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Member Benefits and ServicesEffective October 1, 2018As a member of Horizon NJ Health, you get the benefits and services you are entitled to in the Managed Long Term Services andSupports (MLTSS) program. In addition to your NJ FamilyCare A or NJ FamilyCare ABP benefits, other MLTSS services may beavailable to you when assessed as a need and identified in your plan of care.If you are not sure whether a service is covered, call Member Services toll free at 1-844-444-4410 (TTY 711).What Horizon NJ Health CoversNJ FAMILYCARE BENEFITDESCRIPTIONAbortions and Related ServicesCovered by Fee-for-ServiceAcupunctureCovered when provided by a licensed doctorAdult Day Health/Medical Day CareCoveredAudiologyCoveredBlood and Blood PlasmaCoveredChiropractic ServicesCoverage is limited to spinal manipulationCognitive Rehabilitation TherapyCoveredDDD Division of Developmental Disabilities FIDE-SNP Horizon NJ TotalCare (HMO SNP) MLTSS Managed Long Term Services & SupportsOctober 2018 Member Services: 1-844-444-4410 (TTY 711)1
What Horizon NJ Health CoversNJ FAMILYCARE BENEFITDESCRIPTIONComprehensive DentalCovered. Some services require prior authorization.Dental OrthodonticsCoverage includes: limited interceptive and comprehensive based on demonstrated medical necessity.Age limits apply. All services require prior authorization.Diabetic Supplies and EquipmentCoveredDurable Medical Equipment& Assistive Technology DevicesCoveredEmergency Medical Care/Emergency ServicesCoveredEPSDT (Early and PeriodicScreening, Diagnosis and Treatment)Covered, including medical exams, dental, vision, hearing and lead screeningservices. Covered for treatment services identified through the exam.Family PlanningCovered. Covered by Fee-for-Service when services are not given by a Horizon NJ Health doctor.Group Homes and DCPPResidential Treatment FacilitiesCoveredHearing Aid ServicesCoveredHome Health Agency ServicesCovered, including nursing services by a registered nurse and/or licensed practical nurse; home health aide service; medical suppliesand equipment; physical, occupational and speech therapy services; pharmaceutical services; and durable medical equipment.Hospice ServicesCovered in the community as well as in institutional settings. Room and board are included only when services are delivered in aninstitutional (non-private residence) setting. Hospice care for children under age 21 shall cover both palliative and curative care.Hospital Services (Inpatient)CoveredHospital Services (Outpatient)CoveredIntermediate Care Facilities/Intellectual DisabilityCovered by NJ FamilyCare Fee-for-ServiceDDD Division of Developmental Disabilities FIDE-SNP Horizon NJ TotalCare (HMO SNP) MLTSS Managed Long Term Services & SupportsOctober 2018 Member Services: 1-844-444-4410 (TTY 711)2
What Horizon NJ Health CoversNJ FAMILYCARE BENEFITDESCRIPTIONLaboratory ServicesCovered, including routine testing related to the administration of atypical antipsychotic drugsMaternity ServicesCovered, including related newborn care and hearing screeningMedical SuppliesCoveredMental Health Inpatient HospitalServices (Including PsychiatricHospitals)CoveredMental Health Outpatient ServicesCovered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.Mental Health – Home HealthCovered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.Nurse MidwifeCoveredNurse PractitionerCoveredNursing Facility Services(Custodial Care, Rehabilitation,Post-acute Care, Skilled NursingCare and Services in Special CareNursing Facilities, Such asVentilator Facilities, PediatricLongterm Care and Treatmentfor AIDS)CoveredOpioid Treatment (Maintenanceand Administration)Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.Covered for select eyeglasses and contact lenses as follows:Optical Appliances 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 changesReplacement 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.DDD Division of Developmental Disabilities FIDE-SNP Horizon NJ TotalCare (HMO SNP) MLTSS Managed Long Term Services & SupportsOctober 2018 Member Services: 1-844-444-4410 (TTY 711)3
What Horizon NJ Health CoversNJ FAMILYCARE BENEFITDESCRIPTIONOptometrist ServicesCovered for one routine eye exam per yearOrgan TransplantsCovered for transplant-related medical costs for the donor and recipient, including donor and recipient costs.Orthodontic Comprehensive ServicesCoverage is limited to members up to age 21 who require these services due to medical need, including developmentalproblems or jaw injury. Prior authorization required.OrthoticsCovered for children under 19 years old when medically necessary.Outpatient Diagnostic TestingCoveredPartial Care ProgramCovered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.Partial Hospital ProgramCovered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.Personal Care Assistant(PCA Services)CoveredPersonal Preference Program ServicesCoveredPodiatrist ServicesCovered. Routine hygienic care of feet, including the treatment of corns and calluses, trimming of nails and other hygienic carein the absence of a pathological condition, is not covered.Coverage includes:Prescription Drugs(Retail Pharmacy) 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 coverageCoverage excludes: Erectile dysfunction drugs; and Drugs not covered by a third-party Medicare Part D formularyDDD Division of Developmental Disabilities FIDE-SNP Horizon NJ TotalCare (HMO SNP) MLTSS Managed Long Term Services & SupportsOctober 2018 Member Services: 1-844-444-4410 (TTY 711)4
What Horizon NJ Health CoversNJ FAMILYCARE BENEFITDESCRIPTIONPrescription Drugs — Medicare PartB (Doctor Administered)CoveredPrimary Care, Specialty Careand Women’s Health ServicesCoveredPrivate Duty NursingCoveredProstheticsCoveredRadiology Services(Diagnostic & Therapeutic)CoveredRehabilitation Services(Outpatient Physical Therapy,Cognitive Rehabilitation Therapy,Occupational Therapy, and SpeechPathology)CoveredSex Abuse Examinationsand Related Diagnostic TestingCovered by NJ FamilyCare Fee-for-ServiceSpecialty Foods (Medical Foods)Coverage is limited to nutritional supplements requiring medical supervision for members with inborn errors of metabolismand related genetic conditions. Medical foods and special diets for all other medical conditions are not covered.Substance use(Inpatient and Outpatient)Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.Transportation Services –Emergency Ambulance (911)Coverage is limited to medical emergencies onlyTransportation to MedicallyNecessary Services(mid and lower mode)Covered by NJ FamilyCare Fee-for-Service through LogistiCare. To schedule, call LogistiCare (State transportation contractor).NOTE: Members should call LogistiCare at 1-866-527-9933 (TTY 1-866-288-3133) to book a trip by 12 p.m. at least 48 hoursin advance of a routine transportation need.DDD Division of Developmental Disabilities FIDE-SNP Horizon NJ TotalCare (HMO SNP) MLTSS Managed Long Term Services & SupportsOctober 2018 Member Services: 1-844-444-4410 (TTY 711)5
Additional ServicesIn addition to your NJ FamilyCare A or NJ FamilyCare ABP benefits, these MLTSS services may be availableto you when assessed as a need and identified in your plan of care.MLTSS BenefitDescriptionAcute Partial Hospitalization(Mental Health)Services that provide a non-residential psychiatric rehabilitation program for members with serious mental illnessAdult Family CareLiving in the home of a trained caregiver who provides support and services to the memberAdult Mental Health Rehabilitation(AMHR)A supervised residential group home or apartment that provides mental health servicesAssisted Living ServicesA facility licensed by the Department of Health to provide apartment-style housingAssisted Living ProgramAssisted living service to tenants of certain publicly subsidized senior housing buildingsBehavioral Management –Traumatic Brain Injury (TBI)(Group and Individual)Program provided in or out of the home designed to treat the member and caregivers when the member has a TBI diagnosisCaregiver/Participant TrainingTraining for caregiversChore ServicesServices needed to maintain the home in a clean and safe environment; not every day housekeeping tasksCognitive Therapy(Group and Individual)Services to help support loss in functionCommunity Residential ServicesServices that help support and provide supervision for members with a TBI diagnosisCommunity Transition ServicesServices provided to help move from an institutional setting into his/her own home in the communityHome-Based Supportive CareServices that assist with household needs (e.g., meal preparation, laundry)Home-Delivered MealsPrepared meals brought to your homeInpatient Mental Health ServicesMental health care services that you get in a hospital that requires you to be admitted as an inpatientOctober 2018 Member Services: 1-844-444-4410 (TTY 711)6
MLTSS BenefitDescriptionInpatient Psychiatric Hospital CareProvides therapeutic treatment for individuals with intense mental or emotional problems that may be a threat to themselves,their families or their communityMedication Dispensing DeviceA device to help give medications and medication remindersNon-Medical TransportationTransportation to gain access to community services and activitiesNursing Facility Services (Custodial)Facility care with 24-hour medical supervision and continuous nursing careOccupational Therapy(Group and Individual)Services to help prevent loss of functionOpioid Treatment ServicesMedication for maintenance and/or detoxification in combination with substance use disorder counselingin a licensed treatment facilityOutpatient Mental Health Clinic/Hospital ServicesMental health services provided in a community setting for members with a psychiatric diagnosisPartial Care ServicesNon-residential recovery and clinical services to help individuals with serious mental illness get back into having a successfulrole in the community and avoid hospitalization and relapse (e.g., counseling, pre-vocational services)Personal Emergency Response SystemsA device that allows a member to call for help in an emergencyPhysical Therapy (Group and Individual)Services to help prevent loss of functionPrivate Duty Nursing (Adult)Medically necessary nursing servicesResidential ModificationsPhysical 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 restSocial Adult Day CareCommunity-based group program that provides health, social and related support services in a protective settingSpeech, Language and HearingTherapy (Group and Individual)Services to help prevent loss of functionStructured Day ProgramStructured day program to assist with the development, independence and community living skills of membersSupported Day ServicesActivities directed at the development of productive activity patterns for membersVehicle ModificationsModifications to a member or family vehicle to allow greater independenceOctober 2018 Member Services: 1-844-444-4410 (TTY 711)7
Services not covered by NJ FamilyCare Fee-for-Service orHorizon NJ Health ervices not covered by Horizon NJ Health or theSNJ FamilyCare Fee-for-Service program include: All services not medically necessary, provided, approved orarranged by a Horizon NJ Health participating doctor (withinhis or her scope of practice) except emergency services. Any service or items for which a provider does notnormally charge. Cosmetic services or surgery except when medically necessaryand approved. Experimental procedures or procedures not acceptedas being effective, including experimental organ transplants. Services provided by or in an institution run by the federalgovernment, such as the Veterans Health Administration. Respite care for more than 30 days per year. Rest cures, personal comfort, convenience items and servicesand 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 therequirements of the procedure described or procedure codeused by the provider. S ervices provided by an immediate relative or householdmember, unless being delivered under the Self Directed Program. Services involving the use of equipment in facilities in whichits purchase, rental or construction has not been approved bythe State of New Jersey. Services resulting from any work-related condition oraccidental injury when benefits are available from anyworkers’ compensation law, temporary disability benefits law,occupational disease law or similar law. Services provided or started while on active duty in the military. Services or items reimbursed based on submission of a coststudy in which there is no evidence to support the costs allegedlyincurred or beneficiary income to make up for those costs. Iffinancial records are not available, a provider may verify costs oravailable income using other evidence that the NJ FamilyCareprogram accepts. Services provided outside the United States and its territories. Infertility diagnoses and treatment services (including sterilizationreversals and related medical and clinic office visits, drugs,laboratory services, radiological and diagnostic services andsurgical procedures). Services provided without charge. Programs offered free ofcharge through public or voluntary agencies should be usedto the fullest extent possible. Any service covered under any other insurance policy or otherprivate or governmental health benefit system or third-party liability.Products and policies provided by Horizon NJ Health and services provided by Horizon Blue Cross Blue Shield of New Jersey, each anindependent licensee of the Blue Cross and Blue Shield Association. Communications may be issued by Horizon Blue Cross Blue Shieldof New Jersey in its capacity as administrator of programs and provider relations for all of its companies. 2018 Horizon Blue CrossBlue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.EC00497October 2018 Member Services: 1-844-444-4410 (TTY 711)8
As a member of Horizon NJ Health, you get the benefits and services you are entitled to in the Managed Long Term Services and Supports (MLTSS) program. In addition to your NJ FamilyCare A or NJ FamilyCare ABP benefits, other MLTSS services may be . Covered for select eyeglasses and contact lenses as follows: Age 18 and under and 60 and .
