Member Rights and Responsibilities

Your Rights and Responsibilities

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 can expect 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 race, color, religion, sex, age, or national origin.
  • 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 Primary Care Provider (PCP) or a 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 in the Horizon NJ Health network who can treat you.

  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 that are tied to making medical decisions.

  6. Not have healthcare providers give you a bill for extra money. Your health insurance pays an amount of money to the provider. The provider cannot charge you more than your plan allows, even if that amount is not what the provider 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. Have care given to you that supports a meaningful quality of life that is free of harmful procedures including unnecessary physical restraints or isolation, excessive medication, physical or mental abuse or 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 help finding a specialist if you need one.

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

  3. See a specialist who has experience in treating your disability or health condition.

  4. Get care from a doctor or provider who does not work with Horizon NJ Health when a Horizon NJ Health provider 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 emergency room, this includes the right to:
  1. Have Horizon NJ Health pay for a medical screening exam in the emergency room 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 is no longer in the Horizon NJ Health network including:

             – Up to 6 months after surgery

             – 6 weeks after childbirth

             – 1 year of psychological or oncologic (cancer) treatment.

No coverage may be continued if the doctor is let go from his or her job because he or she is 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 own health care and the right to name someone else to make health 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 providers to ask about a member’s Advance Directive.

You have the right to:

  • Ask questions to get answers and information about the health plan and anything you do not understand. You can also make suggestions. This includes the right to:
    1. Timely notice of changes to your benefits or the status of your provider.
    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 own 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 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. Make 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 Banking and Insurance or the Department of Human Services if you are not satisfied with Horizon NJ Health’s decision about a grievance or appeal.

  4. Use the Medicaid 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 to minors when decisions are not made with their parent(s) or guardian(s) in the following cases:

  • Minors who go to an emergency room for treatment because of an emergency medical condition. The minor will be treated without their parents or guardians saying it is okay.
  • Minors who want family planning services, maternity care or sexually transmitted diseases (STD) services. These services will be given as medically necessary without a parent’s or guardian’s approval.
  • Minors living totally on their own and have their own Medicaid ID number as head of their own household.

Your Personal Health Information

Federal rules protect your Personal Health Information (PHI). This is information that is about you and may describe your medical history, insurance information, tests and their results, and other information that help you get the best care. 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 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, please contact Horizon NJ Health toll free at 1-800-682-9090 (TTY 711). Ask to speak to the HIPAA Privacy Coordinator. “HIPAA” stands for the Health Insurance Portability and Accountability Act.

Your Member Responsibilities

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

  • Treating doctors and all healthcare 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 the 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 you and your doctor agree on.
  • Following your doctor’s advice that was agreed upon and considering the results if you don’t.
  • Keeping appointments and calling in advance if you need to cancel.
  • Reading all Horizon NJ Health member materials and following the rules of membership.
  • Following the right steps when making grievances about care.
  • Learning about health issues through education when it is offered.
  • Paying any copays 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.