Horizon HMO Member Rights
Your Horizon HMO Member Rights and Responsibilities As a Horizon HMO member, you have the right to: Access information - Receive information about Horizon HMO and its services, policies and procedures, products, physicians, appeals procedures, member rights and responsibilities, coverage limitations and other information about the organization and the care provided.
- Be provided with the information needed to understand your benefits and obtain care through the Horizon Managed Care Network.
- Obtain a current directory of participating physicians in our network, upon request. The directory includes addresses, telephone numbers and a listing of physicians who speak languages other than English.
- Receive prompt notification of termination of your Primary Care Physician (PCP) or material changes in benefits, services or the Horizon Managed Care Network within 30 days prior to the date of any change or termination, as appropriate.
- Obtain information about whether a referring physician has a financial interest in the facility or services to which a referral is being made.
- Know how Horizon HMO pays its physicians, so you know if there are financial incentives or disincentives tied to medical decisions.
- Receive from your physician or health care professional, in terms you understand, an explanation of your complete medical condition, recommended treatment, risk(s) of the treatment, expected results of the treatment and reasonable medical alternatives, whether or not these are covered benefits. If you are not capable of understanding the information, the explanation shall be provided to your next of kin or guardian and documented in your medical record.
- Have full, candid discussions regarding appropriate or medically necessary diagnostic and treatment options with your participating physicians, regardless of cost or benefit coverage.
Your Primary Care Physician (PCP) - Choose and change your PCP within the limits of your benefits and the physician's availability.
- Have access to your PCP and available services when medically necessary. This includes the availability of care 24 hours a day, seven days a week, 365 days a year for urgent or emergency conditions.
Medical emergency and urgent care - Call the 911 emergency response system or an appropriate local emergency number in a potentially life-threatening situation, without prior approval.
- Have your Horizon HMO plan pay for a medical screening exam in an emergency facility to determine whether a medical emergency condition exists.
- Go to an Emergency Room without prior approval when it appears to you that serious harm could result from not obtaining immediate treatment.
Specialty and hospital care - Choose from appropriate, participating specialists following an authorized referral (if necessary), subject to the specialist's availability to accept new patients.
- Obtain assistance and referrals to participating health care professionals with experience in treatment of patients who have chronic disabilities.
- Know all the rights afforded by law or regulation as a patient in a licensed healthcare facility, including the right to refuse medication and treatment after possible consequences have been explained in a language you understand.
Approval of your care - Receive a written explanation why approval of a covered service requested by youor your physician was denied or limited under your Horizon HMO plan.
- Have a Horizon HMO physician determine to deny or limit your admission, service, procedure or extension of stay. Our physician who made the decision must directly communicate with your physician or supply your physician with his/her telephonenumber. You also have the right to know that the person denying or limiting a covered service is a physician.
- Be free from balance billing by participating physicians for medically necessary services that were authorized or covered by Horizon HMO (not including copaymentsand coinsurance).
Voice a concern - Voice complaints or file internal and external appeals about your plan or the care provided. Please see the Voicing a Concern section of your Member Handbook for full details.
- File a complaint or appeal with Horizon HMO or the New Jersey Department of Banking and Insurance. You have the right to receive an answer to your complaint or appeal within a reasonable period of time.
- Know that neither you nor your physician can be penalized for voicing a complaint or appeal about your Horizon HMO plan or the care provided.
Your personal rights - Participate with your physicians in decision making regarding your health care.
- Be treated with courtesy and consideration, and with respect for your dignity. You also have the right to privacy.
- Formulate and have advance directives implemented.
- Make recommendations for changes to the Horizon HMO Member Rights and Responsibilities Policy.
- Receive covered services from a terminated health care professional who was under contract with us at the time treatment was initiated, for up to four months, where medically necessary. Other periods may apply to obstetrical care, post-operative care, oncological treatment or psychiatric treatment.
As a Horizon HMO member, you have the responsibility to:- Read and understand your Horizon HMO Member Handbook, Evidence of Coverage (EOC) and all other member materials.
- Use the PCP you selected to receive in-network benefits.
- Coordinate most nonemergency care through your PCP.
- Provide, to the extent possible, information regarding your health that Horizon HMO and its physicians and other health care professionals need in order to care for you.
- Know how to change your PCP.
- Obtain referrals from your PCP, as appropriate, and use the Horizon Managed Care Network to receive the in-network level of benefits.
- Understand your health problems and participate in developing mutually agreed upon treatment goals and medical decisions regarding your health (to the degree possible).
- Follow the plans and instructions for care that you agreed upon with your physician.If you choose not to comply, you will advise your physician.
- Be considerate and courteous to physicians and staff.
- Make payment for copayments, deductibles and coinsurance as listed in your EOC.
- Know your rights and responsibilities as a Horizon HMO member.
- Pay for charges incurred that are not covered under the policy or contract.
 
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