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Member Rights and Responsibilities

As a member of Horizon NJ TotalCare (HMO D-SNP), you have certain rights concerning your health care. You also have certain responsibilities to the health care providers who are taking care of you. Regardless of your health condition, you cannot be refused medically necessary treatment. You can use these rights without losing your health care services. We will tell you about your rights at least once a year. For more information on your rights, please read the Evidence of Coverage.

Your rights include, but are not limited to, the following:

  • You have a right to respect, fairness and dignity. This includes the right to:
    • Get covered services without concern about race, ethnicity, national origin, color, religion, creed, sex (including sex stereotypes and gender identity), age, health status, mental, physical, or sensory disability, sexual orientation, genetic information, ability to pay, or ability to speak English. No health care provider should engage in any practice, with respect to any member that constitutes unlawful discrimination under any state or federal law or regulation.
    • Ask for and get information in other formats (for example, large print, braille, audio) free of charge
    • Be free from any form of physical restraint or seclusion
    • Not be billed by network providers
    • Have your questions and concerns answered completely and courteously
    • Apply your rights freely without any negative effect on the way Horizon NJ TotalCare (HMO D-SNP) or your provider treats you
  • You have the right to get information about your health care. This includes information on treatment and your treatment options, regardless of cost or benefit coverage. This information should be in a format and language you can understand. These rights include getting information on:
    • Horizon NJ TotalCare (HMO D-SNP)
    • The services we cover
    • How to get services
    • How much services will cost you
    • Names of health care providers and Care Managers
    • Your rights and responsibilities
  • You have the right to make decisions about your care, including refusing treatment. This includes the right to:
    • Choose a primary care provider (PCP). You can change your PCP at any time during the year. You can call 1-800-543-5656 if you want to change your PCP.
    • See a women’s health care provider without a referral
    • Get your covered services and drugs quickly
    • Know about all treatment options, no matter what they cost or whether they are covered
    • Refuse treatment as far as the law allows, even if your health care provider advises against it
    • Stop taking medicine, even if your health care provider advises against it
    • Ask for a second opinion about any health care that your PCP or your Care Team advises you to have. Horizon NJ TotalCare (HMO D-SNP) will pay for the cost of your second opinion visit.
    • Make your health care wishes known in an advance directive
  • You have the right to timely access to care that does not have any communication or physical access barriers. This includes the right to:
    • Get timely medical care
    • Get in and out of a health care provider’s office. This means barrier-free access for people with disabilities, in accordance with the Americans with Disabilities Act
    • Have interpreters to help with communication with your doctors, other providers, and your health plan. Call 1-800-543-5656 (TTY 711) if you need help with this service
    • Have your Evidence of Coverage and any printed materials from Horizon NJ TotalCare (HMO D-SNP) translated into your primary language, and/or to have these materials read out loud to you if you have trouble seeing or reading. Oral interpretation services will be made available upon request and free of charge.
    • Be free of any form of physical restraint or seclusion that would be used as a means of coercion, force, discipline, convenience or retaliation
  • You have the right to seek emergency and urgent care when you need it This means you have the right to:
    • Get emergency and urgent care services, 24 hours a day, 7 days a week, without prior approval
    • See an out-of-network urgent or emergency care provider, when necessary
  • You have a right to confidentiality and privacy. This includes the right to:
    • Ask for and get a copy of your medical records in a way that you can understand and to ask for your records to be changed or corrected
    • Have your personal health information kept private. No personal health information will be released to anyone without your consent, unless required by law.
    • Have privacy during treatment
  • You have the right to make complaints about your covered services or care. This includes the right to:
    • Access an easy process to voice your concerns, and to expect follow-up by Horizon NJ TotalCare (HMO D-SNP)
    • File a complaint or grievance against us or our providers. You also have the right to appeal certain decisions made by us or our providers
    • Ask for a State Appeal (State Fair Hearing)
    • Get a detailed reason why services were denied

Your responsibilities include, but are not limited to, the following:

  • You have a responsibility to treat others with respect, fairness and dignity. You should:
    • Treat your health care providers with dignity and respect
    • Keep appointments, be on time, and call in advance if you’re going to be late or have to cancel
  • You have the responsibility to give information about you and your health. You should:
    • Tell your health care provider your health complaints clearly and provide as much information as possible
    • Tell your health care provider about yourself and your health history
    • Tell your health care provider that you are a Horizon NJ TotalCare (HMO D-SNP) member
    • Talk to your PCP, Care Manager, or other appropriate person about seeking the services of a specialist before you go to a hospital (except in cases of emergency)
    • Tell your PCP, Care Manager, or other appropriate person within 24 hours of any emergency or out-of-network treatment
    • Notify Horizon NJ TotalCare (HMO D-SNP)’s Member Services if there are any changes in your personal information, such as your address or phone number
  • You have the responsibility to make decisions about your care, including refusing treatment. You should:
    • Learn about your health problems and any recommended treatment, and consider the treatment before it’s performed
    • Partner with your Care Team and work out treatment plans and goals together
    • Follow the instructions and plans for care that you and your health care provider have agreed to, and remember that refusing treatment recommended by your health care provider might harm your health
  • You have the responsibility to obtain your services from Horizon NJ TotalCare (HMO D-SNP). You should:
    • Get all your health care from Horizon NJ TotalCare (HMO D-SNP), except in cases of emergency, urgent care, out-of-area dialysis services, or family planning services, unless Horizon NJ TotalCare (HMO D-SNP) provides a prior authorization for out-of-network care
    • Not allow anyone else to use your Horizon NJ TotalCare (HMO D-SNP) Member ID Card to obtain healthcare services
    • Notify Horizon NJ TotalCare (HMO D-SNP) when you believe that someone has purposely misused Horizon NJ TotalCare (HMO D-SNP) benefits or services

For more information about your rights, you can read the Horizon NJ TotalCare (HMO D-SNP) Evidence of Coverage. If you have questions, you can also call Horizon NJ TotalCare (HMO D-SNP) Member Services at 1-800-543-5656 (TTY 711), 24 hours a day, 7 days a week.

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