Handbooks

MLTSS Member Handbook

NJ FamilyCare Member Handbook

Hearing or Vision Impaired

For members with hearing or vision impairments, Horizon NJ Health offers member materials in different formats that meet your needs.

To request a copy of our Member Handbook in Braille, call Member Services at 1-800-682-9090 (TTY/TDD 711) or send an email to: Contact Us

For an audio version of Horizon NJ Health’s Handbook, please click on one of the following subjects:

Tikka Attach

Managed Long-Term
Services & Supports (MLTSS)
Member Handbook

horizonNJhealth.com



horizonNJhealth.comMember Services: 1-844-444-44101 2

Welcome What?s Inside
You deserve quality health care coverage. Now
that you have joined Horizon NJ Health, you can
count on it. The Managed Long-Term Services
& Supports (MLTSS) program is designed for
people who have Medicaid and who need health
and long-term care services like home care
and personal care to stay in their homes and
communities as long as possible. 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.

This MLTSS Member Handbook tells you about
the benefits Horizon NJ Health covers for those
enrolled in the MLTSS program. It also tells you
about your rights and responsibilities and how
to request a service and file a complaint
or grievance.

So welcome and thank you for joining
Horizon NJ Health.

Remember, if you have questions any time ? day
or night ? call our Member Services department
toll free at 1-844-444-4410. (TTY/TDD 711).

You may also write to Horizon NJ Health at:

Horizon NJ Health
MLTSS Member Services
210 Silvia Street
West Trenton, NJ 08628

We are here to help you.

Your Horizon NJ Health MLTSS ID card ?????????????????????????????????????????????????????? 3

How your benefits work ??????????????????????????????????????????????????????????????????? 5

Emergencies ???????????????????????????????????????????????????????????????????????????? 11

Your benefits ???????????????????????????????????????????????????????????????????????????? 13

Programs for you ???????????????????????????????????????????????????????????????????????? 23

Your rights and responsibilities ???????????????????????????????????????????????????????????? 26

More about Horizon NJ Health ???????????????????????????????????????????????????????????? 29

Other health insurance ??????????????????????????????????????????????????????????????????? 31

Managed Long-Term Services & Supports Program ?????????????????????????????????????????? 32

Your Plan of Care ???????????????????????????????????????????????????????????????????????? 37

Complaint/grievance & appeal procedures ?????????????????????????????????????????????????? 52

Interdisciplinary team (IDT) meeting ???????????????????????????????????????????????????????? 57

Member Services
Someone is available 24 hours a day, seven days a week: 1-844-444-4410

TTY/TDD Services
For people with hearing or speech difficulties: 711

24/7 Nurse Hotline 1-800-711-5952

We?ve highlighted some key words throughout this handbook.
Look for these boxes for definitions that will help you get the most from
your Horizon NJ Health membership.

Important Phone Numbers Words to Know



3 4horizonNJhealth.comMember Services: 1-844-444-4410

Your Horizon NJ Health
MLTSS ID card
Always have it available
Before your membership begins, a Horizon
NJ Health MLTSS ID card is mailed to you.
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 MLTSS
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 face prosecution.

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

Benefit ? Service given to a person that
is paid for by the insurance plan.

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

? 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 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 your HBID
card to get Fee-for-Service covered benefits that
Horizon NJ Health does not cover (see the Your
Benefits section on page 13).

Member online services
As a Horizon NJ Health MLTSS member you
have access to our secure online member portal.
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, and what is covered under your plan.
MLTSS members do not have copays for MLTSS
services, but they do have a cost share, or Patient
Payment Liability for Assisted Living and custodial
care in a Nursing Facility. There is also a cost share
for Community Residential Services.

? Complete a health assessment ? complete a survey
about your health, 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 so on the portal.

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

? Enroll in disease management ? 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).

Issue Date
Effective Date

Member ID Number
Primary Care Provider
Primary Care Provider Phone

Dental Benefit
Indication



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? 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 Horizon NJ Health?s member
portal, visit our website at horizonNJhealth.com.
From the home page, click Member Support,
then Resources, then Member Online Services.

We encourage you to sign up for the online
member portal as soon as possible. We hope
you find this self-service tool to be a useful
resource for managing your health plan!

How your benefits work
Selecting your Horizon NJ Health doctor

You can choose a personal Horizon NJ Health
doctor, known as a Primary Care Provider (PCP).

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.
Call Member Services if you would like to
change your PCP. Member Services can also
help you find a doctor in your area.

Provider directory

Horizon NJ Health has a list of providers that
service members. This publication is called the
Provider Directory. There are three different
ways to view the 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.

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

3. The Physician and Health Care Directory ?
updated twice a year, this book lists all
specialists, hospitals, pharmacists and other
providers. Your doctor may use this version
when they need to send you to a specialist.

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

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 Resources.

The role of your Primary Care Provider (PCP)

Call your doctor?s office first ? 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, 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 help give timely
care to you.

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
will be made through your Care Manager.

Questions and answers about your
doctor and dentist

Q. If I have Medicare and Medicaid, 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 Medicaid does. These include
but are not limited to:

? Comprehensive dental services
? Vision services
? Hearing services
? Incontinence supplies
? Personal care assistant services

(agency or Personal Preference Program)
? Medical day care

MLTSS members may also be eligible for
certain MLTSS services. These can include but
are not limited to:

? Home-delivered meals
? Personal Emergency Response System
? Home-based supportive care
? Chore services

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

Specialist ? A doctor who has been
specially trained in a certain field of medicine,
such as cardiology.

Provider ? A person or location
(such as a hospital) that gives medical care.



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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

? Mammograms
? Routine obstetrical care
? 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

? Emergency Room visits
? Medicare-covered services for members

enrolled in Medicare

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. Your Care
Manager can help you with this request.

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

A. Horizon NJ Health contracts with thousands
of doctors and specialists throughout New
Jersey. 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 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 opinion for

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

Q. How do I reach my Care Manager
or get answers about my care plan?

A. You can call our multilingual MLTSS Member
Services staff anytime at 1-844-444-4410
(TTY/TDD 711). Your Care Manager will be
available Monday through Friday, from 8 a.m.
to 8 p.m. At other times, you can call and
leave a message for your Care Manager.
When leaving a message, please be sure to
give enough detail for us to understand why
you are calling. We will return your call
within 24 hours.

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, root canals,
extractions, dentures and crowns (caps).

? 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,
or maxillofacial prosthetics.

You can also call Member Services for help
at 1-844-444-4410 (TTY/TDD 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 give you a paper referral form
or a prescription with the specialist?s name
and phone number.
You do not need a referral for:
? Routine gynecological care
? Family planning services

Referral ? Approval from a PCP to visit
a specialist. The doctor will give you either
a paper referral form or a prescription to
take to the specialist.



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Q. What if I have questions about
authorizations for MLTSS covered
services?

A. If you have any questions about how to
get covered MLTSS services authorized
or if you are not sure whether a service is
covered, the MLTSS Member Services call
center is available to assist you 24 hours
a day, seven days a week at 1-844-444-4410
(TTY/TDD 711). A member?s Service Plan
of Care (SPOC) is developed collaboratively
between members and their Care Manager
and needed services are authorized
based on the member?s SPOC.

Q. What if I have questions about MLTSS
eligibility requirements?

A. Eligibility for MLTSS services is based on
multiple pieces of information, including
how well a person can perform Activities
of Daily Living (ADLs) for example; bathing,

dressing, toileting. Our multilingual MLTSS
Member Services staff is ready to help people
who want to know if they could possibly
be eligible for these services and start the
process to refer for an in-person assessment.
You can call anytime at 1-844-444-4410
(TTY/TDD 711).

The State of New Jersey, Division of Aging
Services, Office of Community Choice Options,
makes all final eligibility decisions on clinical
eligibility.

Make an appointment right away

Soon after becoming a member, you should see
your PCP. A baseline physical specific to your age
and sex will let your doctor measure your health,
review your health history and help prevent future
health problems. It is also important to complete
all treatment which your dentist recommends.
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.

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
at least twice a year. Be sure to complete all
treatment recommended by your dentist.

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 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 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 or 24
hours in advance. That way, your doctor can use
the time to help another patient.

Appointment availability

Emergency services: Immediately upon
presentation at a service delivery 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 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 10 business days of receipt, or
24 hours for urgent care.

Dental care: Routine care is available within
30 days, urgent care within three days and
emergency care within 48 hours.

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

Regular Checkups Are Important ?
Regular medical, mental health and dental
exams and tests can help find problems
before they start. They can also help find
problems early. Your age, health and family
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.



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Mental health care: Appointments are
available within 10 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 mental health provider.

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

Emergencies
Go or do not go?
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.

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. For urgent needs, call your Horizon
NJ Health Care Manager. To access emergency
behavioral health services call toll free
1-877-695-5612 (TTY/TDD 711).

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:

? 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.

You should contact your MLTSS Care Manager
for coordination of care after an emergency room
visit. Be sure to contact your PCP to continue
treatment and support.

Behavioral health emergency
If you are in danger of hurting yourself or others,
you should do one of the following immediately:

? Call 911 if a life is in danger
? Go to the closest emergency room

for attention
? Call your provider if you have one

You do not need to get approval to get
emergency services. After an emergency,
you should contact your provider to continue
treatment and support.

Dental emergencies
A dental emergency is when injury to 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:

? A broken or dislocated jaw
? Heavy, uncontrolled bleeding
? Infection or swelling involving the face or jaw
? Pain from injuries to the mouth or jaw

These conditions can be dangerous to your
health. Go to the ER or call 911. For the
treatment of other kinds of dental emergencies,
call your dentist first. If you do not have a
dentist, please contact Member Services toll
free at 1-844-444-4410 (TTY/TDD 711). For
emergencies that occur after business hours, or
if you are unable to reach your dentist, you can
call Horizon NJ Health?s 24/7 Nurse Hotline at
1-800-711-5952 (TTY/TDD 711).

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 dysfunction of
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.



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What Horizon NJ Health Covers
You have access to NJ FamilyCare benefits

NJ FAMILYCARE BENEFIT DESCRIPTION

Abortions and Related Services Covered by fee-for-service when medically necessary

Acupuncture Covered when provided by a licensed doctor
Adult Day Health/Medical Day Care Covered
Audiology Covered
Blood and Blood Plasma Covered
Chiropractic Services Coverage is limited to spinal manipulation
Cognitive Rehabilitation Therapy Covered

Dental Covered

Dental Orthodontics Coverage includes: limited interceptive and comprehensive orthodontic treatment based on demonstrated medical necessity.

Diabetic Supplies and Equipment Covered

Durable Medical Equipment
& Assistive Technology Devices Covered

Emergency Medical Care/
Emergency Services Covered

EPSDT (Early and Periodic Screening,
Diagnosis and 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



Your benefits
As a member of Horizon NJ Health, you get
the benefits you are entitled to through the NJ
FamilyCare program. You may also be eligible for
certain MLTSS services listed on page 41, depending
on the needs identified in your Plan of Care.

Members with MLTSS benefits do not have
copayments for covered services. MLTSS members
do have a cost share, or Patient Payment Liability
for Assisted Living and custodial care in a Nursing
Facility. There is also a cost share for Community
Residential Services.

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 not covered by Horizon NJ Health or
authorized by your 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 1-844-444-4410
(TTY/TDD 711).

Services not covered by NJ FamilyCare
or Horizon NJ Health
? 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.

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

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

? Experimental procedures, or procedures
not accepted as being effective, including
experimental organ transplants.

Urgent 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:

? Backaches from a pulled muscle
? Broken natural teeth or lost fillings or crowns

? Bruises, small cuts or minor burns
? Cold, cough or sore throat
? Cramps
? Earaches
? Rashes or minor swelling
? Swelling of the gums around a tooth
? Teething discomfort
? Toothaches

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 finding 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 are also covered
and do not require prior approval.

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



15 16horizonNJhealth.comMember Services: 1-844-444-4410

NJ FAMILYCARE BENEFIT DESCRIPTION

Group Homes and 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

Intermediate Care Facilities/
Intellectual Disability Covered by fee-for-service

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 Supplies Covered

NJ FAMILYCARE BENEFIT DESCRIPTION

Mental Health Inpatient Hospital
Services (Including Psychiatric Hospitals)

Covered for DDD and MLTSS members by Horizon NJ Health.
Non-DDD and non-MLTSS members are covered by fee-for-service

Mental Health Outpatient Services
(Excluding Partial Care Services)

Covered for DDD and MLTSS members by Horizon NJ Health.
Non-DDD and non-MLTSS members are covered by fee-for-service

Mental Health ? Home Health Covered for DDD and MLTSS members by Horizon NJ Health. Non-DDD and non-MLTSS members are covered by fee-for-service

Nurse Midwife Covered

Nurse Practitioner Covered

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

Opioid Treatment
(Maintenance and Administration)

Covered for MLTSS members by Horizon NJ Health.
Non-MLTSS members are covered by fee-for-service.

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.

What Horizon NJ Health Covers
You have access to NJ FamilyCare benefits

What Horizon NJ Health Covers
You have access to NJ FamilyCare benefits



17 18horizonNJhealth.comMember Services: 1-844-444-4410

NJ FAMILYCARE BENEFIT DESCRIPTION

Optometrist Services Covered for one routine eye exam per year

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

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

Orthotics Covered for children under 19 years old when medically necessary.

Outpatient Diagnostic Testing Covered

Partial Care Program Covered by fee-for-service

Partial Hospital Program Covered by fee-for-service

Personal Care Assistant (PCA Services) Covered

Personal Preference Program Services 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.



NJ FAMILYCARE BENEFIT DESCRIPTION

Prescription Drugs (Retail Pharmacy)

Coverage includes:
? Atypical antipsychotics,
? Methadone, Suboxone and Subutex or any other drug within

this category when used for the treatment of opioid dependence
? Drugs that may be excluded from Medicare Part D coverage

Coverage excludes:
? 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

Private Duty Nursing ? Under age 21
for non-MLTSS members Covered

Prosthetics Covered

Radiology Services
(Diagnostic & Therapeutic) Covered

Rehabilitation Services (Outpatient
Physical Therapy, Cognitive
Rehabilitation Therapy, Occupational
Therapy, and Speech Pathology)

Covered

Sex Abuse Examinations and
Related Diagnostic Testing Covered by fee-for-service



What Horizon NJ Health Covers
You have access to NJ FamilyCare benefits

What Horizon NJ Health Covers
You have access to NJ FamilyCare benefits



19 20horizonNJhealth.comMember Services: 1-844-444-4410

NJ FAMILYCARE BENEFIT DESCRIPTION

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 and MLTSS members by Horizon NJ Health. Non-DDD
and non-MLTSS members who are in ABP are covered by NJ FamilyCare
fee-for-service. Medical detox is covered by Horizon NJ Health for all members.

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

Transportation to Medically Necessary
Services (mid and lower mode)

Covered by fee-for-service through LogistiCare. To schedule, call LogistiCare
(State transportation contractor).
NOTE: Members should call LogistiCare at 1-866-527-9933 (TTY/TDD
1-866-288-3133) to book a trip by 12:00 noon at least 48 hours in advance
of a routine transportation need.



What Horizon NJ Health Covers
You have access to NJ FamilyCare benefits

? 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).

? 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.

? Self-initiated care without referral/authorization.

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

? 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 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
NJ FamilyCare accepts.

? Services provided by an immediate relative
or household member.

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

? Services provided in an inpatient psychiatric
institution, that is not an acute care hospital,
to those over 21 years of age or under 65
years of age.

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

? Services provided outside the United States
and its territories.

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

? 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.

Dental services
Good oral health is important to your body?s overall
health. You should visit your dentist at least twice
a year for an oral exam and cleaning. A child?s
first dental visit should be completed by the first
birthday or soon after the tooth erupts.

You can select your PCD from the list of Horizon
NJ Health participating general dentists. Children
may have a pedodontist (children?s dental specialist)
or a general dentist as a PCD. You may obtain a
second opinion from any participating Horizon NJ
Health dentist or dental specialist without a referral.
You do not need permission to change your PCD.
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.
Some dental services such as crowns, dentures and
root canals may require prior authorization. Ask
your dentist about this requirement. If you need
to make an appointment with a dental specialist
use the online provider directory for a list of
participating dental specialists. Be sure to complete
all treatment recommended by your dentist.

Horizon NJ Health is committed to the oral care
needs of our special health care members. When
medically necessary, members may receive sedation
dentistry in a hospital operating room or at an
acute surgical center. The dental provider will assess
the member and suggest the appropriate setting to
provide the highest quality of dental care services.

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. Check the Provider
Directory for a list of eye doctors.

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 of its 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 Beacon: Patient, an online
service, to download and print your test results
on your own. Visit http://patient.labcorp.com
to register. Note that LabCorp will give your test
results to your doctor before posting them
to your online account.

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



21 22horizonNJhealth.comMember Services: 1-844-444-4410

Prescription services
Horizon NJ Health covers many medications that
are offered to you at a low cost. 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 that reviews and approves our
formulary. 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
1-844-444-4410 (TTY/TDD 711).

Prescription ? An order written by a doctor
for a drug, test or other health service.

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.

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 newsletter, which
is mailed quarterly to all members. Covered
pharmaceuticals, including those that require
prior authorization, are listed on our website at
horizonNJhealth.com. There is no copayment
for your prescription drugs.

In general, Horizon NJ Health allows up to a
30-day supply for drugs. If you are currently
in a long term care facility, there is generally a
maximum of a14-day drug supply eligibility. A
supply of greater than 14 days is permitted for
certain units of medication (for example, eye
drops). If you live in a long term care facility,
the use of institutional sized drug products, for
example, insulin, will be utilized where available.

The website also has information on
pharmaceutical management procedures,

including the formulary listing, policies and
limitations. Limitations include quantity limits/
plan limitations, days? supply/fill limits, step
therapy and age limits. Paper copies of the
pharmaceutical management procedures are
available by contacting the Pharmacy Department
at 1-844-444-4410 (TTY/TDD 711).

Pharmacy lock-In

Members who see many 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.
If you wish to file an appeal regarding the lock-
in decision, follow the complaint process on
page 52.

Medical transportation
Horizon NJ Health will provide emergency
ground transportation for MLTSS members.

All non-emergency medical transportation services
will be provided by the NJ FamilyCare Fee-for-
Service program but may require medical orders
from your provider. If you need special services
or transportation for your medical care, you can
call the transportation broker, LogistiCare, at
1-866-527-9933 (TTY/TDD 1-866-288-3133). For
livery service, such as car service to a medical
appointment, etc., you can also call LogistiCare for
reservations. 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/TDD 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 their hotline at 1-866-333-1735.
You may also visit the LogistiCare website
at https://wecare.logisticare.com, to complete
an online form and LogistiCare will respond to
your inquiry.

Remember ? do not call an ambulance for
routine transportation.

Mental health services
Horizon Behavioral Health provides mental health
benefits for members. You do not need a referral
from your PCP to see a mental health or substance
use provider. If you need medicine for mental
health and/or substance use, your mental health

Formulary ? A list of approved medicines
that Horizon NJ Health covers.



23 24horizonNJhealth.comMember Services: 1-844-444-4410

and/or substance use provider can prescribe the
medicine for you. Contact a behavioral health
provider or inform your MLTSS Care Manager
if you are experiencing the following:

? Constantly feeling sad
? Feelings of hopelessness or helplessness
? Difficulty concentrating

? Irritability
? Loss of interest in things you once enjoyed
? Poor appetite
? Trouble sleeping

Utilization management
Horizon NJ Health wants to make sure you
receive the most appropriate care for your
problem, in the right setting. To do this, we
have a Utilization Management (UM) team that
works in collaboration with your MLTSS Care
Manager to ensure 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. Horizon NJ Health has special staff who
can help you with UM questions. If you have
questions about our UM process, please contact
your MLTSS Care Manager or MLTSS Member
Services at 1-844-444-4410 (TTY/TDD 711).

Programs for you
Horizon NJ Health helps members manage
many health issues. Talk to your Care Manager
for information about these issues:
? Asthma
? Congestive Heart Failure
? COPD
? Diabetes
? HIV/AIDS
? Hypertension

If you are enrolled in any of our disease
management programs and no longer wish
to be, please call Member Services toll free
at 1-844-444-4410 (TTY/TDD 711).

Family planning services
If you are interested in family planning and
contraceptive services, including genetic testing
and counseling, Horizon NJ Health can help

Ambulatory Surgical Center ? A site that
provides surgical care but does not provide
overnight care.

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 Medicaid and the NJ FamilyCare
program but who are not in the Horizon
NJ Health network. Use your Health Benefits
Identification (HBID) card if you visit them.

Horizon Healthy Journey
Horizon NJ Health understands that it may
be hard to remember all of your health care
recommendations and appointments. 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 your recommended services.

Help for pregnant women: Mom?s GEMS ?
Getting Early Maternity Services
If you think you are pregnant, call your MLTSS
Care Manager right away for an appointment.
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
? Between three weeks and two months 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. Your Care Manager will help
you to apply and to set up an appointment.

Keeping children healthy with CHAMPS
The Early Periodic Screening, Diagnostic and
Treatment (EPSDT) program is a government
benefit that helps keep children healthy. Horizon
NJ Health has several programs to make sure
children get all the EPSDT benefits.

CHAMPS stands for ?Children?s Health
Assessment and Maintenance of Preventive
Services,? and the program helps maintain the
health of children from birth until they are 21
years old. CHAMPS helps keep immunizations
and well-child visits on track and reminds

Prenatal Care ? Care for pregnant women.

Postpartum ? Care for a woman after
she delivers a baby.



25 26horizonNJhealth.comMember Services: 1-844-444-4410

parents to have their child?s PCP screen for
medical problems early and keep checking for
problems as the child grows.

Taking children to the doctor is very important
for their healthy growth and development.
Children need to go to the doctor several
times a year up to age 2 and at least once a
year from the ages of 2 to 20. Call your child?s
PCP to schedule visits when your baby is at
these ages:
? Newborn ? 3 days post hospital discharge
? 2 to 6 weeks ? 2 months ? 4 months
? 6 months ? 9 months ? 12 months
? 15 months ? 18 months
? And once a year between ages 2 and 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 the doctor questions and talk
about any problems or concerns you have.

Your child should have a first dental exam by
age 1 and at least twice-yearly dental exams
and cleanings. These visits will include fluoride
varnish and anticipatory guidance. Be sure to
complete all recommended dental treatment.
The NJ Smiles program allows non-dental
providers to perform oral screenings, 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 Resources.

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 ? Diphtheria ? Hepatitis A
? Tetanus ? Hepatitis B ? Polio
? Pertussis ? Influenza ? Meningitis
? Measles ? Rotavirus ? Rubella
? Chicken pox ? Pneumococcal invasive disease

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

Test your child for lead poisoning
According to New Jersey state law, children 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 tested. Children between
the ages of 27 months and 6 years should
be tested if not previously tested. Lead case
management is given to all Horizon NJ Health
members up to 6 years of age who have high
blood lead levels. 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.

Your Horizon NJ Health Care Manager 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.

Your rights
and responsibilities
As a Horizon NJ Health member you have
the right to:

? Get services 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.

? Be treated with respect, dignity and a right
to privacy at all times.

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

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

4. 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.

5. 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.

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

Lead ? Can be found in places you don?t expect.
Cooking tools, toys and candies imported from
other countries may contain lead.



27 28horizonNJhealth.comMember Services: 1-844-444-4410

7. Refuse care from a specific doctor.

8. 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 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

Emergency Room (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.

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

3. Look at your medical records at no charge.

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

5. 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 treatment/

medical care, your MLTSS Plan of Care, and
eligibility determinations, first within Horizon
NJ Health and then through an external
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 complaint about the organization or
the care provided using your first language.

2. Know that you or your doctor cannot be
punished for filing a complaint or appeal
against Horizon NJ Health. Also, you
cannot be disenrolled as a member for
filing a complaint 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 complaint
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 of
minors when decisions are not made with their
parents or guardians 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



29 30horizonNJhealth.comMember Services: 1-844-444-4410

If the service is: Use this type of doctor:

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

Use a Horizon NJ Health network doctor

An approved, covered benefit from the other insurance,
including referrals from that insurance?s PCP,

prescription drugs and inpatient hospital stays

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)

If the service is: Use this type of doctor:

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

Inpatient hospital care

Emergency care received at a hospital
emergency department

A medically necessary service not covered
by Medicare but covered by Horizon NJ Health

(for example: dental services or hearing aids)

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

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

Go to the nearest hospital

Use a Horizon NJ Health network doctor

When you have both Medicare and NJ FamilyCare

When you have other insurance and NJ FamilyCare

? Minors living on their own who have their
own Medicaid ID number as head of
their household

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

? 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.

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

? 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 making
complaints 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.

More about
Horizon NJ Health
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 1-844-444-4410
(TTY/TDD 711). The guidelines are also on our
website at horizonNJhealth.com/for-providers/
clinical-guidelines.

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 at 1-844-444-4410 (TTY/TDD 711) or
email communications@horizonNJhealth.com.

We also invite you to join the Talk to Horizon
NJ Health member community to take short
online surveys to share your thoughts and opinions
to help us make changes to serve you better.

To sign up, visit talktohorizonNJhealth.com/
jointoday. We will not share any of the
information you give us. It will be used only
for research purposes.



31 32horizonNJhealth.comMember Services: 1-844-444-4410

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 benefits. 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 1-844-444-4410
(TTY/TDD 711) 24 hours a day, seven days a week.

Other health insurance
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. For more information please contact
Member Services, your MLTSS Care Manager or
visit NJ Division of Medical Assistance and Health
Services on the web http://www.state.nj.us/
humanservices/dmahs/home/Medicaid_TPL_
Coverage_Guide.pdf.

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.

Horizon NJ Health
Managed Long Term
Services & Supports
Program
The Managed Long Term Services &
Supports (MLTSS) program provides services
and supports to adults and children to help
them perform activities of daily living such as
bathing, dressing, eating and toileting, as well
as supportive activities such as making meals,
shopping, cleaning and laundry. Eligibility for
these services is based on multiple pieces of
information, including how well a person can
perform these basic life tasks. The State of
New Jersey, Division of Aging Services, Office
of Community Choice Options, makes all
final clinical eligibility decisions. The County
Welfare Agency (CWA) makes all financial
eligibility decisions.

Horizon NJ Health members who are eligible
for MLTSS will be assigned a dedicated Care
Manager. The Care Manager, with your input,
and with input from your PCP, will create a Plan
of Care based on your care needs. Once the
Plan of Care is completed, the Care Manager will
arrange for service providers and for admission
to a nursing facility or community residential
setting if needed. The Care Manager will follow
up with you to make sure that the services
continue to meet your care needs.

Horizon NJ Health wishes to provide quality
MLTSS that promote independence, dignity, and
choice. Horizon NJ Health understands that many
people want to stay in their homes as they get
older or need help with everyday tasks to be on
their own; some cannot afford to pay privately for
this help and get most of their help from family,
friends and neighbors.

We refer to help from family, friends and
neighbors as ?informal support.? Horizon
NJ Health?s MLTSS program is NOT intended to
replace this valuable assistance but to make it
even stronger by offering some support to fill the
gaps that cannot be met by family and friends. By
offering a flexible package of services based on
the member?s needs, the MLTSS program makes
it easier for caregivers to remain in their critical
role as the main support system.

At times, despite Horizon NJ Health?s and the
member?s best efforts, it may no longer be
safe for a member to remain in the community.
In such situations, the Care Manager may
recommend that the member be placed in a
nursing facility or community residential setting.

Help from Member Services (1-844-444-4410)
(TTY/TDD 711)
Our multilingual Member Services staff is ready
to help you get the most out of your Horizon
NJ Health membership. You can call us anytime
at 1-844-444-4410 (TTY/TDD 711). Your Care
Manager will be available Monday through Friday,
from 8 a.m. to 8 p.m. At other times, you can call
and leave a message for your Care Manager.



33 34horizonNJhealth.comMember Services: 1-844-444-4410

When leaving a message, please be sure to
give enough detail for us to understand why
you are calling. We will return your call within
24 hours. Horizon NJ Health is available 24
hours a day, seven days a week to review
concerns regarding your Plan of Care or if
you need an urgent authorization, by calling
1-844-444-4410 (TTY/TDD 711). Although your
Care Manager may not be available after hours,
you will have access to a nurse or social worker
(backup Care Manager) who will be able to
help you in your time of need.

Translation services and audio/
visual information
We have staff members who know many
languages. If you speak another language,
our customer service representative can use
the Language Line service, which has more
than 100 languages and dialects.

We can also 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 and they are
easy to use. Just call Member Services toll free
at 1-844-444-4410 (TTY/TDD 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.

Welcome packet

You will receive a welcome packet when you
become enrolled in the Horizon NJ Health MLTSS
Program. The welcome packet includes:

? A Welcome Letter
? MLTSS Member Handbook
? Personal Representative Form
? Personal Preference Information
? Important Phone Numbers

Who qualifies for MLTSS

To qualify for Horizon NJ Health?s MLTSS
program, you must meet all of the following
standards.

? Be a resident of New Jersey

? Be 65 years old or older, or determined
physically disabled by the Social Security
Administration or by the Disability Review
Section of the Division of Medical Assistance
and Health Services

? Qualify for Medicaid financial eligibility by:

? Qualifying for SSI in the community, or

? Qualifying for Medicaid Only - Institutional
Level, or

? Qualifying for New Jersey Care (with
income at or below 100% of the Federal
Poverty Level and resources at or below
$2,000 for individual or $4,000 for a
couple).

? Meet clinical eligibility, which is determined
by a state or county professional as needing
nursing facility level of care

? Reside in an approved community living
arrangement

? Want to enroll and receive services in a
nursing home or in a community setting
instead of living in a nursing home

To enroll in Medicaid MLTSS, contact your
local County Welfare Agency (Board of Social
Services) or your local County Area Agency on
Aging (AAA) ? Aging and Disability Resource
Connection (ADRC). The Office of Community
Choice Options (OCCO) makes the final
decisions about enrollment into the
MLTSS program.

Keeping your membership
Once enrolled in the MLTSS program, you may
remain enrolled if you remain financially and
clinically eligible, follow all the program rules,
and your needs and general health and welfare
can be addressed by the MLTSS program.

You must renew your Medicaid eligibility
annually. You will be notified in writing when
it is time to renew your coverage.

MLTSS member 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 expects you to live up to.

You will get a copy of the following Member
Rights & Responsibilities when you join Horizon
NJ Health. You must sign and return this form,
so we can be sure you have read and understand
these guidelines.

You have the right to:
1. Ask for and receive information on the choice

of services and providers available to you.

2. Have access to and choice of qualified
service providers.

3. Be told about all of your rights before
receiving chosen and approved services.

4. Get services no matter what your race,
religion, color, creed, gender, national origin,
political beliefs, sexual orientation, marital
status, age pregnancy, gender identity, sex
or disability.

5. Have access to all services that are best
for your health and welfare.



35 36horizonNJhealth.comMember Services: 1-844-444-4410

6. Make the right decisions after being made
to understand the risks and possible effects
of the decisions made.

7. Make decisions about your own care needs.

8. Help develop and change your own Plan
of Care.

9. Ask for changes in services at any time,
including to add, increase, decrease or
discontinue them.

10. Ask for and receive from your Care Manager
a list of names and duties of any people
assigned to provide services to you under
the Plan of Care.

11. Receive support and direction from your
Care Manager to resolve concerns about
your care needs and/or complaints about
services or providers.

12. Be told about a list of resident rights,
and receive a copy in writing, upon
admission to an institution or community
residential setting.

13. Be told of all the covered/required services
you are entitled to, required by and/or
offered by the institutional or residential
setting, and of any charges not covered by
Horizon NJ Health while in the facility.

14. Not to be discharged or transferred out
of a facility unless it is medically necessary;
to protect your welfare and safety as well
as the welfare and safety of other residents;
or because of failure, after reasonable

and appropriate notice, to pay the facility
from available income as reported on the
statement of available income for Medicaid
payment.

15. Have Horizon NJ Health protect and promote
all your rights that are outlined in this document.

16. Have all rights and responsibilities outlined here
shared with your authorized representative or
court-appointed legal guardian.

Along with rights come responsibilities. Here are
some of the key responsibilities for MLTSS members:

1. Provide all health and treatment-related
information, including but not limited to,
medication, circumstances, living arrangements,
and informal and formal supports, to the Care
Manager to identify care needs and develop
a Plan of Care.

2. Understand your health care needs and work
with your Care Manager to develop or change
goals and services.

3. Work with your Care Manager to develop and/
or revise your Plan of Care to facilitate timely
authorization and delivery of services.

4. Ask questions when you need more information.

5. Understand the risks that come with your
decisions about care.

6. Develop an emergency backup plan for
care and services with your Care Manager.

7. Report any major changes about your health
condition, medication, circumstances, living
arrangements, informal and formal supports
to the Care Manager.

8. Notify your Care Manager should any
problems occur or if you are not pleased
with the services being provided.

9. Pay your room and board in a nursing facility
or community residential setting and your
cost share on time each month (if applicable).

10. Treat service workers and care providers
with dignity and respect.

11. Keep all Horizon NJ Health documents, such
as your Plan of Care, emergency backup plan,
etc., for your personal records and future
reference.

12. Follow Horizon NJ Health?s rules and/or
those rules of institutional or community
residential settings.

MLTSS care management
Horizon NJ Health provides every MLTSS
member with a Care Manager and care
management team. The Care Manager leads
the team. Your Care Manager is a health care
professional, generally a nurse or a social worker.
The care management team includes nurses,
behavioral health professionals, social workers
and a clinical care support coordinator to help
with your daily needs.

The MLTSS Care Manager will visit you in your
home and talk to you about your needs. Together,

you will develop your Plan of Care. Your Plan of
Care is based on your health status and health
care needs. Your Care Manager will discuss your
rights as a member, the services available through
the MLTSS program and services that are offered
in your community.

We also get input from your family, caregivers
and others you think are important for us to talk
with and understand how you want them involved
with your care. The care plan will list the services
you will get from Horizon NJ Health and describe
the services that Horizon NJ Health will schedule
for you. Your care plan is important. It shows we
have all worked together to decide how we will
help you. Remember, your Care Manager is your
advocate and the goal of the care plan is to help
you get and stay as healthy as you can be to keep
your independence and stay in your community.
You have the right to choose your goals.

After your care plan is developed, your care
team will help you get all the care and services
you need. The care management team will work
with you to schedule appointments. Your Care
Manager will call you at least once a month to
check on you. Your Care Manager will also come
to your home. You will always have your Care
Manager?s phone number. If you leave a message
for your Care Manager, your Care Manager will
return your call within one business day. You can
call to talk to the clinical care coordinator for help
at any time. If you need help after work hours or
on weekends, your call will be sent to someone
who can help you right away.



37 38horizonNJhealth.comMember Services: 1-844-444-4410

For example, if you need to know where to
go for urgent care, your call will be sent to the
on-call staff. If that happens, your Care Manager
will get information about your call to be sure
you got what you needed.

Services will be provided to you within
30 calendar days of your enrollment, except
for residential modification and vehicle
modification. Your care management team will
help coordinate your care, such as physician
visits, prescription drugs, behavioral health
(mental health/addiction services), applying
for services and coordinating other health
providers. You can participate in your care by
sharing your needs and concerns with your
care management team so you may continue
to live independently in your community.

You and your care management team will review
your care plan at least every 90 days. The care
team may also review your care plan if your
condition changes. Horizon NJ Health members
must use in-network, contracted providers to
get covered MLTSS services.

Horizon NJ Health ensures that its MLTSS Care
Managers work in a conflict-free environment.
Care Managers cannot work directly with
members who are blood relatives or related
by marriage. They also cannot be a direct-paid
caregiver or be financially responsible for or
empowered to make financial or health-related
decisions on behalf of a member they are
assigned to.

Your Horizon NJ Health MLTSS Care Manager
will call you to introduce him/herself when
you join. You have the right to change your
Care Manager. You may do so by telling your
Care Manager or calling Member Services
at 1-844-444-4410 (TTY/TDD 711).

Your Plan of Care
What is a Plan of Care?
The Plan of Care is based on your assessed care
needs. It outlines what services and supports
are needed to help you. Your Plan of Care is
personalized for you.

The Plan of Care form and the tools and
methods used to support and develop it help
make sure you are getting comprehensive
and cost-effective delivery of services. The Plan
of Care is reviewed often and updated at least
every year to ensure you get the services
you need.

The Plan of Care will be developed with you
and/or your authorized representative, based
on your needs. The plan will include unmet
needs, personal goals, risk factors, and backup
plans to address instances where services are
not delivered as per your Plan of Care.

The Plan of Care will be signed and dated by
you and/or your authorized representative and
you will get a copy within 30 days. You will be
told about any changes to the Plan of Care and
you must state if you agree or disagree with the
following statements:

? I agree with the Plan of Care.

? I had the freedom to choose the services
in the Plan of Care.

? I had the freedom to choose the providers
of my services based on available providers.

? I helped develop this Plan of Care.

? I am aware of my rights and responsibilities
as a member of this program.

? I am aware that the services outlined
in this Plan of Care are not guaranteed.

? I have been told about potential risk factors
outlined in this Plan of Care.

? I understand and accept these potential
risk factors.

If you disagree with any of these statements,
your concerns will be noted on the plan before
you sign it. You must review and sign off on any
changes to your plan.

The Care Manager will also explain and
sometimes remind you that specific clinical and
financial criteria are required to participate in this
program. They will tell you who is responsible for
making sure you continue to be eligible for both.

Participant direction and personal
preference program
MLTSS program was designed to give you the
most possible responsibility and independence
so you have more control over making decisions,

planning and managing your care. You can
choose who provides your care, what type of
care you want and need, when you want care,
and where the care will be provided.

Caregivers or service providers become
accountable to you. For those members who
are capable of and choose to direct their own
care, you may do so under the Personal
Preference Program (PPP).

Members who participate in the Participant
Direction of Home- and Community-Based
Services choose either to serve as the employer
of record of their workers or to name a
representative to serve as employer of record
on his/her behalf.

As the employer of record, you and/or your
representative are responsible for:

1. Recruiting, hiring and firing workers

2. Determining workers? duties and creating
job descriptions

3. Scheduling workers

4. Supervising workers

5. Evaluating worker performance and
addressing any faults or concerns

6. Setting the wage to be paid to each worker
within the boundaries of the Plan of Care
funds

7. Training workers to provide personalized
care based on your needs and preferences



39 40horizonNJhealth.comMember Services: 1-844-444-4410

8. Ensuring that workers deliver only those
services authorized, and reviewing and
approving hours of workers

9. Reviewing and ensuring documentation
for services provided

10. Developing and implementing as needed
a backup plan to address instances when
a scheduled worker is not available or does
not show up as scheduled

You or your guardian may designate a
representative to take over the participant
direction responsibilities on your behalf.
The representative must:

1. Be at least 18 years of age

2. Understand your support needs

3. Know your daily schedule and routine,
medical and functional status, medication
regimen, likes and dislikes, and strengths
and weaknesses

4. Be physically present in your residence on
a regular basis or at least often enough to
supervise and evaluate each worker

Your representative may not be paid for serving
this role and may not serve as your worker for
any participant-directed service.

You may change your representative at any
time. Contact your assigned Care Manager
and the Participant Directed Program agency
right away if you would like to change
representatives.

If Participation Direction and PPP is something
you are interested in, your Care Manager can tell
you more about the program.

Health care appointments
Tell your care management team about your
medical appointments. You should tell your
Care Manager about what happened at your
appointment. Include information about any
changes to your medications or services. If you
are unsure about what happened, tell your care
management team. Your Care Manager will
help you understand what happened. Your Care
Manager will also help you include any new
information in your care plan.

Bills
You should not get a bill from Horizon NJ Health
network providers for covered services. You do
not have to pay a network provider for covered
services even if Horizon NJ Health denies
payment to them. If we do not pay for all or part
of a covered service, the provider is NOT allowed
to bill you for what we did not pay.

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

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

If you receive a bill for any covered medical
service, call your Care Manager or Member
Services 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

This is to remind you that Division of Medical
Assistance and Health Services (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.

MLTSS services
Covered services are services Horizon NJ
Health will pay for because you are a member.
These services should be provided by a
network provider. The exact service(s) you

receive and how often and how long you get
them is based on your medical condition(s) and
health and social needs. You can get covered
services as long as they are medically necessary.
A service is medically necessary if it is needed to
prevent, diagnose, correct or cure conditions that
may cause acute suffering, endanger life, result
in illness, interfere with your capacity for normal
activity, or threaten some serious handicap.

The care plan you develop with your Care
Manager will help make sure you get what you
need. Sometimes Horizon NJ Health may need to
review your request before you get a service. We
may ask your primary care provider for an order
or referral. This is to make sure you get the right
care at the right place when you need it.

You will be able to get the care and services
you need by calling your care management team.
The services you need will be put on your care
plan. Most of the time, your Care Manager will
know what you need by just talking to you. You
may always ask for a service you think may help
you take better care of yourself.

If you get a bill ? Do not ignore it; call Member
Services for instructions and we will help you.

Pediatric Day Health ? A program that
provides medical and rehabilitation services
to children in a groupsetting during the day.

Personal Care Assistant ? Staff that assist
members with hands-on activities of daily living
(e.g., bathing, dressing).



41 42horizonNJhealth.comMember Services: 1-844-444-4410

MLTSS BENEFIT DESCRIPTION
Acute Partial Hospitalization
(Mental Health)

Services that provide a non-residential psychiatric rehabilitation program
for members with serious mental illness

Adult Family Care Living in the home of a trained caregiver who provides support and services to the member
Adult Mental Health Rehabilitation
(AMHR) A supervised residential group home that provides mental health services

Assisted Living Services A facility licensed by the Department of Health to provide apartment-style housing

Assisted Living Program Assisted living service to tenants of certain publicly subsidized senior housing buildings
Caregiver/Participant Training Training for caregivers

Chore Services Services needed to maintain the home in a clean and safe environment; not every day housekeeping tasks
Cognitive Therapy
(Group and Individual)

Services to help support loss in function for members with a traumatic
brain injury (TBI) diagnosis

Community Residential Services Services that help support and provide supervision for members with a TBI diagnosis

Community Transition Services Services provided to help move from an institutional setting into his/her own home in the community
Home-Based Supportive Care Services that assist with household needs (e.g., meal preparation, laundry)
Home-Delivered Meals Prepared meals brought to your home

Inpatient Psychiatric Hospital Care Provides therapeutic treatment for individuals with intense mental or emotional problems that may be a threat to themselves, their families or their community
Medication Dispensing Device A device to help give medications and medication reminders
Non-Medical Transportation Transportation to gain access to community services and activities
Nursing Facility Services (Custodial) Facility care with 24-hour medical supervision and continuous nursing care

The following services may be available to you when assessed as a need and identified in your Plan of Care

MLTSS BENEFIT DESCRIPTION
Occupational Therapy
(Group and Individual) Services to help prevent loss of function for members with a TBI diagnosis

Opioid Treatment Services Medication for maintenance and/or detoxification in combination with substance use counseling in a treatment facility
Outpatient Mental Health Clinic/
Hospital Services

Mental health services provided in a community setting for members
with a psychiatric diagnosis

Partial Care Services
Non-residential recovery and clinical services to help individuals with severe
mental illness get back into having a successful role in the community and avoid
hospitalization and relapse (e.g., counseling, pre-vocational services).

Personal Emergency Response Systems A device that allows a member to call for help in an emergency
Physical Therapy (Group and Individual) Services to help prevent loss of function for members with a TBI diagnosis
Private Duty Nursing (Adult) Medically necessary nursing services

Residential Modifications Physical adaptations to a member?s private primary residence necessary to ensure health and safety (e.g., wheelchair ramp)
Respite (Daily and Hourly) A benefit to give caregivers a rest

Social Adult Day Care Community-based group program that provides health, social and related support services in a protective setting
Speech, Language and Hearing
Therapy (Group and Individual) Services to help prevent loss of function for members with a TBI diagnosis

Structured Day Program Structured day program to assist with the development, independence and community living skills of members with TBI diagnosis

Supported Day Services Activities directed at the development of productive activity patterns for members with TBI diagnosis
TBI Behavioral Management
(Group and Individual)

Program provided in or out of the home designed to treat the member
and caregivers when the member has a TBI diagnosis

Vehicle Modifications Modifications to a member or family vehicle to allow greater independence





43 44horizonNJhealth.comMember Services: 1-844-444-4410

Your assigned Care Manager can give you a
detailed description of each MLTSS service.
Your Care Manager will also explain that there
are limits on the amount, frequency and length
of time of each service. Before services can
begin, your Care Manager must approve and
arrange the services.

MLTSS services are subject to limitations; your
Care Manager can give you more information
on these restrictions. Here is a list of limitations
that apply to all MLTSS services:

? Services must be cost-effective, while
supporting your care needs.

? Services are designed to supplement, not
replace, assistance already being provided
by family, friends and neighbors.

? Services are for the MLTSS member, with the
exception of caregiver participant training.

? Services are requested according to the
Plan of Care.

? MLTSS cannot be used to pay for what is
already being paid for privately, through
another program or through another
insurance plan.

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.

How do I get these services?
To obtain any covered services listed above,
talk to your Care Manager. Your Care Manager
will be able to review and approve most
services you need. When you are approved to
receive services, we will pay for you to receive
the services for a period of time. If we think that
you need more or fewer services, your Care
Manager will talk to you about your needs.
After that discussion and with your agreement,
we may change the amount or type of services
you are receiving to keep you independent in
the community. Your care plan ? with your input
? will be updated to reflect these changes.

Who provides these services?
Services, as authorized and arranged by your
assigned Care Manager, may only be given by
approved, contracted providers with Horizon
NJ Health.
All service providers must meet qualification
requirements determined by the State of New
Jersey, approved by the federal government
(if applicable), and credentialed by Horizon
NJ Health.

Reporting abuse, neglect or exploitation
You have the right to be free from exploitation,
fraud and abuse. Professionals, including care,

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 your Care Manager and 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/TDD 711)

Child Protective Services
The New Jersey Division of Child Protection
and Permanency (DCP&P) 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/TDD 1-800-835-5510

Facility-Based Complaints and Investigation
Office of the Ombudsman for the Institutionalized
Elderly investigates claims of abuse and neglect
of people age 60 and older living in nursing
homes and other long-term health care facilities,
such as assisted living facilities.

24-Hour Toll-Free Hotline: 1-877-582-6995
Email: ombudsman@advocate.state.nj.us

Write:
The Office of the Ombudsman

PO Box 852
Trenton, NJ 08625-0852

Fax: 1-609-943-3479 (TTY/TDD 711)

NJ Division of Health Facilities Evaluation and
Licensing investigates all complaints against
health care facilities, nursing homes, assisted
living residences, comprehensive personal care
homes, adult medical day care, and other
licensed acute and long-term care facilities.

24-Hour Toll-Free Hotline: 1-800-792-9770
(TTY/TDD 711)

Write:
New Jersey Department of Human Services

Division of Health Facilities Evaluation
and Licensing
PO Box 367

Trenton, NJ 08625-0367
Adult Day Health ? A program that
provides medical and rehabilitation services
to adults in a group setting during the day.



45 46horizonNJhealth.comMember Services: 1-844-444-4410

Advance directive
An advance directive is a legal document you
can complete on your own that can help ensure
your preferences for various medical treatments
are followed if you become unable to make
your own health care decisions. Your advance
directive only goes into effect if your physician
has evaluated you and determined that you are
unable to understand your diagnosis, treatment
options or the possible benefits and harms of
the treatment options.

New Jersey has two kinds of advance directives
? a ?proxy directive? and an ?instruction
directive.? It is your decision whether to have
both kinds or just one of them. You can find
more information online at: www.state.nj.us/
health/advancedirective/whatis.shtml.

Proxy Directive
(Durable Power of Attorney for Healthcare)
A proxy directive is a document you use to
appoint a person to make health care decisions
for you in the event you become unable to
make them yourself. This document goes into
effect whether your inability to make health
care decisions is temporary because of an
accident or permanent because of a disease.
The person you appoint is known as your
?health care representative? and they are
responsible for making the same decisions you
would have made under the circumstances. If
they are unable to determine what you would

want in a specific situation, they are to base
their decision on what they think is in your
best interest.

Instruction Directive
(Living Will)
An instruction directive is a document you use
to tell your physician and family about the
kinds of situations in which you would want or
not want life-sustaining treatment in the event
you are unable to make your own health care
decisions. You can also include a description
of your beliefs, values and general care and
treatment preferences. This will guide your
physician and family when they have to make
health care decisions for you in situations not
specifically covered by your advance directive.

Plan ahead for emergencies
The first line of defense against the effects of
a disaster is to make sure you are prepared.
During a State or National emergency, the
government and other agencies may not be
able to meet your needs. It is important for you
to create your own emergency plan and prepare
for your own care and safety in an emergency.
Your Care Manager will review your MLTSS
back-up plan with you during the development
of your emergency plan.

The NJ Office of Emergency Management has
a website for residents of NJ with special needs
and their families to register. The information
will allow emergency responders to better
serve them in a disaster or other emergency.

https://www13.state.nj.us/SpecialNeeds/
signin.aspx

If you would like to register and need assistance
your MLTSS Care Manager can assist you.

Privacy and confidentiality

It is the policy of Horizon NJ Health to protect
your confidentiality and that of your family.
To protect this confidentiality:

? All information in your member record is
confidential. Horizon NJ Health?s staff protects
against accidental release of information
by safeguarding records and reports from
unauthorized use.

? All requests for information will be reviewed
by the Horizon NJ Health Compliance Officer
to protect your right to privacy. Only necessary
information will be shared with community
agencies, hospitals, long-term care facilities,
and other providers to ensure the continuity and
coordination of your care.

? Horizon NJ Health will permit only legally
authorized representatives of Horizon NJ
Health to inspect and request copies of your
medical record and other records of the
covered services provided to you according to
the written consent you will have been asked
to execute authorizing Horizon NJ Health to
release such information.

? Horizon NJ Health will follow all federal and
New Jersey state laws regarding confidentiality,
including those that relate to HIV testing results.

? Horizon NJ Health will maintain all records
relating to you for a period of not less than
seven years after your disenrollment. Horizon
NJ Health medical and financial records are,
and will remain, the property of Horizon NJ
Health except in accordance with applicable
state and federal law, regulations, and Horizon
NJ Health policy and procedures.

? Any requests for information received from
law enforcement agencies regarding your care,
such as from the police or district attorney?s
office, will be brought to the attention of
Horizon NJ Health legal counsel prior to
providing any information to ensure that the
proper authorization is obtained when the law
requires it.

Fraud, waste and abuse
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.



47 48horizonNJhealth.comMember Services: 1-844-444-4410

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

? Billing members for covered services
(other than your copayments)

? Offering gifts or money for services

? Offering free services or supplies to use
your Horizon NJ Health ID card number

? Giving services you do not need

? Abuse by medical staff

Examples of Member Fraud,
Waste and Abuse

? Selling or lending your Horizon NJ Health
ID card to someone else

? Trying to get drugs or services you
do not need

? Forging or changing prescriptions

Misuse of your Medicaid card or 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/TDD 711), or the
New Jersey Medicaid Fraud Division at
1-888-937-2835 (TTY/TDD 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.

Change of information
It is very important that we have your correct
information. If not, your Horizon NJ Health
Care Manager or clinical care coordinator may
not be able to contact you. If you change your
address or phone number, you must call
Member Services at 1-844-444-4410 (TTY/TDD
711), your Care Manager or the Clinical Care
Coordinator.

You also must contact your County Welfare
Office to let them know about the change.
If not, you may not get important notices
regarding your Medicaid coverage and
annual renewal.

Ending your membership
The following are reasons you can be
disenrolled from Horizon NJ Health?s Managed
Long Term Services & Supports (MLTSS)
program:

? You are no longer enrolled with Horizon
NJ Health

? You no longer meet financial or clinical
eligibility criteria for long-term level of care

? You will not allow the Department of Human
Services staff or its designee complete the
clinical eligibility assessment

? You relocate to an unapproved licensed
residence/setting

? You move out of New Jersey

? You are incarcerated

? You were transferred/enrolled into another
Medicaid waiver or the State?s Program
of All Inclusive Care for the Elderly (PACE)

? You refuse to pay your room and board
and/or patient payment liability

? You no longer need the services offered
in the MLTSS program

? You have not received services and/or cannot
be contacted or located at the last known
address for two months

? You refuse services that are outlined in your
Plan of Care and you refuse to voluntarily
withdraw

? You fail to act in accordance with the rules
governing involvement in the program

If you are disenrolled from the program,
you will be told the reason and any rights
you may have to appeal the disenrollment.

You can choose to end your membership
Being a Horizon NJ Health member
is your choice.

MLTSS 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. The
State?s Open Enrollment Period occurs between
October 1 and November 15 each year.

Members may leave Horizon NJ Health
with good cause at any time. Good cause
reasons include:

? When Horizon NJ Health is not providing
services or access to care as agreed on with
the New Jersey Division of Medical Assistance
and Health Services (DMAHS)



49 50horizonNJhealth.comMember Services: 1-844-444-4410

? The member has filed a grievance or appeal
against Horizon NJ Health and is not satisfied
with the results or if Horizon NJ Health did
not respond in a timely manner

? The member has more convenient access
to a doctor who participates in another plan
in the same enrollment area

As an NJ FamilyCare MLTSS 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.

If you choose to voluntarily withdraw from the
MLTSS program, your Care Manager will hold
a face-to-face meeting with you to discuss your
options for care. You will be given a Voluntary
Withdrawal Form to sign. This decision to leave
the MLTSS program does not necessarily mean
that you will no longer have NJ FamilyCare
benefits. The Office of Community Choice
Options (OCCO) will work with you if your
decision to leave the program results in the loss
of Medicaid due to your financial standings.

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 Maintenance
Organization (HMO) if you do not select Horizon
NJ Health or if Horizon NJ Health cannot accept
any more members in your county.

When you leave Horizon NJ Health
? 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.

? 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 Medicaid 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 the
New Jersey DMAHS.

? 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.

MLTSS member advocate
Horizon NJ Health cares about making sure
that members in the MLTSS program have
the information they need to make informed
decisions and have someone they can speak
to if they have any issues or questions.
Every MLTSS member will be assigned a Care
Manager and there is also a MLTSS member
advocate available to you.

The MLTSS member advocate
is responsible for:

? Participating in Interdisciplinary Team (IDT)
meetings and reviewing with the member,
as needed, the IDT process.

? Interacting with members to provide
additional support, education and
clarification regarding the MLTSS program
and what services are available.

? Encouraging members to be fully informed
of their Rights and Responsibilities.

? Assisting members with information needed
in filing complaints, appeals, and grievances,
as warranted.

? Supporting members in navigating Horizon
NJ Health?s MLTSS program.

You can reach the member advocate Monday
through Friday from 8:30 a.m. to 5 p.m. by
calling 1-844-444-4410 (TTY/TDD 711).

Residence Options
The MLTSS program helps qualified members
get care in the most cost-effective, integrated
and least restrictive environment that allows
your needs to be met while feeling safe and
secure with life, including your health and well-
being. You may get services in various settings
based on your desires, the cost of the services
and the safest environment.

For members who meet program requirements,
you have a right to choose between living in
a nursing facility or in a home and community-
based setting. You cannot be moved out of a
nursing facility and into the community unless
you agree to be moved under the MLTSS
program. If you choose to live in a home
and community-based setting, your needs
must be met safely and cost effectively in the
community. Your assigned Care Manager will
evaluate the cost effectiveness of the Plan of
Care if you receive home and community-based
services in your community home. The cost of
your Plan of Care is limited and must not be
more than the rate set by the state.



51 52horizonNJhealth.comMember Services: 1-844-444-4410

Members living in or placed in a nursing
facility may have to pay Patient Payment
Liability. The Patient Payment Liability for Cost
of Care is that portion of the cost of care that
nursing facility and assisted living residents
must pay based on their income as determined
by the County Welfare Agency.

Members pay this amount directly to the
facility every month. You must pay your Patient
Payment Liability to remain eligible for the
MLTSS program. Your Care Manager can tell
you about any Patient Payment Liability you
will owe to the facility.

Members residing in Community Residential
Services (CRS) facilities also have a Patient
Payment Liability.

Individuals who are living or placed in an
assisted living residence must pay room and
board payments and may have to pay Patient
Payment Liability as well. These payments are
paid directly to the facility every month.

You must pay your Patient Payment Liability
to remain eligible for the MLTSS program. Your
Care Manager can tell you about any Patient
Payment Liability you will owe to the facility.

Nursing facility to community transition
If you live in a nursing facility, you may want
to move out of the facility and into the
community. Your assigned Care Manager will
work with you to assess the ability to move

you out of the nursing facility and back into a
community setting. You and your Care Manager
will create a Plan of Care needed for your
expected services to live in the community.
The cost of your Plan of Care in the community
is limited and must not be more than the rate set
by the state.

If it is determined that you can safely and
cost-effectively move from the nursing facility
back to the community, you may be able to use
the Community Transition Services benefit. This
service aids in the transition from an institutional
setting to your own home in the community by
covering transitional expenses. This benefit can
only be used one time and has a limit of $5,000.

Allowable expenses are those needed for
a person to establish a basic household that do
not constitute room and board and may include,
but are not limited to:
? Security deposits required to get a lease

on an apartment or home

? Necessary household furnishings including
furniture, kitchen items, food preparation items
and bed/bath linens

Community Transition Services does NOT
include items such as:
? Payment for room and board

? Monthly rental or mortgage expenses

? Recurring expenses such as food
and regular utility charges

Services must be reasonable and necessary as
determined through the Plan of Care process
developed by your and your Care Manager.
Services must also be based on need. You must
have no other way to obtain these services
yourself or from any other sources, including
community resources.

Your Care Manager can give you more
information about this benefit and help
coordinate these services during the transition.

Money follows the person ? also known
as I choose Home NJ
Members who are determined eligible to
move from an institution to the community may
be eligible for the Money Follows the Person
(MFP) program.

The MFP program is a grant that helps
states rebalance their Medicaid long-term
care systems and helps more people move
out of institutions into the community. The
MFP program increases the use of home and
community-based services and reduces the
use of institutionally-based services. It also
strengthens the ability of Medicaid programs
to provide home and community-based services
to people who choose to transition out of
institutions. The program participation period
is for 365 calendar days.

Participation in the MFP program is voluntary.
Your Care Manager will discuss the program
with you if you appear to qualify and ask you

if you are interested in participating. They will
assess if you meet criteria for the program.
You will have to sign a form stating that you
are interested in participating in the program.

You will also be asked to participate in two
Quality of Life surveys to determine if you feel
good about living in the community after living
in an institution. Someone will contact you or
visit you to ask you these questions.

Complaint/grievance
and appeal procedures
Horizon NJ Health has a complaint procedure
for resolving disagreements between members,
providers and/or Horizon NJ Health. Disputes
may involve Horizon NJ Health?s benefits, the
delivery of services or Horizon NJ Health?s
operation. This procedure includes both
Utilization Management (UM) and non-UM
issues. The notification of grievance and appeal
rights shall be in your primary language.
You may file your complaint and/or appeal
in your primary language. You will also receive
the decision in your primary language (when
requested). 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 complaint,
grievance or appeal.



53 54horizonNJhealth.comMember Services: 1-844-444-4410

Complaint/grievance procedure
A complaint, by phone or in writing, can usually
be resolved by contacting Member Services.
If you have a complaint, call 1-844-444-4410
(TTY/TDD 711) to talk about it with one of our
Member Services representatives. If you want,
you may send a written complaint to:

Horizon NJ Health
Attn: Member Complaints

Member/Provider Correspondence
210 Silvia Street

West Trenton, NJ 08628

Members may also submit a verbal or
written complaint directly to the Department
of Banking and Insurance by phone at
1-609-292-5316 (TTY/TDD 711), by fax
at 1-609-292-5865 or by using the online
complaint form at www.state.nj.us/dobi/
enfcon.htm.

Horizon NJ Health has a complaint procedure
for dental appeals that follows the same
procedures and timelines of medical appeals.
The Dental Operations group will handle all
dental complaints, grievances and appeals.
Any notifications you receive will come from
Dental Operations.

When we receive your call or letter,
the following steps will occur:
1. A Member Services representative will

be available to discuss and resolve your
complaint. If you submit a complaint by
mail, a Member Services representative will

try to contact you by telephone within 24 hours
of receipt of the complaint to discuss and
resolve your complaint. The representative will
document all the information discussed with
you on an electronic form.

2. If you are not satisfied with the resolution
from the Member Services representative, tell
the representative and the complaint will be
forwarded to Horizon NJ Health?s complaint
coordinator for further investigation.

3. The complaint coordinator will investigate
the complaint and you will be notified in the
following time frames:

? If the complaint is resolved within five business
days, you may receive verbal notification. If
Horizon NJ Health cannot reach you through a
telephone call, you will get written notification
about the outcome.

? If the complaint is not resolved within five
business days, your issue will be treated as
a grievance. You will get written notification
about the outcome within 30 days of receipt
of the complaint.

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. All appeals must be
submitted within 90 days of receipt of the denial
determination. Please follow the appeal process
described below.

You also have the right to ask Medicaid to review
Horizon NJ Health?s decision about your service.
This is called a Medicaid Fair Hearing. You may
request a Medicaid Fair Hearing at any time
during the appeal process; however, you must
request a Medicaid Fair Hearing in writing within
20 days of a denial determination.

Appeal process
The appeal process has three stages. In Stage
1 and Stage 2, 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
Stage 2, or if Horizon NJ Health?s decision was
not made by the deadline set for each stage,
you may ask to have your request reviewed by
someone outside of Horizon NJ Health. This is
a Stage 3 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.

You may ask for a copy of the benefit provision,
guideline, protocol or other criterion on which
the appeal decision was based. You can also

request copies of all the documents related
to your appeal.

Stage 1 appeal
Your appeal must be started no later than
90 days after the date of the denial letter sent
to you. You or your doctor must:

? Call Horizon NJ Health toll free at
1-844-444-4410, (TTY/TDD 711), or

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

? Send us a letter to:
Horizon NJ Health
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 10 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).



55 56horizonNJhealth.comMember Services: 1-844-444-4410

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 a Stage 2 appeal.

Stage 2 appeal
If you want to appeal Horizon NJ Health?s
denial of your Stage 1 appeal, then as soon
as you can, but no later than 90 days after
you receive the written denial of your
Stage 1 appeal, you or your doctor must:

? Call Horizon NJ Health toll free at
1-844-444-4410, (TTY/TDD 711), or

? Fax your letter to the Appeals department
at 1-609-538-3028, or

? Send us a letter to:
Horizon NJ Health
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 will send you a letter letting
you know that we have your appeal request.

This will be done within 10 business days
(weekends and holidays do not count) after
we get your phone call or letter.

We will get back to you with a decision on your
appeal within 20 business days. If your appeal is
about services for urgent or emergency treatment,
we will get back to you within 72 hours (three days
? weekends and holidays count).

At this appeal level, you are allowed to present
important information about your appeal directly
to the Appeals Subcommittee, either in person
or by telephone.

If we do not approve the services you are asking
for in your Stage 2 appeal, Horizon NJ Health
will send you a letter explaining why. The letter
will also let you know how to file a Stage 3
external appeal. If you wish to appeal certain
benefits administered by the Personal Preference
Program, the medical necessity of the service
may not be the issue, and the Stage 3 External
Appeal process may not apply. These benefits
may include:

? Adult Family Care
? Assisted Living Program
? Assisted Living Services (when the denial is not

based on medical necessity)
? Caregiver/participant training
? Chore Services
? Community Transition Services
? Home-Based Supportive Care

? Home-Delivered Meals
? PCA (including Personal Preference Program)
? Respite (daily and hourly)
? Social Day Care
? Structured Day Program (when the denial

is not based on medical necessity)
? Supported Day Services (when the denial

is not based on the diagnosis of TBI)

In these cases, please use the Medicaid Fair
Hearing process explained on this page. Please
note that these types of appeals cannot be
pursued through a Stage 3 External Appeal.

Stage 3 external appeal
If you want to appeal the denial of your Stage
2 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
four months of getting Horizon NJ Health?s
written notice of denial, 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 Stage 2
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 (TTY/TDD 711), 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.

Medicaid fair hearing
In addition to your right to Horizon NJ Health?s
appeal process, you may have the right to
ask the New Jersey DMAHS to review
Horizon NJ Health?s decision about your service.
This is known as a Medicaid Fair Hearing.

If you want to ask for a Medicaid Fair Hearing,
as soon as you can, but no later than 20 calendar
days from the date of Horizon NJ Health?s denial
letter, you must send a letter to Medicaid at:

New Jersey Department of Human Services
Division of Medical Assistance

and Health Services
Medicaid Fair Hearing Section

PO Box 712
Trenton, NJ 08625-0712



57 58horizonNJhealth.comMember Services: 1-844-444-4410

Let Medicaid know in your letter:

1. Your name and Horizon NJ Health ID number

2. Your doctor?s name

3. That you want a Medicaid Fair Hearing

4. The reason you want a Medicaid 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

Members must request continuation of benefits
within 20 days of the date of the denial letter
when they request a Medicaid Fair Hearing.
This request must be made in writing.

At the hearing, someone outside of Horizon
NJ Health and Medicaid 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 Medicaid Fair Hearing or have a lawyer,
friend or other person go with or for you.

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

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

Further assistance
In addition to contacting the DMAHS at
1-800-356-1561, you may also get assistance
by contacting the Department of Banking and
Insurance (DOBI), which assists covered persons
who have questions about claims, internal
appeals, and external appeals. You can reach
DOBI by calling 1-800-446-7467.

Interdisciplinary
team (IDT) meeting
Horizon NJ Health is responsible for holding
Interdisciplinary Team (IDT) meetings when your
care plan changes, or you ask for a change to
your care plan, and one of the following applies:

? There is a health or safety risk

? Prior to the denial or reduction of services,
or setting placement, due to costs exceeding
or expecting to exceed the annual cost
threshold

? There is a change in your level of care need

? A significant change in service hours or costs
has occurred since your last IDT

In cases where one of the situations listed
above applies, your MLTSS Care Manager
will schedule the IDT meeting, which occurs
as a telephone/conference call, to discuss
your care. Your Care Manager will explain the
IDT process and what to expect. Your Care
Manager will explain who will be participating,
what will be discussed regarding your care
needs and annual cost cap threshold, and will
also ensure you are aware of your grievance
and appeal rights.

The Interdisciplinary Team includes your Care
Manager, the Care Canager?s supervisor, a
Horizon NJ Health medical director, a MLTSS
member advocate, a representative of the
OCCO, you and/or your family member or
an authorized personal representative, and
the Horizon NJ Health behavioral health
administrator (if behavioral health services
are received). You have the right to ask for an
Interdisciplinary Team meeting if you think you
need one and you can invite any individual
to participate in your IDT, including your PCP.
Most often, your Care Manager, and possibly
the member advocate, will be with you in
your home for the IDT meeting, but all other
participants will be on the telephone.

During the IDT meeting, the cost effectiveness
limitations of the program will be discussed,
as well as the different options available in
terms of services and settings, such as Nursing

Facility settings and services provided in
home and community-based settings. During
the meeting you will be told of the decision
verbally. If at any time during the IDT you or
your representatives have questions, you are
encouraged to ask them.

If at the end of the IDT meeting you are
not satisfied with the outcome, you have the
right to request a Medicaid Fair Hearing.
The MLTSS Department will send you a letter
with the IDT outcome. The IDT outcome letter
will include your Medicaid Fair Hearing rights
and application form.



59 60horizonNJhealth.comMember Services: 1-844-444-4410

Getting help in another language
Multi-language Interpreter Services



61 62horizonNJhealth.comMember Services: 1-844-444-4410

Notice of nondiscrimination

Horizon NJ Health complies with applicable Federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability or sex. Horizon NJ Health does
not exclude people or treat them differently because of race, color, national origin, age,
disability or sex.

Horizon NJ Health provides free aids and services to people with disabilities or those whose
first language is not English, to communicate effectively with us, such as:

? Qualified sign language interpreters
? Information written in other languages

If you need these services, contact Horizon NJ Health?s Director of Regulatory Compliance
at the phone number, fax or email listed below.

If you believe that Horizon NJ Health has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, age, disability or sex, you can
file a grievance with:

Horizon NJ Health ? Director, Regulatory Compliance
Three Penn Plaza East, PP-16C, Newark, NJ 07105
Phone: 1-800-658-6781 (TTY/TDD 711)
Fax: 1-973-466-7759
Email: ComplianceAndEthicsOffice@HorizonBlue.com

You can file a grievance in person, or by mail, fax or email. If you need help filing a grievance,
Horizon NJ Health?s Director of Regulatory Compliance is available to help you.

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 (TDD)

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/TDD 711).

Notes
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210 Silvia Street
West Trenton, NJ 08628
1-844-444-4410 (TTY/TDD 711)
horizonNJhealth.com

Horizon NJ Health is part of the Horizon Blue Cross Blue Shield of New Jersey enterprise, an independent licensee
of the Blue Cross and Blue Shield Association.
? 2017 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.

Facebook? is a registered mark of Facebook, Inc.
Twitter? is a registered trademark of Twitter, Inc.

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28086 (W04/17)

Si desea recibir un ejemplar en espa?ol del manual para los miembros de Horizon NJ Health,
llame a Servicios para Miembros, sin cargo, al 1-844-444-4410 (TTY/TDD 711). Esta oficina
atiende durante las 24 horas, todos los d?as.



2018
Member Handbook

horizonNJhealth.com



Member Services: 1-800-682-90901

Welcome

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
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.
Please look through this Member Handbook to
understand all the benefits we offer.

Remember, if you have questions any time ? day
or night ? call our Member Services Department
toll free at 1-800-682-9090 (TTY 711).
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 Someone is available 24 hours a day, seven days a week: 1-800-682-9090
Horizon NJ Health
Enrollment Hotline

For information about enrolling in Horizon NJ Health: 1-800-637-2997

Horizon NJ Health
Care Manager

To speak with a Care Manager or learn about a disease management
program: 1-800-682-9094, x89634

TTY/TDD Services For people with hearing or speech difficulties: 711
24/7 Nurse Hotline 1-800-711-5952
New Jersey State
Health Benefits
Coordinator (HBC)

For questions about the status of your application: 1-800-701-0710
(TTY 1-800-701-0720)

Behavioral Health
Services

Members enrolled with Division of Developmental Disabilities (DDD),
call Horizon Behavioral Health for mental health or addiction services:
1-877-695-5612

Choice Counseling
Services

Members who need oral interpretation of the information given in
printed materials can call NJ FamilyCare: 1-800-701-0710
(TTY 1-800-701-0720)

Printed Member
Materials

To request a member communication in writing, please call
1-800-682-9090 (TTY 711). There is no charge for printed materials and
the request will be processed within five (5) business days.

Members not enrolled with DDD should call their local Medical Assistance Customer Center
(MACC) for mental health services. To find the number of a local MACC, call NJ FamilyCare at
1-800-356-1561. For substance use services and referrals, call the New Jersey Addiction Services
Hotline at 1-844-276-2777. You can also call 1-844-REACHNJ (1-844-732-2465).



horizonNJhealth.com

Words to Know
We?ve highlighted some key words
throughout this handbook.

Look at these boxes for definitions
that will help you understand your
benefits and services.

2

What?s Inside

Becoming a member ?????????????????????????? 3

Premiums and copayments ???????????????????? 3

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

Your Horizon NJ Health ID card ???????????????? 8

Your personal doctor ?????????????????????????? 9

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

Your benefits and services ???????????????????? 15

Programs for you and your family ????????????? 32

Keeping you healthy ????????????????????????? 38

Your rights and responsibilities ???????????????? 39

More about Horizon NJ Health ???????????????? 44

Other health insurance ??????????????????????? 45

Bills ????????????????????????????????????????? 46

Ending your membership ????????????????????? 47

Fraud, waste and abuse ?????????????????????? 48

Grievance and appeal procedures ????????????? 49



3 Member Services: 1-800-682-9090

Becoming a Member
Who Can Join?
Many people can join NJ FamilyCare including
children, pregnant women, parents/caretaker
relatives, 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
Member Services.

You can also join Horizon NJ Health if you live in
New Jersey and receive NJ FamilyCare through
one of these programs:

? Aid to Families with Dependent Children
(AFDC)/Temporary Assistance for Needy
Families (TANF)

? AFDC-related New Jersey Care for Pregnant
Women and Children

? Supplemental Security Income (SSI) for Aged,
Blind, Disabled (ABD) and Essential Spouses

? New Jersey Care for ABD and Essential
Spouses

? Division of Child Protection and Permanency
(DCPP)

Legal immigrant adults who are lawfully
admitted for permanent residency can apply
for NJ FamilyCare after they have lived in the
United States for more than five years (legal
immigrant children and pregnant women are
exceptions to this rule).

Signing Up and Getting Started
To become a Horizon NJ Health member, call a
New Jersey State Health Benefits coordinator
toll free at 1-800-701-0710. People with hearing
difficulties may call the State?s 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 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 Board of Social Services, they will contact
you when it is time for a renewal.

If your NJ FamilyCare application was not
processed at your local County Board of
Social Services, 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 Board of Social Services or
Health Benefits Coordinator at New Jersey
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.



4horizonNJhealth.com

Renewal Process
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 NJ FamilyCare 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 CWA, you can call
the NJ FamilyCare hotline toll free at
1-800-356-1561 (TTY 711).
NJ FamilyCare members who are not Aged,
Blind and Disabled (ABD) can fill out a renewal
application online at njfamilycare.org. 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.

You must include a form showing your income
for the past month and family size when
you send in your renewal application. Other
documents may also be needed.

Return all materials in the self-addressed
envelope that came with your renewal
application at least 30 days before your renewal
date. If you have questions or need help
completing the renewal application, call the
Horizon NJ Health Outreach Center toll free
at 1-800-682-9094, x81004 (TTY 711).

Provider Directory
Horizon NJ Health has a list of providers that
service members. This publication is called the
Provider Directory. There are three different
ways to view the 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 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.



5 Member Services: 1-800-682-9090

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.

Premiums and Copayments
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 $43.00 to $144.50 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 $78,225 a
year, the maximum amount of their copayments
is $3,911.25. 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.



6horizonNJhealth.com

Member Services
(1-800-682-9090)
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).

Member Online Services
As a Horizon NJ Health member, you have
access to our secure online member portal. 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. To 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 GEMS maternity 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 Horizon NJ Health?s member
portal, visit our website at horizonNJhealth.com.
From the home page, click Member Support,
then Resources, then Member Online Services.

We encourage you to sign up for the online
member portal as soon as possible. We hope
you find this self-service tool to be a useful
resource for managing your health plan!

Words to Know
Provider
A person or location (such as a
hospital) that gives medical care

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. For example,
NJ FamilyCare D members must
pay a $5 copayment for laboratory
services when they are not part of an
office visit.

Benefit
Service given to a person that is paid
for by the insurance plan



7 Member Services: 1-800-682-9090

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 and they are
easy to use. 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.

Your Horizon NJ Health ID Card
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 face prosecution.



8horizonNJhealth.com

Issue date

Copayment
amount

Effective date

Member ID number
Primary Care Provider
Primary Care Provider phone

Dental benefit indication

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).



9 Member Services: 1-800-682-9090

Your Personal Doctor
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, 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 right away?

There could be times ? maybe at
night or on weekends ? when your
doctor is not in the office. You
should still call your doctor?s
office. Your doctor 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
or dentist?

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



10horizonNJhealth.com

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

If you want to change your dentist, you
may select one from our list of participating
providers at horizonNJhealth.com. Simply
click Need a Doctor and select Dentist, or
call Member Services for assistance at
1-800-682-9090 (TTY 711).

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,
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 care/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

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.

Words to Know
Specialist
A doctor who has been specially
trained in a certain field of medicine

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



11 Member Services: 1-800-682-9090

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 longer, healthier
life. Your age, health and family
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.



12horizonNJhealth.com

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 upon
presentation at a service delivery 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.

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

Remember:

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



13 Member Services: 1-800-682-9090

Emergencies
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 there is an injury
or serious infection in your mouth, or the area
around your mouth. This 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

? 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
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 dysfunction of
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.



14horizonNJhealth.com

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.



15 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
Coverage is limited to when performed as a form of
anesthesia in connection with covered surgery by a
licensed doctor

Audiology Covered Covered for members under the age of 16

Behavioral Health Outpatient Services
(Excluding Partial Care Services)

Covered for DDD and MLTSS members by Horizon NJ Health.
Non-DDD/non-MLTSS members are covered by Fee-for-Service

Covered for DDD members by Horizon NJ Health.
Non-DDD members are covered by Fee-for-Service Covered by Fee-for-Service

Blood & Blood Plasma Covered
Coverage is limited to administration of blood, processing
of blood, processing fees and fees related to autologous
blood donations

Chiropractic Services Coverage is limited to spinal manipulation Coverage is limited to spinal manipulation with a $5 copayment Not Covered

Cognitive Rehabilitation Therapy Covered Coverage limited to 60 visits per therapy, per incident, per calendar year
Coverage is limited to treatment for non-chronic conditions
and acute illnesses and injuries. Limited to 60 visits per
therapy, per incident, per calendar year

Dental
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 canal,
extractions, complex oral surgery and orthodontics.

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 canal, surgical extractions, complex oral surgery and orthodontics.

Diabetic Supplies & Equipment Covered

Your Benefits and Services
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 not covered by Horizon
NJ Health or authorized by your 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).



16horizonNJhealth.com

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
Coverage is limited to when performed as a form of
anesthesia in connection with covered surgery by a
licensed doctor

Audiology Covered Covered for members under the age of 16

Behavioral Health Outpatient Services
(Excluding Partial Care Services)

Covered for DDD and MLTSS members by Horizon NJ Health.
Non-DDD/non-MLTSS members are covered by Fee-for-Service

Covered for DDD members by Horizon NJ Health.
Non-DDD members are covered by Fee-for-Service Covered by Fee-for-Service

Blood & Blood Plasma Covered
Coverage is limited to administration of blood, processing
of blood, processing fees and fees related to autologous
blood donations

Chiropractic Services Coverage is limited to spinal manipulation Coverage is limited to spinal manipulation with a $5 copayment Not Covered

Cognitive Rehabilitation Therapy Covered Coverage limited to 60 visits per therapy, per incident, per calendar year
Coverage is limited to treatment for non-chronic conditions
and acute illnesses and injuries. Limited to 60 visits per
therapy, per incident, per calendar year

Dental
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 canal,
extractions, complex oral surgery and orthodontics.

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 canal, surgical extractions, complex oral surgery and orthodontics.

Diabetic Supplies & Equipment Covered


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.



17 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

Durable Medical Equipment
& Assistive Technology Devices Covered

Coverage is limited to specific equipment. Talk to your
doctor or call Member Services for more information.

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

EPSDT (Early & Periodic Screening,
Diagnosis & Treatment)

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

Coverage is limited to well-child care, newborn hearing
screenings, immunizations and lead screening and
treatment

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.

Covered. 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. Must use Horizon NJ Health
participating network providers.

Group Homes & DCPP Residential Treatment Facilities Covered Not Covered

Hearing Aid Services Covered Covered for members under the age of 16

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.

Coverage is limited to skilled nursing provided or
supervised by a registered nurse and home health aide
when the purpose of the treatment is skilled care. Coverage
includes medical social services necessary for treatment of
the member?s medical condition.

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.

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 shall cover both palliative and
curative care.

Hospital Services (Inpatient) Covered

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



18horizonNJhealth.com

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

Durable Medical Equipment
& Assistive Technology Devices Covered

Coverage is limited to specific equipment. Talk to your
doctor or call Member Services for more information.

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

EPSDT (Early & Periodic Screening,
Diagnosis & Treatment)

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

Coverage is limited to well-child care, newborn hearing
screenings, immunizations and lead screening and
treatment

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.

Covered. 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. Must use Horizon NJ Health
participating network providers.

Group Homes & DCPP Residential Treatment Facilities Covered Not Covered

Hearing Aid Services Covered Covered for members under the age of 16

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.

Coverage is limited to skilled nursing provided or
supervised by a registered nurse and home health aide
when the purpose of the treatment is skilled care. Coverage
includes medical social services necessary for treatment of
the member?s medical condition.

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.

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 shall cover both palliative and
curative care.

Hospital Services (Inpatient) Covered

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



19 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

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
Covered, including routine testing related to the
administration of atypical antipsychotic drugs, with
a $5 copayment when not part of an office visit

Maternity Services Covered, including related newborn care and hearing screening

Medical Day Care Covered Not Covered

Medical Supplies Covered Limited coverage. Talk to your doctor or call Member Services for more information.

Mental Health Inpatient Hospital Services
(Including Psychiatric Hospitals)

Covered for DDD and MLTSS members by Horizon NJ Health.
Non-DDD/non-MLTSS members are covered by Fee-for-Service

Covered for DDD members by Horizon NJ Health.
Non-DDD members are covered by Fee-for-Service Covered by Fee-for-Service

Mental Health ? Home Health Covered for DDD and MLTSS members by Horizon NJ Health. Non-DDD/non-MLTSS members are covered by Fee-for-Service Covered for DDD members by Horizon NJ Health. Non-DDD members are covered by Fee-for-Service

Methadone (Maintenance and Administration) Covered by Fee-for-Service

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

Covered with a $5 copayment for the first prenatal
care visit. $10 copayment for services rendered during
non-office hours. No copayment for preventive services
for newborns covered under Fee-for-Service.

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

Covered with a $5 copayment for each visit during office
hours, except for preventive care services.$10 copayment
for visits during non-office hours.

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 Covered, no Custodial Care Not covered

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.



20horizonNJhealth.com

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

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
Covered, including routine testing related to the
administration of atypical antipsychotic drugs, with
a $5 copayment when not part of an office visit

Maternity Services Covered, including related newborn care and hearing screening

Medical Day Care Covered Not Covered

Medical Supplies Covered Limited coverage. Talk to your doctor or call Member Services for more information.

Mental Health Inpatient Hospital Services
(Including Psychiatric Hospitals)

Covered for DDD and MLTSS members by Horizon NJ Health.
Non-DDD/non-MLTSS members are covered by Fee-for-Service

Covered for DDD members by Horizon NJ Health.
Non-DDD members are covered by Fee-for-Service Covered by Fee-for-Service

Mental Health ? Home Health Covered for DDD and MLTSS members by Horizon NJ Health. Non-DDD/non-MLTSS members are covered by Fee-for-Service Covered for DDD members by Horizon NJ Health. Non-DDD members are covered by Fee-for-Service

Methadone (Maintenance and Administration) Covered by Fee-for-Service

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

Covered with a $5 copayment for the first prenatal
care visit. $10 copayment for services rendered during
non-office hours. No copayment for preventive services
for newborns covered under Fee-for-Service.

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

Covered with a $5 copayment for each visit during office
hours, except for preventive care services.$10 copayment
for visits during non-office hours.

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 Covered, no Custodial Care Not covered

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.



21 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

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.

Coverage is limited to members up to age 19 who
require these services due to medical need, including
developmental problems or jaw injury, with a
$5 copayment. Prior authorization required.

Orthotics Covered Not Covered

Outpatient Diagnostic Testing Covered

Partial Care Program Covered by Fee-for-Service for NJ FamilyCare A, B, C and ABP members. Covered for MLTSS members by Horizon NJ Health. Covered by Fee-for-Service ? limited service

Partial Hospital Program Covered by Fee-for-Service for NJ FamilyCare A, B, C and ABP members. Covered for MLTSS members by Horizon NJ Health. Covered by Fee-for-Service ? limited 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.



22horizonNJhealth.com

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

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.

Coverage is limited to members up to age 19 who
require these services due to medical need, including
developmental problems or jaw injury, with a
$5 copayment. Prior authorization required.

Orthotics Covered Not Covered

Outpatient Diagnostic Testing Covered

Partial Care Program Covered by Fee-for-Service for NJ FamilyCare A, B, C and ABP members. Covered for MLTSS members by Horizon NJ Health. Covered by Fee-for-Service ? limited service

Partial Hospital Program Covered by Fee-for-Service for NJ FamilyCare A, B, C and ABP members. Covered for MLTSS members by Horizon NJ Health. Covered by Fee-for-Service ? limited 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.



23 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

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 (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.

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.

Covered with a $5 copayment for brand-name and generic
drugs. If greater than a 30-day supply, a $10 copayment
applies. 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 over-the-counter drugs, 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 smears.

Covered with a $5 copayment for each visit during office
hours. $10 copayment for each visit during non-office
hours. No copayment for well-child visits, lead screening/
treatment, age-appropriate immunizations or preventive
dental services. $5 copayment for first prenatal visit, then
no subsequent copayments.

Private Duty Nursing Covered for members under age 21 Covered if authorized by Horizon NJ Health

Prosthetics Covered

Coverage is limited to the initial provision of a prosthetic
device that temporarily or permanently replaces all or
part of an external body part lost or impaired as a result
of disease, injury or congenital defect. Repair and
replacement services are covered only when needed
due to congenital growth.

Radiology Services (Diagnostic & Therapeutic) Covered Covered with a $5 copayment when not part of an office visit

Rehabilitation Services (Outpatient Physical Therapy,
Occupational Therapy and Speech Therapy) Covered Covered for 60 visits per therapy, per incident, per calendar year

Covered with a $5 copayment; limited to 60 visits per ther-
apy, per incident, per calendar year. Speech therapy for
developmental delay, unless resulting from disease, injury
or congenital defects, is not covered. Cognitive rehabilita-
tion therapy services limited to treatment for non-chronic
conditions and acute illnesses and injuries.



24horizonNJhealth.com

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

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 (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.

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.

Covered with a $5 copayment for brand-name and generic
drugs. If greater than a 30-day supply, a $10 copayment
applies. 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 over-the-counter drugs, 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 smears.

Covered with a $5 copayment for each visit during office
hours. $10 copayment for each visit during non-office
hours. No copayment for well-child visits, lead screening/
treatment, age-appropriate immunizations or preventive
dental services. $5 copayment for first prenatal visit, then
no subsequent copayments.

Private Duty Nursing Covered for members under age 21 Covered if authorized by Horizon NJ Health

Prosthetics Covered

Coverage is limited to the initial provision of a prosthetic
device that temporarily or permanently replaces all or
part of an external body part lost or impaired as a result
of disease, injury or congenital defect. Repair and
replacement services are covered only when needed
due to congenital growth.

Radiology Services (Diagnostic & Therapeutic) Covered Covered with a $5 copayment when not part of an office visit

Rehabilitation Services (Outpatient Physical Therapy,
Occupational Therapy and Speech Therapy) Covered Covered for 60 visits per therapy, per incident, per calendar year

Covered with a $5 copayment; limited to 60 visits per ther-
apy, per incident, per calendar year. Speech therapy for
developmental delay, unless resulting from disease, injury
or congenital defects, is not covered. Cognitive rehabilita-
tion therapy services limited to treatment for non-chronic
conditions and acute illnesses and injuries.



25 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

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

Social Necessity Days Covered by Fee-for-Service; limited to no more than 12 inpatient hospital days Not 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.

Not Covered

Substance use (Inpatient and Outpatient)

Covered for DDD members by
Horizon NJ Health. Medically
managed detox in an acute care
setting is covered by Horizon
NJ Health.

Covered for DDD members by
Horizon NJ Health. Medically
managed detox in an acute care
setting is covered by Horizon
NJ Health Non-DDD members
are covered by Fee-for-Service.

Covered for DDD members by Horizon NJ Health. Medically managed detox in an acute care setting is covered by Horizon NJ Health.

Substance use (Day Treatment/Partial Hospitalization) Covered by Fee-for-Service Not Covered

Substance use (Outpatient and Intensive Outpatient) Covered by Fee-for-Service Not Covered

Substance use (Residential and Short-term Residential) Covered by Fee-for-Service Not Covered

Sub-acute Medically Managed Detoxification and
Enhanced Medically Managed Detoxification

Covered by Fee-for-Service Not Covered

Transportation Services ? Emergency Ambulance (911) Coverage is limited to ambulance 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)



26horizonNJhealth.com

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

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

Social Necessity Days Covered by Fee-for-Service; limited to no more than 12 inpatient hospital days Not 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.

Not Covered

Substance use (Inpatient and Outpatient)

Covered for DDD members by
Horizon NJ Health. Medically
managed detox in an acute care
setting is covered by Horizon
NJ Health.

Covered for DDD members by
Horizon NJ Health. Medically
managed detox in an acute care
setting is covered by Horizon
NJ Health Non-DDD members
are covered by Fee-for-Service.

Covered for DDD members by Horizon NJ Health. Medically managed detox in an acute care setting is covered by Horizon NJ Health.

Substance use (Day Treatment/Partial Hospitalization) Covered by Fee-for-Service Not Covered

Substance use (Outpatient and Intensive Outpatient) Covered by Fee-for-Service Not Covered

Substance use (Residential and Short-term Residential) Covered by Fee-for-Service Not Covered

Sub-acute Medically Managed Detoxification and
Enhanced Medically Managed Detoxification

Covered by Fee-for-Service Not Covered

Transportation Services ? Emergency Ambulance (911) Coverage is limited to ambulance 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)



27 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 for members age 0-6 years old.

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.
Check the Provider Directory for a list of
eye doctors.

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.



28horizonNJhealth.com

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), but are not available to
Plan D members. 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 newsletter, which
is mailed quarterly 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, the copayment is $1 for
generic drugs and $5 for brand name drugs.
For NJ FamilyCare D members, the copayment
is $5 for generic drugs and $10 for brand name
drugs greater than a 34-day supply. 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).

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



29 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.
If you wish to file a grievance about the lock-in
decision, follow the grievance process on
page 49.

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 but may require

medical orders from your provider. 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.
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. Transportation services,
except for emergency ground ambulance, are
not available for Plan D members.

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.



30horizonNJhealth.com

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.

Services Not Covered by
NJ FamilyCare or Horizon NJ Health
Services not covered by Horizon NJ Health or
the NJ FamilyCare 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 procedures
not accepted as being effective, including
experimental organ transplants.

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

? Respite care.

? 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.

? 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.



31 Member Services: 1-800-682-9090

? 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 in an inpatient psychiatric
institution, that is not an acute care
hospital, to those over 21 years of age and
under 65 years of age.

? 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.

Services Not Covered by
NJ FamilyCare or Horizon NJ Health
for NJ FamilyCare D
? Acupuncture and acupuncture therapy,

except when performed as a form of
anesthesia in connection with covered
surgery

? Audiologist services, except for children
under 16 years old

? Biofeedback

? Blood and blood plasma, except
administration of blood, processing of
blood, processing fees and fees related to
autologous blood donations

? Chiropractic services

? Cosmetic services

? Court-ordered services

? Custodial care

? Early and Periodic Screening, Diagnostic
and Treatment (EPSDT) services, except for
well child care, including immunizations and
lead screening/treatments

? Experimental and investigational services

? Hearing aid services, except for children
under 16 years old

? Infertility services

? Intermediate care facilities/intellectual
disability

? Managed Long Term Services and Supports
(MLTSS) not otherwise listed above

? Medical day care services

? Non-medically necessary services

? Nursing facility services

? Orthotic devices

? Personal care assistant services

? Private duty nursing unless authorized by
Horizon NJ Health

? Radial keratotomy

? Recreational therapy

? Rehabilitative services for substance use

? Religious non-medical institutional care
and services

? Residential treatment center psychiatric
programs

? Respite care

? Sleep therapy

? Special remedial and educational services

? Thermograms and thermography

? Transportation services, including
non-emergency ambulance, invalid coach
and lower mode transportation

? Weight reduction programs or dietary
supplements, except surgical operations,
procedures or treatment of obesity when
approved by Horizon NJ Health



32horizonNJhealth.com

Programs for You and
Your Family
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 Coordination nurse
or social worker will complete a comprehensive
needs assessment. After the screening is
completed, a care coordinator 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 ? Parenting assistance

? Personal care ? Food

? Domestic violence ? Advocacy

? Housing issues ? WIC

? Clothing ? NJ FamilyCare

? Mental health ? Support groups

? Substance use

? 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 your medical needs are met and
that you receive the education and support you
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.



33 Member Services: 1-800-682-9090

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
HBID card if you visit them.

NJ FamilyCare D members must use Horizon
NJ Health family planning service providers.
Out-of-network providers will not be covered
for NJ FamilyCare D members.

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. You must choose
an Ob/Gyn or CNM who is part of the Horizon
NJ Health network.

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.



34horizonNJhealth.com

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 and 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.

Words to Know
Pap test
A cervical cancer test

Prenatal care
Care for pregnant women

Postpartum
Care for a woman after she delivers
a baby



35 Member Services: 1-800-682-9090

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 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

? 2 to 6 weeks

? 2 months

? 4 months

? 6 months

? 9 months

? 12 months

? 15 months

? 18 months

? And once a year between ages 2 and 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 ? Diphtheria

? Polio ? Tetanus

? Rubella ? Hepatitis B

? Chicken pox ? Pertussis

? Influenza ? Rotavirus

? Hepatitis A ? Measles

? Meningitis ? Pneumococcal invasive
disease

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

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
? Asthma
? Diabetes
? Congestive Heart Failure (CHF)
? Hypertension
? COPD
? HIV/AIDS



36horizonNJhealth.com

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, 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.

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.

Words to Know
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.

Lead
Can be found in places you don?t
expect. Cooking tools, toys and
candies imported from other
countries may contain lead.



37 Member Services: 1-800-682-9090

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.

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).

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.



38horizonNJhealth.com

Keeping You Healthy
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
here 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.

Words to Know
COPD
A lung disease that makes it hard
to breathe



39 Member Services: 1-800-682-9090

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)

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 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 beliefts, 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:



40horizonNJhealth.com

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 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.



41 Member Services: 1-800-682-9090

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.

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 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.



42horizonNJhealth.com

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 49.



43 Member Services: 1-800-682-9090

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.

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.



44horizonNJhealth.com

More About
Horizon NJ Health
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/for-providers/
clinical-guidelines.

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).



45 Member Services: 1-800-682-9090

Other Health Insurance
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).

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



46horizonNJhealth.com

Bills
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.

If you get a bill

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

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.



47 Member Services: 1-800-682-9090

Ending Your Membership
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 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.



48horizonNJhealth.com

When You Leave Horizon NJ Health
? 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).

Fraud, Waste and Abuse
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.



49 Member Services: 1-800-682-9090

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.

Grievance and Appeal
Procedures
Horizon NJ Health has a grievance procedure
for resolving disagreements between members,
providers and/or Horizon NJ Health. Disputes
may involve Horizon NJ Health?s benefits,
the delivery of services, denial or approval of
services, 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 when requested. 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.



50horizonNJhealth.com

Grievance Procedure
A grievance, by phone or in writing, 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:

Horizon Grievances
1700 American Blvd.
Pennington, NJ 08534

Horizon NJ Health has a grievance procedure for
dental appeals that follows the same procedures
and timelines of medical appeals. The Dental
Operations group will handle all dental
grievances and appeals. For dental appeals,
members may call 1-855-878-5371
(TTY 1-800-508-6975). Any notifications you
receive will come from Dental Operations.

When we receive your call or letter, the
following steps will occur:
1. A Member Services representative will

be available to discuss and resolve your
grievance. If you submit a grievance by
mail, a Member Services representative
will try to contact you by telephone within
24 hours of receipt of the grievance to
discuss and resolve your grievance. The
representative will document all the
information discussed with you on an
electronic form.

2. If you are not satisfied with the resolution
from the Member Services representative,
tell the representative and the grievance
will be forwarded to Horizon NJ Health?s
grievance coordinator for further
investigation.

3. The grievance coordinator will investigate
the grievance and you will get written
notification about the outcome within
30 days of receipt of the grievance.

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 receipt of the denial determination.
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
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 explained on page 52.

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.



51 Member Services: 1-800-682-9090

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, dial extension 89606
and select prompt 2 for the Appeals
Hotline (TTY 711), 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.

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 getting 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.



52horizonNJhealth.com

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 New Jersey DMAHS 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 denial letter, 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.



53 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.
ATENCION: Si habla espafiol, tiene a su disposici6n servicios gratuitos de asistencia lingiiistica. Llame al

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

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

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

UWAGA: Jezeli m6wisz po polsku, mozesz skorzystac z bezplatnej pomocy j?zykowej. Zadzwori pod numer

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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PAUNA WA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad. Tumawag sa 1-800-682-9090 (TTY 711).

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

t.? ?: ? 3-TfCT ? ? g-ill 3fr1cFl ? .:> ? al ? ti f, I <.l c1 I ? 3 q <>I ?tr g-1
1-800-682-9090 (TTY 711) ? cfiR>f cfiZI
CHU Y: NSu b.;in n6i TiSng Vi?t, c6 cac dich V\l h6 trq ngon ngfr mi?n phi danh cho b.;in. Goi s6
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).

u-:...fi J\.S _ U:H y?..i U:/"' us.a wL.? ? ..l..l.a ? ,:J?j .fi Y.l ? 'Ll:H c11.J-! _,..i) Y.\ pl :)..i ?
1-800-682-9090 (TTY 711).

(TTY 711).



54horizonNJhealth.com

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 and policies provided by Horizon NJ Health and services provided by Horizon Blue Cross Blue Shield of New Jersey, each
an independent licensee of the Blue Cross and Blue Shield Association. Communications may be issued by Horizon Blue Cross
Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all of its companies.
? 2018 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.

CMC0011241 (0318)

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