have
access to a PCP or doctor who will help you.
A PCP is the doctor you will see most of the
time who will coordinate your care. He or
she will be there for you, 24 hours a day,
365 days a year, if you need urgent care.
This includes the right to:

1. Choose your own doctor from the
Horizon NJ Health list of doctors.

2. Get a current list of doctors who can
treat you. They will work in the Horizon
NJ Health network of doctors.

3. Have a doctor make the decision to
say whether your services as a member
should be limited or not given at all.

4. Have no ?gag rules? in Horizon
NJ Health. This means doctors are free
to discuss all medical treatment options
with you even if the services are not
covered by Horizon NJ Health.

5. Know how Horizon NJ Health pays its
doctors. This will help you know if there
are financial reasons tied to making
medical decisions.

6. Not have doctors give you a bill for
extra money. Your health insurance pays
an amount of money to the doctor. The
doctor cannot charge you more, even
if that amount is not what the doctor
chooses to charge.

7. Be part of the discussion with your
doctor in making decisions about your
health care.

8. Information and open talk about your
medical condition and ways of treating
that condition.

9. Choose from different ways of treating
your condition that are presented
in a clear and understandable way,
regardless of the cost or what your
benefits cover.

10. Have your medical condition explained
to a family member or guardian if you
are not able to understand it, and have
it written down in your medical records.

11. Refuse medical treatment with an
understanding of the results if you
choose to not have medical treatment.

12. Refuse care from a specific doctor.

13. Get care that supports a meaningful
quality of life free of harmful procedures,
including unnecessary physical restraints
or isolation, excessive medicine,
physical or mental abuse and neglect.

You have the right to:
? Have a choice of specialists. These are

doctors who treat special illnesses or
problems. This includes the right to:

1. Get information about what you have to
do to see a specialist. This is called the
referral process.

2. Have a second opinion or a visit to
a doctor for another point of view in
certain cases.

3. Be referred to a specialist who has
experience treating your disability or
health condition if you have a disability
or condition that lasts a long time.

4. Request a referral that you can use over
again, known as a standing referral
order, when you need to see a
specialist for a medical condition that
is long-lasting.

5. Get care from a doctor who does not
work with Horizon NJ Health when
a Horizon NJ Health doctor is not
available.

You have the right to:
? Call 911 for what may be a life-threatening

situation without letting Horizon NJ Health
know before you do it. If you go to the ER,
this includes the right to:

1. Have Horizon NJ Health pay for a
medical screening exam in the ER to
see whether an emergency medical
condition exists.

You have the right to:
? Certain coverage benefits after the birth of

a child. This includes the right to:

1. Stays in the hospital after you have had
a baby that are no less than 48 hours
for a normal vaginal delivery and no
less than 96 hours after a cesarean
section birth.

2. Get up to 120 days of continued
coverage, if it is medically necessary,
from a doctor who no longer works with
Horizon NJ Health, including:

? Up to six months after surgery

? Six weeks after childbirth

? One year of psychological or
oncologic (cancer) treatment

No coverage may be continued if the
doctor is let go from his or her job
because they are a danger to their
patients, has committed fraud or has
been disciplined by the State Board of
Medical Examiners.

You have the right to:
? Give instructions about your health care

and name someone else to make health
care decisions for you. This includes the
right to:

1. Make an advance directive about
medical care. An advance directive is
also known as a living will. It includes
instructions that say what actions
should be taken for a person?s health
if they are no longer able to make
decisions. Federal law requires doctors
to ask about a member?s advance
directive.

Your Rights and Responsibilities



40horizonNJhealth.com39 Member Services: 1-800-682-9090

You have the right to:
? Ask questions and get answers and

information about your health plan and
anything you do not understand. You can
also make suggestions. This includes the
right to:

1. Get timely notice of changes to your
benefits or the status of your doctor.

2. Get information about Horizon
NJ Health?s services, doctors and
providers.

3. Offer suggestions for changes in
policies, procedures and services.
This can include your own rights and
responsibilities.

4. Look at your medical records at
no charge.

5. Be informed in writing if Horizon
NJ Health decides to end your
membership.

6. Tell Horizon NJ Health when you no
longer want to be a member.

You have the right to:
? Appeal a decision based on medical

necessity to deny or limit coverage your
doctor recommends, first within Horizon
NJ Health and then through an
independent organization that can make a
decision. An appeal is a request you make
to Horizon NJ Health on decisions made
about your care. This includes the right to:

1. File a grievance about the organization
or the care provided using your first
language.

2. Know that you or your doctor cannot
be punished for filing a grievance or
appeal against Horizon NJ Health. Also,
you cannot be disenrolled as a member
for filing a grievance or appeal against
Horizon NJ Health.

3. Contact the Department of Human
Services if you are not satisfied with
Horizon NJ Health?s decision about a
grievance or appeal.

4. Use the Fair Hearing process if you are
eligible.

Treatment of Minors
Horizon NJ Health will provide care for members
younger than 18 years old following all laws.
Treatment will be at the request of the minor?s
parent(s) or other person(s) who have legal
responsibility for the minor?s medical care. You
have the right to make informed decisions and
allow treatment of your dependents who are
minors, or under 18 years old.

In certain cases, New Jersey law allows minors
to make health care decisions for themselves.
Horizon NJ Health will allow treatment of minors
when decisions are not made with their parent(s)
or guardian(s) in the following cases:

? Minors who go to an ER for treatment
because of an emergency medical
condition

? Minors who want family planning services,
maternity care or sexually transmitted
diseases (STD) services

? Minors living on their own who have their
own NJ FamilyCare or Health Benefits ID
(HBID) card as head of their household

Your Personal Health Information
Federal rules protect your personal health
information (PHI). This is information about you
and may describe your medical history, insurance
information, tests and their results and other
information that helps you get the right care.

Horizon NJ Health uses your PHI to manage and
pay for your health care. This includes using the
information to:

? Pay provider claims

? Give you information about care
management programs and services that
fit your needs

? Share with a personal representative, like
a family member, at your request

? Share with law enforcement when required
by law

? Share with researchers when requested,
following legal requirements

Horizon NJ Health has many procedures to help
ensure that your PHI stays private. This includes
using secure technological systems, offices and
records management procedures and training
staff.

In addition, you have a right to:
? Privacy of your medical information and

records

? Request access to inspect and copy your
PHI

? Request something be added to your PHI

? Request certain use of the PHI and that the
sharing of some information be restricted

? Request to receive confidential
communications of your PHI if the
disclosure to others could harm you

? Receive information on certain things that
are disclosed about you

If you want to make any requests about your
legal rights or would like information, contact
Horizon NJ Health toll free at 1-800-637-2997
(TTY 711). Ask to speak to the Health Insurance
Portability and Accountability Act (HIPAA)
privacy coordinator.

If you would like to file a grievance about how
your PHI was used, you may do so following the
Grievance process described on page 48.

Your Member Responsibilities
As a member of Horizon NJ Health, you also
have responsibilities. You are responsible for:

? Treating doctors and all health care
providers with respect and kindness.

? Talking openly and honestly with your
PCP or specialist when telling them about
your health.

? Seeking care regularly from a doctor to
protect your health. This includes making
appointments for routine checkups and
shots.

? Following Horizon NJ Health?s rules for
medical care.

? Giving information that is needed to a
doctor and Horizon NJ Health so care can
be provided to you.

? Asking questions of your doctor so you can
understand your health problems and the
care you are receiving.

? Being part of developing treatment goals
that you and your doctor agree on.

? Following your doctor?s advice that was
agreed on and considering the results if
you do not.

? Keeping appointments and calling in
advance if an appointment must be
cancelled.

? Reading all Horizon NJ Health member
materials and following the rules of
membership.

? Following the right steps when filing
grievances about care.

? Learning about health issues through
education when it is offered.

? Paying any copayments or premiums (the
amount of money your health plan says you
need to pay when getting care) when you
have to do so.

? Letting the Health Benefits Coordinator
and Horizon NJ Health know about any
doctors you are seeing when you enroll in
Horizon NJ Health.

Your Rights and Responsibilities (continued)



42horizonNJhealth.com41 Member Services: 1-800-682-9090

Advance Directives
It is a good idea to make an advance directive.
An advance directive is a legal document in
which you state instructions about how you want
to be cared for during the end stages of your life.
It is sometimes called a living will. This document
can help your family and doctors know how to
treat you if you become too sick to tell them.

There are three kinds of advance directives in
New Jersey:

? A proxy directive means you can name
a person (18 years old or older) to make
health care decisions when you no
longer can.

? An instruction directive states your desires/
instructions for care.

? A combined directive names a person and
gives instructions for care.

Now, while you are healthy, is the time to think
about an advance directive. Your doctor can help
you make one. Talk to him or her about your care
options and what to include in the document.

You can also get more information from your
County Welfare Agency. The State of New Jersey
has forms and information on their website at
state.nj.us/health/advancedirective.

Reporting Abuse, Neglect or
Exploitation
You have the right to be free from exploitation,
fraud and abuse. Professionals, including care
takers, are required to report suspected abuse,
neglect or exploitation of any:

? Child or adult who resides in a community
setting

? Elderly living in nursing homes or other
long-term care facilities

If you believe you are the subject of abuse,
neglect or exploitation, report it immediately to
the appropriate source outlined below:

Adult Protective Services
The New Jersey Adult Protective Services (APS)
program has offices in each of the 21 counties.
Reports may be made to those County APS
offices or to:

The Public Awareness, Information, Assistance
& Outreach Unit 24-Hour Toll-Free Hotline:
1-800-792-8820 (TTY 711)
Child Protective Services
The New Jersey Division of Child Protection and
Permanency (DCPP) handles all reports of child
abuse and neglect, including those occurring in
institutional settings such as child care centers,
schools, foster homes and residential treatment
centers. These must be reported to the State
Central Registry (SCR).

Child Abuse Hotline (SCR)
24-Hour Toll-Free Hotline: 1-877-NJ ABUSE
(1-877-652-2873) (TTY 1-800-835-5510)

Horizon NJ Health evaluates and approves
new technology, including reviewing guidelines
from Horizon Healthcare of New Jersey, Inc.,
leading medical literature and published clinical
guidelines and speaking with experts in specific
areas, including practicing doctors. We do all of
this to make sure that you are receiving the best
possible health care.

If you would like a copy of the clinical or
preventive guidelines that Horizon NJ Health
follows, call Member Services at 1-800-682-9090
(TTY 711). The guidelines are also on our website
at horizonNJhealth.com/clinicalguidelines.

We Value Your Opinion
Every few months, Horizon NJ Health hosts
a community health advisory meeting with
members, community health advocates and
community leaders to talk about ways to improve
member services, health education and member
outreach activities. If you would like to join us at
this meeting, call Horizon NJ Health?s Marketing
Department at 1-800-682-9094 (TTY 711) or
email communications@horizonNJhealth.com.

Member Satisfaction Survey Results
Each year, Horizon NJ Health members are
asked what things we and our doctors do well
and what things could be done better. This is
called the Consumer Assessment of Healthcare
Providers and Systems (CAHPS) Survey. Answers
to these questions help us improve the services
that we provide. Results of the most recent
member satisfaction survey are available on
our website at horizonNJhealth.com or can be
mailed to you by calling Member Services.

How Your Doctor is Paid
Doctors in our network are paid by Horizon
NJ Health in different ways. Your doctor may
be paid each time he or she treats you (fee-for-
service) or a doctor may be paid a set fee each
month for each member whether or not the
member actually gets services (capitation).
Your doctor may also get a salary.

These payment methods can include financial
reward agreements to pay some doctors more
(bonuses) based on many things, such as
member satisfaction, quality of care, control of
costs and use of services. Financial incentives do
not encourage decisions that result in providing
fewer services. Horizon NJ Health does not
reward providers for issuing denials of coverage.

Medical Decision-Making
Utilization Management (UM) decisions are
made based on the member?s health care needs
and services and the NJ FamilyCare benefit.
Horizon NJ Health does not offer rewards or pay
to those who make UM decisions. Horizon
NJ Health does not offer any rewards or pay to
its staff who handle the UM decisions for denials
of coverage or services that are needed for good
health. Horizon NJ Health does not stop doctors
from discussing all treatment options with their
patients, even if the service(s) is not a covered
benefit.

If you would like more information about how
your doctor is paid or decisions are made, call
Member Services at 1-800-682-9090 (TTY 711).

Your Rights and Responsibilities (continued) More About Horizon NJ Health



44horizonNJhealth.com43 Member Services: 1-800-682-9090

!

If you have coverage through another insurance
plan, including Medicare, as well as Horizon NJ
Health, your doctor must use the other insurance
plan for payment before he or she bills Horizon
NJ Health for your care. To be sure that the
doctor bills the correct plan, show ALL of your
insurance member ID cards when you go to the
doctor.

When using benefits covered by the other
insurance plan, follow the requirements of that
plan. This includes the need for referrals or using
network doctors.

The Division of Medical Assistance and Health
Services (DMAHS) has a publication with more
information for members enrolled in both
Medicare and Medicaid, ?When You Have
Medicaid and Other Insurance.? This can be
found on their website at www.state.nj.us/
humanservices/dmahs/home/Medicaid?TPL?
Coverage?Guide.pdf. If you would like a copy of
the publication or have questions, you may call
Member Services at 1-800-682-9090 (TTY 711).

The only time you should get a bill from a doctor
is when you have:

? Been treated for a service not covered by
Horizon NJ Health.

? Sought care from a non-participating
doctor without a referral or authorization
from Horizon NJ Health.

? Received a service not covered by the
NJ FamilyCare program.

? Not paid your NJ FamilyCare copayment
when services were delivered.

In these cases, you will be responsible to pay
the entire cost of the service and must make
payment arrangements directly with the doctor.

In all other cases, you should not get bills for any
covered medical services. Please note that this
does not apply to copayments or deductibles
required for certain NJ FamilyCare C and
D members.

If you receive a bill for any covered medical
service, call Horizon NJ Health?s Member
Services Department about the bill. Member
Services may ask you to send the bill to:

Horizon NJ Health
Member/Provider Correspondence
PO Box 24077
Newark, NJ 07101-0406

NJ FamilyCare C and D members must pay any
required copayments.

This is to remind you that DMAHS has the
authority to file a claim and lien against the
estate of a deceased Medicaid client or former
client to recover all Medicaid payments for
services received by that client on or after
age 55. Your estate may be required to pay
back DMAHS for those benefits.
The amount that DMAHS may recover includes,
but is not limited to, all capitation payments to
any managed care organization or transportation
broker, regardless of whether any services were
received from an individual or entity that was
reimbursed by the managed care organization or
transportation broker. DMAHS may recover these
amounts when there is no surviving spouse,
no surviving children under the age of 21, no
surviving children of any age who are blind,
and no surviving children of any age who are
permanently and totally disabled as determined
by the Social Security Administration. This
information was previously provided to you when
you applied for NJ FamilyCare.

To learn more, visit http://www.state.nj.us/
humanservices/dmahs/clients/The?NJ?
Medicaid?Program?and?Estate?Recovery?
What?You?Should?Know.pdf.

If you get a bill

Do not ignore it; call Member Services
for instructions, and we will help you.

When You Have Both Medicare and NJ FamilyCare

If the Service Is: Use This Type of Doctor:

An approved, Medicare-covered benefit (for
example: primary care, lab tests, specialists)

Use a Medicare doctor (does not need to be in
the Horizon NJ Health network)

Inpatient hospital care
Use a Medicare hospital. If possible, use a
hospital also in the Horizon NJ Health network

Emergency care received at a hospital
emergency department

Go to the nearest hospital

A medically necessary service not covered by
Medicare but covered by Horizon NJ Health
(for example: dental services or hearing aids)

Use a Horizon NJ Health network doctor

When You Have Other Insurance and NJ FamilyCare

If the Service Is: Use This Type of Doctor:

An approved, covered benefit from the
other insurance, including referrals from
that insurance?s PCP, prescription drugs and
inpatient hospital stays

Use a doctor from that insurance?s network
(does not need to be in the Horizon NJ Health
network)

A medically necessary service that may not be
covered by the other insurance but is covered
by Horizon NJ Health (for example: personal
care assistance services, family planning
services)

Use a Horizon NJ Health network doctor

Other Health Insurance Bills



46horizonNJhealth.com45 Member Services: 1-800-682-9090

There are a few ways that your Horizon
NJ Health membership could end:

You Can Choose to End Your
Membership
If you decide to end your membership or change
to another health plan, you may do so without
cause during the yearly open enrollment period
from October 1 to November 15 by calling a
Health Benefits Coordinator at 1-800-701-0710
(TTY 1-800-701-0720).
? NJ FamilyCare program members may end

their membership without cause during the
first 90 days after the date of enrollment or
notice of enrollment (whichever happened
later), and then every 12 months during the
Open Enrollment Period.

? Except for Division of Child Protection and
Permanency (DCPP) members, if a member
moves out of New Jersey, he or she must
leave Horizon NJ Health. DCPP members
will be moved to Fee-for-Service coverage.

Members may leave Horizon NJ Health with
good cause at any time.
If you are a NJ FamilyCare A or ABP member,
you must choose another health plan before
your membership ends. Once you ask to be
disenrolled, it will take about 30 to 45 days from
the date you ask until the time you are enrolled
in the new health plan you select.

During this time, Horizon NJ Health will continue
to provide your health care services. This
includes transferring to another Managed Care
Organization or the NJ FamilyCare Fee-for-
Service Program. A Health Benefits Coordinator
will help you understand this process.

? If you lose eligibility, you will be disenrolled
from Horizon NJ Health. If you get your
eligibility back within 60 days, you will be
re-enrolled in Horizon NJ Health. If you
become eligible again after 60 days, you
may be enrolled in a different health plan
if you do not select Horizon NJ Health or if
Horizon NJ Health cannot accept any more
members in your county.

You Could Lose Your Membership
? If you reside outside New Jersey for more

than 30 days.

? If you do not keep your appointment to
renew your NJ FamilyCare eligibility at
the County Welfare Agency or the State-
contracted vendor.

? If you refuse to uphold your responsibilities
(by loaning your ID card to someone else,
for example). You will be told in writing
about this decision and the date that your
membership will end. You have the right
to file an official grievance if you are not
satisfied with this decision.

? If you do not send in a renewal application
on time.

? If NJ FamilyCare D members do not pay
their premiums.

? If you are incarcerated, your membership
will be suspended until you are released.

When You Leave Horizon NJ Health
? You will need to sign your enrollment

application to allow us to send your medical
records to your new health plan.

? If your enrollment with Horizon NJ Health
ends before an approved dental service
has been completed, Horizon NJ Health
will cover the service until completion,
unless there is a change in the treatment
plan by the treating dentist. This prior
authorization approval will be honored for
as long as it is active, or for a period of six
months, whichever is longer. If the prior
authorization has expired, a new request
for prior authorization will be required.

? Destroy your Horizon NJ Health ID card.
It is very important that you protect your
privacy by destroying the old cards so no
one can steal your identity or your benefits.

? It will take 30 to 45 days between when you
ask to leave and the date your enrollment
with Horizon NJ Health ends. Horizon
NJ Health or NJ FamilyCare will continue
to provide services until the disenrollment
date.

? If you decide to disenroll voluntarily from
Horizon NJ Health, you can list your reasons
for leaving in writing.

? Enrollment and disenrollment are always
subject to verification and approval by
New Jersey DMAHS. For details, call your
State Health Benefits Coordinator at
1-800-701-0710 (TTY 1-800-701-0720).

Ending Your Membership



48horizonNJhealth.com47 Member Services: 1-800-682-9090

It is very important that you take personal
responsibility for your health care and the costs
of your care. Make sure you know as much as
possible about the doctors you use and the
treatments they provide.

Billions of dollars are lost to health care fraud,
waste and abuse each year. That means money
is paid for services that may never have been
given. It could also mean that the service that
was billed was not the one performed. Fraud,
waste and abuse by doctors and members
threaten our health care system and can
victimize consumers.

What is Fraud, Waste and Abuse?
Fraud and abuse happen when someone
knowingly gives false information that lets
someone get a benefit they are not entitled to.

Examples of Doctor Fraud, Waste and Abuse
? Forging or altering bills or receipts

? Billing for services that were not performed

? Giving a patient a false diagnosis to justify
tests, surgeries or other procedures that
are not medically necessary

? Billing more than once for the same service

Examples of Member Fraud, Waste and Abuse
? Telling a lie on purpose that results in you

or another person receiving benefits that
you or they are not entitled to

? Loaning or selling your Horizon NJ Health
member ID card or the information on the
card to someone else

? Forging or altering prescriptions

Misuse of your Horizon NJ Health ID card
could result in you losing eligibility for health
care services. Fraud and abuse are also crimes
punishable by legal action with possible time
in jail.

If you or someone you know is aware of health
care fraud, waste and abuse, you should
immediately report it to Horizon NJ Health?s
Fraud Hotline at 1-855-FRAUD20
(1-855-372-8320) (TTY 711), or the New Jersey
Medicaid Fraud Division at 1-888-937-2835
(TTY 1-877-294-4356).
When making a report, please be clear about
which person you believe is committing the
fraud, tell us dates of service or items in
question, and describe in as much detail as
possible why you believe fraud may have been
committed. If possible, please include your
name, telephone number and address so we
can contact you if we have questions during the
investigation.

Any information you give us will be treated with
strict confidentiality and no medical information
will be released without lawful authorization.
When reporting suspected insurance fraud, you
do not have to give your contact information. If
you decide to give your contact information, we
will try to keep it confidential as much as legally
possible.

Horizon NJ Health has a grievance procedure
for resolving disagreements between members,
providers and/or Horizon NJ Health?s operation
or any cause of member dissatisfaction. Upon
request, the notification of grievance and appeal
rights shall be in your primary language. You may
file your grievance and/or appeal in your primary
language. You will also receive the decision
in your primary language. Issues regarding
emergency care will be addressed immediately.
Issues regarding urgent care will be addressed
within 48 hours in your primary language.
Horizon NJ Health will not discriminate against
a member or attempt to disenroll a member for
filing a grievance or appeal.

Grievance Procedure
A grievance can be filed by phone or in writing
and can usually be resolved by contacting
Member Services. If you have a grievance, call
1-800-682-9090 (TTY 711), to talk about it with
one of our Member Services representatives. If
you want, you may send a written grievance to:

Grievances Department
1700 American Blvd.
Pennington, NJ 08534

A dental grievance can be filed by calling
1-855-878-5371 (TTY 1-800-508-6975). The
Dental Operations group will handle all dental
grievances and send you a letter with the
outcome.

When we receive your call or letter, the
following steps will occur:
1. If you call to file a grievance, a Member

Services representative will be available to
discuss and help resolve your grievance.
During this call the Member Services
representative will make every attempt to
resolve your grievance.

? If you are not satisfied with the
resolution from the Member Services
representative during your call, tell the
representative and the grievance will
be forwarded to Horizon NJ Health?s
Complaint Resolution Analyst for further
investigation.

? The Complaint Resolution Analyst will
investigate the grievance and you will
get a written notification about the
outcome within 30 days of receipt of the
grievance.

2. If you submit a written grievance by mail,
a Complaint Resolution Analyst will try to
contact you by telephone within 24 hours
of receipt of the grievance to discuss
and assist in resolving your grievance.
The Complaint Resolution Analyst will
document all the information discussed
with you in our complaint tracking system.
An investigation will begin immediately.

? Written grievances are to be resolved as
required by the urgency of the situation,
but no later than 30 days after receipt.
Once complete, you will receive a
written notice with final outcome within
30 days of receipt of the grievance.

Fraud, Waste and Abuse Grievance and Appeal Procedures



50horizonNJhealth.com49 Member Services: 1-800-682-9090

Appeals
You or your doctor (with your written approval)
have the right to ask Horizon NJ Health to review
and change our decision if we have denied or
reduced your benefits. This is called an appeal.
An appeal can be oral or written. Appeals
filed orally must be followed up with a written
request. All appeals must be submitted within
60 days of the date of the denial letter. Please
follow the appeal process described below.

You also have the right to ask the State to
review Horizon NJ Health?s decision about
your service. This is called a Fair Hearing. You
have this benefit if you are a NJ FamilyCare A
or Alternative Benefit Plan (ABP) member. Call
Horizon NJ Health at 1-800-682-9090 (TTY 711)
to ask if you are eligible. You may request a Fair
Hearing following the completion of an Internal
Appeal. However, the timeframe to request a
Fair Hearing in writing is within 120 days from the
date of the notice of adverse decision following
the Internal Appeal of a denial determination.

If you wish to appeal home care benefits, such as
Personal Care Assistance (PCA), administered by
the Personal Preference Program, please use the
Fair Hearing process, after the Internal Appeal
decision, explained on page 51.

Appeal Process
The appeal process consists of an Internal
Appeal completed by Horizon NJ Health.
Horizon NJ Health will review its decision about
the services you asked for. If you are not happy
with our decision at the end of the Internal
Appeal or if Horizon NJ Health?s decision was
not made by the deadline set, you may ask to
have your request reviewed by someone outside
of Horizon NJ Health. This is an External Appeal.

During the appeal process, you have the right to
continue to get the Horizon NJ Health service in
question until the end of the process if:

? Your appeal is filed in a timely fashion

? The service was previously approved by
Horizon NJ Health and the appeal involves
the termination, suspension or reduction of
that service

? The service was ordered by an authorized
provider

? The appeal request is made on or before
the final day of the previously approved
authorization, or within 10 calendar days
of the notification of adverse benefit
determination, whichever is later

In the event that Horizon NJ Health fails to meet
its obligation to send the notification of adverse
benefit determination at least 10 calendar
days prior to the final day of the previously
approved authorization, Horizon NJ Health shall
automatically extend the authorization to a date
10 calendar days after the date on which the
notification was sent.

You may ask for a copy of the benefit provision,
guideline, protocol or other criterion on which
the appeal decision was based. Horizon
NJ Health will provide the medical records
relating to the determination.

Internal Appeal
Your Internal Appeal must be started no later
than 60 days after the date of the denial letter
sent to you. You or your doctor must:

? Call Horizon NJ Health toll free at
1-800-682-9094 (TTY 711). Oral requests
for an appeal must be followed up in
writing, or

? Fax your letter to the Appeals department
at 1-609-583-3028, or

? Send us a letter to:
Horizon Medical Appeals
PO Box 10194
Newark, NJ 07101

Let us know:
1. Your name and Horizon NJ Health

ID number

2. Your doctor?s name

3. That you want to appeal our decision

4. The reason you want to appeal

5. If the services are for urgent or emergency
treatment

Horizon NJ Health must get back to you with a
decision within 30 calendar days. If your appeal
is about services for urgent or emergency
treatment, we will tell you the results of your
appeal within 72 hours (three days ? weekends
and holidays count).

If we do not approve the services you are asking
for in your appeal, Horizon NJ Health will send
you a letter and explain why. We will also tell you
how to file an External Appeal.

Dental Internal Appeals
If you disagree with Horizon NJ Health?s
decision, you (or your provider, with your written
consent) have a right to appeal this action. You
have a right to appeal through Scion Dental?s
Internal Appeal process. You also have the
option to appeal to the Independent Utilization
Review Organization (IURO). NJ FamilyCare A
and ABP members have the right to request
a Fair Hearing. You must follow the following
Internal Appeal Process.

Health Plan Internal Appeal Process:
You can file an Internal Appeal by:

1. Calling Scion Dental at 1-855-878-5371
(TTY 1-800-508-6975); AND

2. Writing to Scion Dental at PO Box 295,
Milwaukee, WI 53201.

If you call first, you must follow-up your
phone request by writing to Scion Dental at
the address in #2 above.

In your letter, you should include an explanation
for the reason you are appealing our decision
and then sign your request for an appeal. You
have 60 calendar days from the date on which
the notification was sent to request an Internal
Appeal.

However, if you are now receiving these services,
and you want these services to continue
automatically during the appeal, you must either
request an Internal Appeal on or before the final
day of the previously approved authorization, or
request an Internal Appeal within 10 calendar
days from the date on which the notification was
sent, whichever is later.

If you do not request your appeal within these
timeframes, the services will not continue during
the appeal. Scion Dental will decide your Internal
Appeal within 30 calendar days of receipt of your
appeal.

If you or your treating provider believe this
30 calendar-day timeframe for deciding your
appeal is too long and could harm your health,
please call Scion Dental at 1-855-878-5371
(TTY 1-800-508-6975) and ask for an expedited,
or fast appeal. An expedited or fast appeal
means that Horizon NJ Health will decide your
Internal Appeal within 72 hours of receipt. You
may ask for an expedited, or fast appeal, if
you are an inpatient in a facility, if the care you
received was for an urgent or emergency health
concern or if it is medically necessary and taking
30 calendar days to decide the appeal could
seriously harm you in some way.

If you call to request an expedited, or fast
appeal, you do not have to follow up your
phone call with a written request.

Grievance and Appeal Procedures (continued)



52horizonNJhealth.com51 Member Services: 1-800-682-9090

Grievance and Appeal Procedures (continued)
External Appeal
If you want to appeal the denial of your Internal
Appeal, you may ask that someone outside
of Horizon NJ Health review your request
for service. This is done by an Independent
Utilization Review Organization (IURO). Within
60 days of the date of Horizon NJ Health?s
written notice of the internal appeal decision,
you or your doctor must:

? Fill out the form called Application for the
Independent Health Care Appeals Program,
sent to you with the results of your Internal
appeal decision from Horizon NJ Health. Be
sure to sign the form. Your signature allows
the IURO to review your medical records
and other medical information that may be
needed for your appeal.

The IURO will give you its decision within 45 days
after it gets all the materials it needs to make
a decision. You may present your information
about your case directly to the Appeals
Committee either in person or by telephone.
You may have someone come with you to the
proceedings.

If your appeal is about services for urgent or
emergency treatment, you should call the DOBI
at 1-609-292-5316 x50998, or call toll free at
1-888-393-1062 and ask that your appeal be
reviewed within 48 hours (two days ? weekends
and holidays count). You still must complete
the form.

Horizon NJ Health must accept the decision of
the IURO.

Fair Hearing
In addition to your right to Horizon NJ Health?s
appeal process, you may have the right to ask
the State to review Horizon NJ Health?s decision
about your service. This is known as a Fair
Hearing. This right applies to all NJ FamilyCare
A members as well as NJ FamilyCare ABP
members.

If you are not sure if you have a right to a Fair
Hearing, call Member Services toll free at
1-800-682-9090 (TTY 711).
If you are eligible and want to ask for a Fair
Hearing, as soon as you can, but no later than
120 calendar days from the date of Horizon
NJ Health?s decision letter on your Internal
Appeal, you must send a letter to the State at:

New Jersey Department of Human Services
Division of Medical Assistance and
Health Services
Fair Hearing Section
PO Box 712
Trenton, NJ 08625-0712

Let the State know in your letter:
1. Your name and Horizon NJ Health

ID number

2. Your doctor?s name

3. That you want a Fair Hearing

4. The reason you want a Fair Hearing

5. If the services are for urgent or emergency
treatment

6. Your telephone number

7. Include a copy of the Horizon NJ Health
denial letter

If you want to continue getting the benefits
in question during the Fair Hearing process,
you must request to do so in writing within
10 calendar days from the date of the notice
of adverse decision following the Internal
Appeal, or until the end of the prior approved
authorization, whichever is later. You must
follow this timeframe, even though you have

120 calendar days to request a Fair Hearing. If
you request continued benefits and your appeal
is denied, you may have to pay the cost of the
services.

At the hearing, someone outside of Horizon
NJ Health and the State will review your request
for services. This person is a judge from the
Office of Administrative Law (OAL), who will
listen to you and others who speak for or with
you at the hearing. You have the right to be at
the Fair Hearing or have a lawyer, friend or other
person go with or for you.

The OAL judge will give the State an opinion
on your request and the State will then decide
whether to accept or deny your request. The
State will give you its decision within 90 days,
unless your request is for urgent or emergency
treatment.

If you want to appeal the State?s decision,
you have the right to appeal to the Appellate
Division of Superior Court.



54horizonNJhealth.com53 Member Services: 1-800-682-9090

Getting help in another language
Multi-language Interpreter Services
ATTENTION: If you speak a language other than English,
language assistance services, free of charge, are available to
you. Call 1-800-682-9090 (TTY 711). This document is also
available in other languages, as well as other formats, such
as large print and Braille.
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Ligue para 1-800-682-9090 (TTY 711).

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1-800-682-9090 (TTY 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti.

Chiamare il numero 1-800-682-9090 (TTY 711).

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walang bayad. Tumawag sa 1-800-682-9090 (TTY 711).

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Rele 1-800-682-9090 (TTY 711).

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1-800-682-9090 (TTY 711).

ATTENTION: Si vous parlez franvais, des services d'aide linguistique vous sont proposes
gratuitement. Appelez le 1-800-682-9090 (ATS 711).

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1-800-682-9090 (TTY 711).

(TTY 711).

Notice of Nondiscrimination

Horizon NJ Health complies with applicable Federal civil rights laws and does not discriminate
against nor does it exclude people or treat them differently on the basis of race, color, gender,
national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or health status
in the administration of the plan, including enrollment and benefit determinations.

Horizon NJ Health provides free aids and services to people with disabilities to communicate
effectively with us, such as qualified sign language interpreters and information written in
other languages.

Contacting Member Services
Please call Member Services at 1-800-682-9090 (TTY 711) or the phone number on the back of
your member ID card, if you need the free aids and services noted above and for all
other Member Services issues, including:

? Claim, benefits or enrollment inquiries
? Lost/stolen ID cards
? Address changes
? Any other inquiry related to your benefits or health plan

Filing a Section 1557 Grievance
If you believe that Horizon NJ Health has failed to provide the free communication aids and
services or discriminated on the basis of race, color, gender, national origin, age, or disability,
you can file a discrimination complaint also known as a Section 1557 Grievance. Horizon
NJ Health?s Civil Rights Coordinator can be reached by calling the Member Services number
on the back of your member ID card or by writing to the following address:

Horizon NJ Health ? Civil Rights Coordinator
PO Box 10194
Newark, NJ 07101
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Office for Civil Rights Headquarters
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019 or 1-800-537-7697 (TTY)
OCR Complaint forms are available at www.hhs.gov/ocr/office/file index.html.
Para ayuda en espa?ol, llame a 1-800-682-9090 (TTY 711).



1700 American Blvd.
Pennington, NJ 08534
1-800-682-9090 (TTY 711)
horizonNJhealth.com

Products are provided by Horizon NJ Health. Communications are issued by Horizon Blue Cross Blue Shield of New Jersey in
its capacity as administrator of programs and provider relations for all its companies. Both are independent licensees of the
Blue Cross and Blue Shield Association.The Blue Cross? and Blue Shield? names and symbols are registered marks of the
Blue Cross and Blue Shield Association. The Horizon? name and symbols are registered marks of Horizon Blue Cross Blue Shield
of New Jersey. ? 2019 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.

EC002651 (0319)

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