Member Rights and Responsibilities

Our statement of member rights includes the following provisions. Our members have the right to:

  • Be provided with information in a way that works for you (in languages other than English and in alternate formats such as large print).
  • Ensure timely access to covered services and medications, as applicable.
  • Receive information about Horizon BCBSNJ 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.
  • Obtain a current directory of participating physicians, upon request. The directory of participating physicians is also posted on the website. It includes addresses, telephone numbers and a listing of physicians who speak languages other than English.
  • Receive prompt notification of termination of your PCP, if applicable or material changes in benefits, services or 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 BCBSNJ 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, such as information regarding your health status, medical care or treatment options, including alternative treatments that may be self-administered, recommended treatment, risk(s) of the treatment, expected results of the treatment and reasonable medical alternatives, whether or not these are covered benefits. The member also has the right to be provided the opportunity to decide among all relevant treatment options. 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 about the risks, benefits and consequences regarding appropriate or medically necessary diagnostic and treatment or non-treatment options with your participating physicians, regardless of cost or benefit options.
  • Refuse treatment and to express preferences about future treatment options.
  • 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.
  • Call the 911 emergency response system or an appropriate local emergency number in a potentially life-threatening situation, without prior approval. The 911 information is listed on your Horizon BCBSNJ ID card.
  • Have your Horizon BCBSNJ 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.
  • 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 who have experience in treatment of patients with chronic disabilities.
  • Know all the rights afforded by law or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences have been explained in a language you understand and be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
  • Receive a written explanation why approval of a covered service requested by you or your physician was denied or limited under your Horizon BCBSNJ plan.
  • Have a Horizon BCBSNJ 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 telephone number. 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 BCBSNJ (not including co-payments, co-insurance and deductible).
  • File a complaint or appeal with Horizon BCBSNJ 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 BCBSNJ plan or the care provided.
  • 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.
  • Request and receive a copy of your Private Information maintained in Horizon BCBSNJ’s records.
  • Exercise your privacy right by requesting an amendment of your Private Information that is believed to be inaccurate.
  • Formulate and have end of life and advance directives implemented.
  • Make recommendations for changes to Horizon BCBSNJs Member Rights and Responsibilities Policy.
  • Receive covered services from a voluntarily 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 timeframes may apply to obstetrical care, post-operative care, oncological treatment or Psychiatric treatment.
  • Right of a covered person to be treated with dignity, courtesy and consideration out of respect for the members’ need for privacy
  • Horizon BCBSNJ or its participating providers will not penalize you for exercising your rights.

Member Responsibilities

Our statement of member responsibilities includes the following provisions: Our members have the responsibility to:

  • Read and understand the Horizon BCBSNJ Member Handbook, if applicable your EOC or other plan documents.
  • Use the PCP you selected, if applicable, to receive in-network benefits.
  • Coordinate most non-emergency care through your PCP, if applicable.
  • Provide, to the extent possible, information regarding your health that Horizon BCBSNJ and its participating physicians and other health care professionals need in order to care for you.
  • Know how to change your PCP if applicable.
  • Obtain referrals from your PCP, as appropriate, and utilize in-network providers in order to receive the in-network level of benefits.
  • Understand your health problems and participate to the degree possible, in developing mutually agreed upon treatment goals and medical decisions regarding your health.
  • Follow the plans and instructions for care that you agreed upon with your physician. If you choose not to comply, you should advise your physician.
  • Be considerate and courteous to physicians and staff.
  • Make payment for co-payments, deductibles and coinsurance as listed in your plan documents.
  • Know your rights and responsibilities as a Horizon BCBSNJ member.
  • Pay for charges incurred that are not covered under the policy or contract.
  • Medicare Advantage members should advise Horizon BCBSNJ when they move out of the service area.
  • Medicare Advantage members should advise Horizon BCBSNJ when you have other insurance coverage or when your coverage changes.
  • Medicare Advantage members should advise their physicians and other health care providers that they are enrolled in a Horizon BCBSNJ plan.