spring 2014 the magazine for horizon blue cross blue...

Spring 2014 THE MAGAZINE FOR HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY MEMBERS

How patient-centered programs focus on better care

Find out if your hospitalmakes the grade

What will you pay for surgery?

Focus - Spring 2014_3_25_FINAL_Layout 1 3/25/14 12:47 PM

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On the go? Download the Horizon Blue App today.

In this issue ...

Ease of Navigating theHealth Care System

3 Making the most of online services

4 Treatment Cost Estimator

5 Your pharmacy benefitsmade simple

Addressing Health Care Costs

6 Stay in network to loweryour costs

Access to Safe and Effective Care

7 Urgent Care Centers

9 Patient-centered programs continue togrow

10 Care for your complexconditions

Healthier Members ...Healthier Communities

12 A woman’s guide to taking charge of herhealth

13 Prostate cancer screening

14 How to prevent caregiver burnout

Service Excellence

16 Blue Distinction®

designation helps youselect high-performinghospitals

17 Hospital safety scoresavailable online

Diversity StatementAt Horizon Blue Cross Blue Shield

of New Jersey, we are proud of ourcommitment to diversity and inclusionamong our employees, members,physicians and business partners.Diversity is part of who we are as aCompany. We embrace and valuedifferences of culture, education,experience and perspective in ourworkplace.

For more information, please visitHorizonBlue.com/Diversity.

With our Horizon Blue App, stayingconnected is easier than ever, with all ofyour essential information right at yourfingertips. Download the Horizon Blue App*

to your iPhone® or AndroidTM today, and sign-in or register for Member Online Services.

You’ll have immediate access to manyexciting features including:

Online Provider Directoryt Search for a doctor or hospital based

on specialty or ZIP code.t View detailed information for a health

care professional through the searchresults.

ID Cardst View the front and back of

identification (ID) cards.t Request a duplicate ID card.

Claims Informationt View your most recent claims and

their details.t View benefit information such as

copayment, coinsurance anddeductibles for a specific claim.

Authorizations and Referralst View authorization and referral details.t Check the status of authorizations.

Benefitst View product and coverage

information.t View benefits information such as

copayment, coinsurance anddeductibles.

Update Your Additional Insurancet Add or update coordination of benefits.

Manage an Account/Profilet Modify your profile (password, email

address or phone number).t Change your Primary Care Physician.t Opt-in or opt-out for paperless

Explanation of Benefits (EOBs), emailsor text alerts.

Contact Ust Email questions via an online form.

* There is no charge from Horizon BCBSNJ to download the Horizon Blue App, but rates from your wireless providers may apply.

iPhone® is a digital mobile device and is a registeredmark of Apple, Inc.

AndroidTM is a trademark of Google, Inc.


http://www.horizonblue.com/diversity

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Ease of Navigating the Health Care System

Member Online Services gives you secure access to your health plan information. It also offers resources for personalizedhealth and wellness advice and hands-on tools that help you get the most out of your health plan.

Visit HorizonBlue.com/Members to:

t Review your benefit details – information about your Primary Care Physician (PCP), plan effective date, costs for in- and out-of-network services and more is right at your fingertips.

t View your claims – review recent claim activity. You can also search for claims by claim number, date and status.

t Manage your authorizations and referrals – search, view and print your authorizations and referrals.

t Access time-saving plan tools – find participating health care professionals, print temporary ID cards, replace a lost ID card,download forms and ensure your information is up to date.

t Learn more about your prescription plan – our pharmacy tools* can help you check drug interactions, view any coveragerestrictions, order prescriptions by mail and find ways to save on prescription costs. Read the article on page 5 formore information.

t Manage your dental plan details – members with Horizon Blue Cross Blue Shield of New Jersey dental benefit plans can check their eligibility, see dental claim statuses, request member ID cards and even change their dentists.

t Get personalized health and wellness support – in addition to your health plan information, you’ll enjoy complimentary access to:• Resources for keeping yourself and your family healthy.

• Educational articles and videos on the latest health topics.

• Tools for tracking your personal health records.

Just a click away …Making the most of Member Online Services

* These tools are only available to members with pharmacy benefits from Horizon BCBSNJ.


http://www.horizonblue.com/Members

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Treatment Cost EstimatorAn online resource to help you better understand health care costs

To help you with your health care decision making, youcan find information on health care costs through our onlineTreatment Cost Estimator (TCE).

The TCE is a secure, interactive online tool that allows youto review estimated cost information for services that can beperformed at hospitals, ambulatory surgery centers, imagingcenters and doctor’s offices. The TCE lets you evaluate cost-related information and become better informed aboutthe estimated costs of future procedures.

Accessing the TCEHorizon BCBSNJ members can access the TCE by visiting

Member Online Services.

1. Visit HorizonBlue.com.

2. Click Member Sign In.

3. Enter your User Name and Password and click Sign In.

4. Mouse over Tools and Resources and click Treatment Cost Estimator.

Using the TCEWithin the TCE, you will select a specific treatment

category within a ZIP code to display average estimatedallowance ranges for a wide variety of inpatient, outpatient,diagnostic and office visit treatment categories.

1. Select the enrolled member for which you’re seekinginformation.

2. Enter a treatment category or select one from withinone of the following categories:

t Treatments A-Z.

t Inpatient.

t Outpatient.

t Diagnostic.

t Office Visit.

3. Enter the desired ZIP Code and select the desiredRadius.

4. Click Get Estimate.

The allowance range for each treatment categoryrepresents procedure bundles, groupings of services (facility, physician, prescription, ancillary, etc.) that aretypically performed/provided as part of a specific treatmentcategory episode. Cost information is based on 12 monthsof network claims data.

If you have questions, please call the Member Servicesnumber on the back of your Horizon BCBSNJ ID card.

TCE categories

With the addition of 1,275 new TCE treatment categoriesin 2013, you can now obtain information on over 1,600 inpatient, outpatient, diagnostic and office visittreatment categories.


http://www.HorizonBlue.com

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If you get a medical bill …When you use a participating doctor or other health care professional, he or she

files claims for you. You should not get a bill, except if your plan has a copayment or other member cost-sharing.

If you do not use a participating doctor, other health care professional or hospital, you may get a medical bill. If you do, please send the bill to the address listed on the claim form. Include your Horizon Blue Cross Blue Shield of New Jersey ID number, name, date of birth and your relationship to the patient, if applicable.

To download and print a claim form, visit HorizonBlue.com/Members and click Forms. Or, call Member Services at 1-800-355-BLUE (2583).

DefinitionsCopayment: the specifieddollar amount a member mustpay for each medical visit orservice.

Cost-sharing: occurs whenmembers pay for a portion ofhealth care costs not covered by health insurance. Examplesinclude copayments,deductibles and coinsurance.

Your pharmacy benefits made simpleFinding information about your pharmacy benefits has never been easier.* Member Online Services

at HorizonBlue.com has easy-to-use tools to help you view important information about the medicineyou take, including your prescription activity and history. You can also find an in-network retailpharmacy and the cost of your medicine.

Visit Member Online Services and sign in. Select Pharmacy Services in the “I Want To” menu and you’llbe automatically connected to Horizon Pharmacy’s website through our pharmacy benefit manager,Prime Therapeutics LLC. The site has been redesigned to offer better self-service capabilities in clearand simple language and is available in Spanish.

You can learn how much your medicine costs and see what you can do to lower your expenses. Forexample, find out if there are lower-cost generic drug alternatives available for your medical condition.Generic drugs work the same way and cost less — they’re a better value. There are generic drugsavailable for most common medical conditions. Why spend more when you don't have to? Ask yourdoctor or pharmacist about generics.

To view our formulary (prescription drug list) visit the Member section of HorizonBlue.com, mouseover Education Center and select Pharmacy & Prescriptions then click Prescription Drug List. If you wouldlike a copy mailed to you, please call Pharmacy Member Services at 1-800-370-5088.

*Services are only available to members who have pharmacy benefits through Horizon Blue Cross Blue Shield of New Jersey. Check with your benefits administrator to find out what kind of benefits you have.Horizon Pharmacy and its network of participating pharmacies are administered by its contracted pharmacy benefits manager, Prime Therapeutics LLC.


http://www.HorizonBlue.com/Members



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Addressing Health Care Costs

As a Horizon Blue Cross Blue Shield of New Jersey member, you have access to a large network of qualified participatingdoctors, laboratories, hospitals and other health care professionals for your care.

By using doctors who participate in our network, you save money on your out-of-pocket medical costs.

If you choose an out-of-network doctor1 for your care, you pay more of the costs. Your costs may include a higher deductible,coinsurance and/or copayment. Also, you pay the difference between the charges Horizon BCBSNJ has agreed to pay(allowance2) and the doctor’s actual charge for the service.

Let’s look at how Jane saves money when she uses an ambulatory surgical center (ASC) that’s in network.

Jane will have surgery at an ASC. There are two ASCs in her area. One participates with Horizon BCBSNJ and the other doesnot. Her health plan pays in-network and out-of-network services differently:

To find a participating doctor in your area, visit HorizonBlue.com/Directory.

To learn about your benefits, claims, authorizations and/or referrals, sign in to Member Online Services at HorizonBlue.com/Members.

1 Out-of-network services require an authorization before you receive services. Horizon HMO and Horizon EPO membersdo not have out-of-network benefits.

2 Allowance is an amount Horizon BCBSNJ has agreed to reimburse. The allowance may be less than the doctor’s charge.In-network doctors have agreed to accept the allowance minus the member’s responsibility. Out-of-network doctorshave not agreed to accept the allowance and may bill the member for the full charge of the service.

Stay in network to lower your costs

ASC Charge Horizon Jane’s Horizon What Jane BCBSNJ’s coinsurance or BCBSNJ’s pays allowance copayment payment

Out of network $5,000 $1,500 $300 $1,200 $3,800

Jane pays 20 percent Horizon BCBSNJ Jane pays the of the allowance for covers 80 percent coinsurance and the out-of-network of the allowance for difference between services. out-of-network the allowance and services. the doctor’s charge.

In network $5,000 $1,500 $35 $1,465 $35

Jane pays her $35 Horizon BCBSNJ Jane pays only her copayment for is responsible for copayment. The ASC in-network services. the balance up cannot bill Jane for to the allowance. more than her $35 copayment.


http://www.HorizonBlue.com/Directory


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Horizon Blue Cross Blue Shield of New Jersey has expanded itsnetwork of participating Urgent Care Centers to provide you with moreways to access quality, cost-efficient medical care.

Urgent Care Centers provide an alternative to the Emergency Room (ER)when you are faced with an injury or illness that requires immediate carebut is not life threatening. Treatment often costs considerably less thancare in an ER, and an average visit usually lasts less than one hour.

The facilities, with extended and weekend hours, treat wounds, sprainsand other conditions that require attention within 24 hours, but do not posea danger to a person’s life or long-term health. All Urgent Care Centersparticipating with Horizon BCBSNJ can perform essential medicalservices, diagnose illness and treat emergent conditions.

Routine office visits, including preventive care, sports physicals, routineobstetric services, occupational medicine and physical therapy are notcovered at Urgent Care Centers.

To receive full in-network benefits, members must go to a participatingHorizon BCBSNJ Urgent Care Center that is listed in the online ProviderDirectory found at HorizonBlue.com/Directory. Members do not need areferral to go to a participating Horizon BCBSNJ Urgent Care Center butare responsible for applicable out-of-pocket costs.

Find participating Urgent Care Centers near youIt is important to go to an Urgent Care Center participating with Horizon

BCBSNJ to keep your out-of-pocket costs low. Know where the closestparticipating Urgent Care Center is located before you become sick or injured.

To find the closest participating Urgent Care Center go toHorizonBlue.com/Directory and:

t Select the Other Healthcare Services tab.t Select Urgent Care Center in the Service Type field.t Enter ZIP code and select a search radius or select a county.t Click Search.

Urgent Care Centers: A wise alternative to the Emergency Room If your doctor is not available, go to an Urgent

Care Center if you have:t Body aches, back pain.t Burning with urination.t Diarrhea, nausea, vomiting.t Ear or eye pain, irritation.t Fever.t Muscle strains or sprains.t Respiratory or sinus infections.t Wounds needing stitches.

Call 911 or go to the nearest Emergency Room inthe following situations:

t Chest pain or pressure.t Difficulty breathing.t High fever with stiff neck, mental

confusion or difficulty breathing.t Partial or total amputation of a limb.t Poisoning.t Possible broken bones.t Signs of a stroke, including numbness in

the face, arm or leg on one side of the body;difficulty talking; sudden loss of vision.

t Sudden or unexplained loss ofconsciousness.

t Sudden, severe abdominal pain.t Trauma to the head.t Vomiting blood.

The 24/7 Nurse Line* is also a safe place to gethealth information. You can trust our nurses withany question and all calls are kept private andconfidential. Our team of registered nurses, whohave an average of 15 years of clinical experience,is supported by doctors. That means you’ll getup-to-date, health information every time you call. Call 1-888-624-3096 to get help with questions about:

t Cuts and burns.t Fever and sore throat.t Vomiting and headaches.t Colds and flu.t Your medicines.t Any health topic.

*Some members may not be eligible to use the services through the24/7 Nurse Line. Please check your plan to see if this service is available to you. This service can help you make decisions about nonemergency, health-related situations. For informational purposesonly. Nurse Line nurses cannot diagnose problems or recommend specific treatment, and are not a substitute for your doctor's care.Nurse Line services are not an insurance program, emergency serviceor urgent care service, and may be discontinued at any time. In theevent of an emergency, call 911 or your local emergent number and/oryour doctor.

Urgent Care versus Emergency Room visitHow to decide?




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Choosing a doctor is an important decision. Your PrimaryCare Physician (PCP)* or personal doctor:

t Identifies and treats common medical conditions.t Provides preventive care and counseling on healthy

lifestyle choices.t Helps coordinate specialty and follow-up care.

How to find doctors who are in networkTo find a Horizon Blue Cross Blue Shield of New Jersey

participating doctor near you, you can:

t Visit Horizon BCBSNJ’s online Provider Directory atHorizonBlue.com/Directory.

t Visit our mobile directory at mobile.HorizonBlue.com.t Call Member Services at 1-800-355-BLUE (2583).

To learn more about choosing the right doctor and the value of staying in network, or to learn how to nominate anout-of-network doctor to be part of one of our networks, visitHorizonBlue.com/Members.

Choosing the right doctor.Do you want a doctor who:

t Participates in your health plan?t Is board certified?t Has special training to meet your unique needs?t Has privileges at the hospital of your choice?

Once you select a doctor, call his or her office to determine if:

t It is easy to get an appointment.t The office hours are convenient for you.t The office staff is friendly and helpful.t The office is good about returning calls.

* Not all plans require or allow you to select a Primary Care Physician.

Finding a doctor who fits your needs

Take control ofyour health

Do you need help managing your chronicconditions? If so, enroll in our Chronic CareProgram.*

It’s a free, voluntary program that promoteshealthy living for eligible members who have been diagnosed with one or more of these chronic conditions:

t Asthma.t Chronic kidney disease (CKD).t Chronic obstructive pulmonary disease

(COPD).t Coronary artery disease (CAD).t Diabetes.t Heart failure.

To learn more about our Chronic Care Programor to enroll, call 1-888-334-9006 or visitHorizonBlue.com/chronic-care.*Not all programs are available to all members. Please check with yourbenefits administrator to find out if you are eligible for this service.

Researching new technology and treatments

Horizon Blue Cross Blue Shield of New Jersey regularlyreviews new medical technology to decide if it is eligible forcoverage and if we need to develop medical policies for it.Horizon BCBSNJ has a process to review new prescriptiondrugs, procedures, devices and treatments. As part of thisprocess, we research peer-reviewed, published scientificliterature. If you and your doctor want us to review newtechnology that would support your treatment plan, pleaseask your doctor to call Horizon BCBSNJ at 1-800-624-1110.



http://mobile.HorizonBlue.com


http://www.HorizonBlue.com/chronic-care

We’re working with our doctors and hospitals to provide highly-personalized, coordinated care to you through ourpatient-centered programs. Our patient-centered programs move reimbursement from a fee-for-service method to apay-for-value model. They will play an important role in improving care, increasing accountability and improving healthoutcomes. Our programs focus on the quality of care you receive and the vital role doctors and care teams play in carecoordination.

More than 500,000 Horizon Blue Cross Blue Shield of New Jersey members and 1,400 doctors are benefiting fromHorizon BCBSNJ’s patient-centered programs that areworking to improve patient care while controlling costs.

Patient-Centered Medical Home (PCMH)A PCMH coordinates patients’ health care needs and helps

ensure that they receive quality care in the right setting and at the right time. This approach provides personalized, proactiveand comprehensive care that enables patients to becomeengaged in their health care.

Our most recent results show the PCMH program isdelivering more effective and efficient care by improving carecoordination and reducing unnecessary complications. Theseresults compared Horizon BCBSNJ members in the PCMHprogram to members in other primary care practices.

Providing Better Caret 5 percent higher rate in improved diabetes control (HbA1c).t 5 percent higher rate in breast cancer screenings.t 11 percent higher rate in pneumonia vaccinations.

Utilization and Cost Measurest 23 percent lower rate in hospital inpatient admissions.t 12 percent lower rate in Emergency Room (ER) visits.t 9 percent lower cost of care for patients with diabetes.

Patient-Centered Pediatric ProgramOur patient-centered programs grew this year to include

Patient-Centered Pediatric practices. The difference inchildren and adults drives different needs in care. Our Patient-Centered Pediatric Program is focused on preventiveand developmental goals, and the needs of children withchronic conditions such as asthma and diabetes.

Accountable Care Organization (ACO) InitiativesACOs are built upon a strong primary care foundation and

help create a healthier population, improve the patient experienceand control the total cost of care. ACOs are designed toachieve measured patient quality outcomes and decreaseunnecessary and duplicative medical tests and treatments.

Horizon BCBSNJ currently has ACO and ACO-likeagreements with Summit Medical Group, Optimus HealthcarePartners, AtlantiCare, Hunterdon Healthcare Partners,Barnabas Health, Partners In Care, JFK Medical Center,through its JFK ACO, Hackensack-Physician Hospital Alliance(HackensackAlliance), Holy Name Medical Center, through itsHNMC Hospital/Physicians ACO and LHS Health Network.

Episode of Care (EOC) Program Under the EOC programs, a single practice or doctor acts

as the conductor who orchestrates the full-spectrum of carefor a specific service or procedure within a defined period oftime. Using national quality standards and best practices forthese procedures, our goals are to achieve better qualityoutcomes, improve the patient experience and reduce the total cost of care.

Over 380 doctors throughout the state are participating inseveral EOC programs that include the following episodes: hipand knee total joint replacement, knee arthroscopy, pregnancyand delivery, colonoscopy and breast cancer.

Horizon BCBSNJ continues our commitment to develop andexpand our new care and payment programs.

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Patient-centered programs continue to grow


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Horizon Blue Cross Blue Shield of New Jersey's Case Management Program

If you have a serious or complex medical condition, ourCase Management Program* helps you get the care andservices you need. The program focuses on:

t Chronic kidney disease.t End-stage renal disease.t High-risk maternity care.t Oncology.t Supportive care.t Transplant case management.t Other general and pediatric conditions.

Our specially trained Case Managers are registered nurseswho work with you to help you understand your health careoptions. They can also coordinate your health care serviceswith your doctor.

Our Case Managers can:

t Provide you with information to help you makedecisions about your health care.

t Help you with getting authorizations for services.t Refer you to other valuable programs or services

when needed, including our Chronic Care Program,(see page 8).

t Give you information on community resources andother health and wellness programs.

You may be referred by your health care professional’soffice, request services yourself or be invited to participatebased on claims data.

All medical and personal information is confidential andshared only with those involved in your care. Considerdiscussing this free, voluntary program with your doctor.

For more information about our Case ManagementProgram, or to self-enroll, please call 1-888-621-5894 andselect prompt 2 or visit HorizonBlue.com/case-management.

* Please check with your benefits administrator to determine if you are eligible.

Care for your complex conditions


http://www.HorizonBlue.com/case-management

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The federal government mandatescertain health coverage for breastreconstructive surgery in any healthinsurance plan that provides medicaland surgical benefits for mastectomies.

If your plan provides medical andsurgical benefits for mastectomies, andyou are receiving benefits in connectionwith a mastectomy and elect to havebreast reconstruction along with thatmastectomy, your plan must provide, ina manner determined in consultationbetween you and the attending doctor,coverage for the following:

t All stages of reconstruction of the breast on which themastectomy was performed.

t Surgery and reconstruction ofthe other breast to produce asymmetrical appearance.

t Treatment of physicalcomplications of the mastectomy,including lymphedemas.

t Breast prostheses, which is anartificial form of a breast to helpreconstruct its original form.

These benefits are provided to thesame extent as any other illness under

your coverage, subject to yourdeductible and coinsurance. All otherfeatures and benefits of your healthinsurance plan remain the same andare not impacted by this notification.

Please refer to your Evidence ofCoverage for more details ondeductibles and coinsurance applicableto your health insurance plan.

Women’s health and cancer rights act

As a Horizon Blue Cross Blue Shieldof New Jersey member, you haveaccess to a broad network of qualityparticipating physicians, health careprofessionals and hospitals.

Depending on your plan, you maychoose from:

t More than 30,000 physicians andother health care professionals.

t 74 hospitals / 95 locations in New Jersey, New York,Pennsylvania and Delaware.

Horizon BCBSNJ offers interactivetools and resources to help you find anin-network physician based on yourplan, compare hospitals based onspecific diagnoses and procedures andmore. Visit HorizonBlue.com to getstarted.

Living or traveling outside New Jersey?Ninety-one percent of doctors and

96 percent of hospitals in the UnitedStates participate in the BlueCard®Program.*

To find doctors and hospitalsavailable to you through the BlueCardProgram:

1. Have your Horizon BCBSNJID card on hand.

2. Visit HorizonBlue.com/Directoryand click Providers Outside of NJ.

3. Follow the directions and clickStart Search.

Or you can call BlueCard Access at1-800-810-BLUE (2583) for the namesand addresses of doctors and hospitalsin the area where you or your covereddependent need care.

* Please check your plan to find out if the BlueCard Program is available to you.

Please note: Network numbers are current at the time of printing.

Access to more options, even when traveling




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Healthier Members ... Healthier Communities

No matter how old you are or what risk factors you mayhave, it is never too late – or too early – to begin takingsteps toward improving your health. Routine screeningsand preventive care are the best ways to help you maintainyour health and happiness, now and later in life.

Which screening tests do I need?Be sure to ask your doctor which tests, screenings and

vaccines are right for you. These can include:t Blood pressure.t Body mass index (BMI).t Bone density screening.t Cancer screenings for your age and family history,

including cervical and breast cancer screenings. t Cholesterol screening.t Colonoscopy.t Screening for diabetes.t Vaccines, including flu and pneumonia.t Glaucoma screening.t Sexually transmitted disease (STD) testing, which may

include screening for human papillomavirus (HPV),chlamydia and gonorrhea.

Prepare for your appointment and be ready to talk with your doctor:

t Before your appointment, make a list of the questions and concerns you have.

t Give your doctor a list of all your medications,including over-the-counter ones.

t Be honest. Tell your doctor about your diet, physical activity, smoking, alcohol or drug use.

t Don’t forget to mention if you are being treated by other doctors, including behavioral healthprofessionals.

t Don’t be afraid to bring up sensitive topics, like overactive bladder and problems with balance or falling.

Don’t wait – call your doctor today! For more information on your preventive health benefits, visitHorizonBlue.com/Members or check your benefitsbooklet.

A woman’s guide to taking charge of her health



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Prostate cancer screeningAre you considering being screened for prostate cancer?

Except for skin cancer, prostatecancer is the most common cancer inAmerican men. It is the second mostcommon cause of death from canceramong white, African American,American Indian/Alaska Native andHispanic men, and the fourth mostcommon cause of death from canceramong Asian/Pacific Islander men.

Many men with prostate cancer—especially those with tumors that havenot spread beyond the prostate—dieof other causes without ever havingany symptoms from the cancer.


Source: Centers for Disease Control and Prevention, cdc.gov/cancer/prostate

Talk to your doctor to determineif screening is right for you.Two tests are commonly used to screen for prostate cancer —

t Digital rectal exam (DRE): A doctor or nurse inserts agloved, lubricated finger into the rectum to estimate the size of the prostate and feel for lumps or otherabnormalities.

t Prostate specific antigen (PSA) test: Measures the level of PSA in the blood. PSA is a substance made by theprostate. The levels of PSA in the blood can be higher inmen who have prostate cancer. The PSA level may also be elevated in other conditions that affect the prostate.

As a rule, the higher the PSA level in the blood, the more likely there is a prostate problem. But many factors, such as age and race, can affect PSA levels. Some prostate glands make more PSA than others. PSA levels can also be affected by:

t Certain medical procedures. t Certain medications.t An enlarged prostate. t A prostate infection.

Because many factors can affect PSA levels, your doctor is the best person to interpret your PSA test results.


http://www.cdc.gov/cancer/prostate

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If you care for a loved one with a life-threatening diseaseor debilitating chronic illness, you know how much work itinvolves. At times, you find caregiving enriches your life. Youmay feel a deep sense of satisfaction and accomplishment.It may also feel good to be helpful and know that a lovedone needs you.

Other times, you may feel frustrated, resentful, burdenedor depressed. It’s important to watch how you feel and totake care of yourself.

According to WebMD®, some symptoms of typicalcaregiver burnout include:

t Changes in appetite, weight or both.t Changes in sleep, whether you want to sleep more or

have trouble falling and staying asleep.t Emotional and physical exhaustion.t Withdrawal from friends, family and other loved ones.

These feelings should not be dismissed as “just stress”since they can lead to physical health problems.

Though you may find it difficult to make time for yourself,it’s critical for your health. Burnout is real and needs to beaddressed. Some tips to reduce stress and create a balancein your life include:

t Find a hobby that takes your mind off your concernsfor a while or learn something new.

t Get enough sleep and eat a healthy diet with plentyof fresh fruit and vegetables. Talk to your doctor if you require a special diet; don’t ignore your dietaryrestrictions.

t Make time to exercise, whether you walk, participatein classes or go to a gym. Try to stick to a regularroutine.

t Be proactive with your health. Make sure you get thecheckups and health screenings you need.

t Set limits as to what you can do and say no when youneed to.

t Find a support group to air your feelings and getstrategies for coping.

t Talk to your doctor or a trusted friend. You may wantto seek counseling when you feel overwhelmed.

Source: WebMD, webmd.com

How to prevent caregiver burnout


http://www.webmd.com

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Colorectal cancer screening Screening for colorectal cancer is recommended for most men and women beginning at age 50 years and continuing until age 75 years. National guidelines for colorectal cancer screening include several screening test options.

Have a doctor’s visit coming up? Here is some useful information to “Know before you go.”

Recommended screening tests: • Colonoscopy (once every 10 years).• High-sensitivity fecal occult blood test, also known as a stool test (once a year). • Flexible sigmoidoscopy (every 5 years). The benefits and risks of these screening methods vary. Discuss with your doctor which test is best for you. Getting screened could save your life!

Questions to ask your doctor: • Do I need to get a screening test for colorectal cancer? • What screening test(s) do you recommend for me? • How do I prepare? Do I need to change my diet or my usual medication schedule? • What’s involved in the test? Will it be uncomfortable or painful? Is there any risk involved?When and from whom will I get results?

• If you’re having a colonoscopy or sigmoidoscopy, you will want to know the following: Who will do the exam? Will I need someone to take me home?

If you’re at increased risk: Some people are at increased risk because they have inflammatory bowel disease, a personal or family history of colorectal polyps or colorectal cancer, or genetic syndromes like familial adenomatous polyposis (FAP) or hereditary non-polyposis colorectal cancer (also known as Lynch syndrome). These people may need to start screening earlier than age 50 years. If you believe you are at increased risk, ask your doctor if you should begin screening earlier than that.

If you’re having symptoms: Tell your doctor if you have any of these symptoms:• Blood in or on your stool (bowel movement).• Stomach pain, aches or cramps that do not go away.• Unexplained weight loss. These symptoms may be caused by something other than cancer, but the only way to knowwhat is causing them is to speak with your doctor.


Source: American CancerSociety, cancer.org


http://www.cancer.org/cancer/colonandrectumcancer/

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Service Excellence

Blue Distinction® designation helpsyou select high-performing hospitals

The hospital you select can have a bigimpact on the care you receive and yourprocedure results. But finding the righthospital can sometimes be a challenge.

That’s why the Blue Cross and Blue Shield Association (BCBSA), inconjunction with Blue Cross and/or Blue Shield Plans throughout the country,developed the Blue Distinction Centers®recognition program.

Blue Distinction Centers have aproven track record for delivering betterresults – including fewer complicationsand readmissions – than hospitalswithout these recognitions.

Looking for Blue Distinction designationscan help you when you and your doctorare looking for a hospital with provenexpertise in delivering specialty care.

Blue Distinction designation evaluationcriteria is based on what impacts youand your care the most, including:t The know-how and expertise of the

medical team;

t The number of times the hospital hasperformed the procedure; and,

t The hospital’s track-record forprocedure results.

Blue Distinction designation identifiesthose hospitals that deliver quality carein bariatric surgery, cardiac care,complex and rare cancers, knee and hipreplacements, spine surgery andtransplants.

More information about the Blue Distinction program is available atBCBS.com/why-bcbs/blue-distinction/.You can access the Blue DistinctionCenter Finder to help you locate alldesignated facilities throughout thecountry, including those in New Jersey.

We proudly list those Horizon HospitalNetwork facilities who have achievedBlue Distinction Center recognition onHorizonBlue.com/Members. Mouse overServices, click Our Networks and clickOur Care Facilities.

Bariatric Surgery AtlantiCare Regional Medical CenterCentraState Medical CenterLourdes Medical Center of Burlington CountyOur Lady of Lourdes Medical Center

Cardiac Care AtlantiCare Regional Medical CenterCooper University Hospital (Blue Distinction Center+)The Valley Hospital (Blue Distinction Center+)

Complex and Rare Cancers Hackensack University Medical CenterJFK Medical CenterRobert Wood Johnson University Hospital

Knee and Hip Replacement AtlantiCare Regional Medical Center (Blue Distinction Center+)Saint Clare's Health System Denville (Blue Distinction Center+)Virtua-Memorial (Blue Distinction Center+)Virtua-West Jersey Health System (Blue Distinction Center+)

Spine Surgery Virtua-Memorial

Transplants Hackensack University Medical Center (Blue Distinction Center+)

Distinction®

BlueTwo recognitions to help you search for the rightspecialty careThe BCBSA continues to

improve and expand the Blue Distinction program.

In addition to Blue DistinctionCenter designation, a new Blue Distinction Center+,designation is awarded tohospitals that meet the samequality-focused criteria and alsomeet cost-efficiency measures.

This new designation is currently available in some of the specialty care categories andwill continue to expand into allspecialty care areas.


http://www.BCBS.com/why-bcbs/blue-distinction/


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Horizon Blue Cross Blue Shield ofNew Jersey is pleased to announcethat, beginning in April 2014, you’ll beable to quickly and easily determine thesafety scores of each Horizon HospitalNetwork facility by special icons thatwe’ll be including in our online ProviderDirectory.

Horizon BCBSNJ recognizes andrewards network hospitals that havegood performance in the areas ofpatient safety, clinical outcomes, qualityand efficiency through the HorizonHospital Recognition Program (HHRP).This program is based on the highly-regarded hospital recognition programsponsored by The Leapfrog Group, aleader in health care transparency andquality.

Through their voluntary completion ofthe Leapfrog Hospital Survey, hospitalsare assessed in three key areas:

t How patients fare.

t Resources used in caring forpatients.

t Leadership and structures thatpromote patient safety.

We’re certain that this importantinformation will be invaluable in helpingyou make your health care decisions.

For more information about TheLeapfrog Group and their Hospital SafetySurvey, please visit leapfroggroup.organd click the Patients tab.

Service Excellence

Hospital safety scores available onlineHospital Safety Score IndicatorsThe Hospital Safety Score is an A, B,C, D or F letter grade reflecting howsafe hospitals are for patients.

We will display one of the followingicons within our Provider Directoryto indicate the safety score of eachhospital in our network.

Horizon Hospital Recognition Program (HHRP)To see the current list of hospitals participating in the HHRP, please visit

HorizonBlue.com/Providers and:

t Mouse over Services and Programs and click Recognition Programs and Partnerships.

t Scroll down to the Facilities section and click View the hospitals participating in the HHRP.

BCDF

ASPRING 2014

SPRING 2014

SPRING 2014

SPRING 2014

SPRING 2014

HOSPITALSAFETYSCOREHOSPITALSAFETYSCOREHOSPITALSAFETYSCOREHOSPITALSAFETYSCOREHOSPITALSAFETYSCORE


http://www.leapfroggroup.org

http://www.horizonblue.com/providers/services-programs/recognition-programs/horizon-hospital-recognition-program

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Service Excellence

One of the most important decisionsyou’ll make is choosing a health careprofessional or hospital that best fitsyour health care needs. We encourageyou to choose wisely.

Horizon Blue Cross Blue Shield ofNew Jersey offers a broad network,making it easy to find a physician orhospital that is right for you and best foryour treatment needs. We understandand value the importance of maintaininga high-quality network of health careprofessionals and hospitals.

As part of our commitment to helpimprove the health of our members, wehave processes in place to monitor,assess and improve the quality andappropriateness of care our networkprovides to you.

We verify the qualifications andbackground of any physician or healthcare professional wishing to join ournetwork and treat our members. Ourcredentialing process is critical toensuring that our standards ofparticipation and quality are met andadhered to. As required by stateguidelines and accreditation bodies, allphysicians and health care professionalsmust be recredentialed every threeyears.

Our network contains over22,000* board certifiedphysicians. All physicians in the United States must belicensed in order to practicemedicine, but they are notrequired to be board certified.Board certification is avoluntary process that goesabove and beyond licensingrequirements. Earning andmaintaining board certification,though not a requirement topractice medicine, represents aphysician’s commitment tocontinually expand and refreshhis or her knowledge in a particular medical specialty.1

Horizon BCBSNJ maintains accessstandards to ensure that members haveaccess to participating physicians andother health care professionals.Specialists who perform a high volumeof services must be located within acertain geographic area in relation to our members.

t The maximum time or distance amember must travel to see aphysician or other health careprofessional. Generally, for a PrimaryCare Physician it is 30 minutes or 10miles from the member’s city/town

and for a specialist it is 60 minutes or45 miles from the member’s city/town.

t The member to physician or otherhealth care professional ratio. Theminimum number of participatingphysicians or other health careprofessionals available near themember’s city/town.

* Numbers are current at the time of printing. 1 American Board of Medical Specialties,www.abms.org.

Your rights and responsibilitiesAs a Horizon Blue Cross Blue Shield of New Jersey member, you have rights. These include the right to receive

information about Horizon BCBSNJ’s services, policies and procedures, products, networks, appeal procedures,coverage limitations and other information you need to understand your benefits and get care.

You also have responsibilities. They include reading and understanding member materials, including your memberrights and responsibilities, and other materials that explain your coverage. They also include providing, to the extentpossible, information about your health that Horizon BCBSNJ, its network doctors and other health care professionalsneed to properly care for you.

To view a full list of your rights and responsibilities, visit HorizonBlue.com/Members, mouse over Education Center and click Member Rights and Responsibilities. If you do not have Internet access, call Member Services at 1-800-355-BLUE (2583) to request a printed copy.

The quality of your care



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Service Excellence

Horizon Blue Cross Blue Shield ofNew Jersey recognizes thedemonstrated commitment ofparticipating doctors to provide qualityhealth care to our members. Ourphysician recognition program is basedon quality criteria developed frominput from participating doctors,health care consultants and national,evidence-based resources.

Specialties that are eligible to receiverecognition in this program include:t Cardiology.t Endocrinology.t Family Practice.t Gastroenterology.t General Surgery.t Internal Medicine.t Multi-specialty.t Nephrology.t Obstetrics/Gynecology.t Orthopedic Surgery.t Otolaryngology.t Pediatrics.t Urology.

Doctors in the above-listedspecialties who have achievedrecognition in our quality recognitionprogram can be identified by a Blue Physician Recognition (BPR)

indicator in our online ProviderDirectory.

The BPR icon helps members makemore informed health care decisions byproviding meaningful and consistentinformation on doctor quality. The BPRicon helps members to quickly andeasily identify those primary caredoctors and specialists recognized forhaving demonstrated a commitment todelivering quality and patient-centeredcare through participation in acceptednational, regional and/or local qualityimprovement or recognition programs.

To access the Horizon BCBSNJ online Provider Directory, visitHorizonBlue.com/Directory.

Blue Physician Recognition Helping you make more informed health care decisions

Horizon Blue Cross Blue Shield of New Jersey, and its affiliated companies subject to the federal privacy rules, want insuredmembers to know that we recognize our obligation to keep your information secure and confidential. Horizon BCBSNJ haspolicies and procedures to protect “Private Information” (PI). We train our employees on the need to maintain your PI in strictconfidence and to report circumstances of breach. We also maintain appropriate administrative, technical and physicalsafeguards to reasonably protect your PI. In those situations where we rely on a third party to perform business, professional or insurance services or functions for us, that third party must agree to safeguard your PI.

When we use the term “Private Information,” we refer to individually identifiable oral, written and electronic informationconcerning the provision of, or payment for, health care services to you. It does not include publicly available information, orinformation reported in a summarized or aggregate fashion that does not identify you. We are generally permitted to makedisclosures of your PI without authorization for purposes of treatment, payment and health care operations purposes. In thosecases, we are not required to seek your authorization. We may sometimes seek your authorization before making otherdisclosures of PI. Also, unless you otherwise notify us in writing, we may disclose your PI to a family member, the subscriber of your health benefits plan or any person who is involved in your care or payment for your care. Further details regardingroutine disclosures, disclosures to people involved in your care or payment for your care and additional information regardingyour legal rights related to PI are available in our Notice of Information Privacy Practices.

To get a copy of our full Notice of Information Privacy Practices for insured members, which describes in greater detail our useand disclosure of your PI and your legal rights as they relate to PI, please visit HorizonBlue.com/privacy-policy or call Member Services at 1-800-355-BLUE (2583).

Annual Privacy Notice NO ACTION REQUIRED



http://www.HorizonBlue.com/privacy-policy

HorizonBlue.com

Your health care news across the regionHorizon Blue Cross Blue Shield of New JerseyEditor: Robyn BennettManaging Editor: Paul SalusDesign & Layout: Laura GrahamDirector: Daisy Chan

Services and products may be provided through Horizon Blue Cross Blue Shield of New Jersey, Horizon Healthcare of New Jersey, Inc., Horizon Insurance Company or Horizon Healthcare Dental, Inc., independent licensees of the Blue Cross andBlue Shield Association. Focus magazine is written exclusively for Horizon Blue Cross Blue Shield of New Jersey members by the Enterprise Communications Department of Horizon BCBSNJ. This magazine provides basic coverage guidelines to help you maximize yourhealth care benefits. It provides general preventive health and wellness guidelines, as well as information on managing specific health conditions. Please read this magazine and use it to help make informed health decisions. You can discussthe enclosed information, which is not medical advice, with your doctor. The information in Focus is for educational purposes only and does not replace your doctor’s medical advice. Your doctor can diagnose a medical condition and help youmake health choices that are right for you. If you would like to comment on the information enclosed in this magazine, please send an e-mail to [email protected], or write to: Enterprise Communications, c/o Paul Salus, Horizon BCBSNJ, 1427 Wyckoff Road, WL-03M, Farmingdale, NJ 07727.

The Blue Cross® and Blue Shield® names and symbols, BlueCard®, Blue Distinction Centers® and Blue Distinction® areregistered marks of the Blue Cross and Blue Shield Association.The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey.Facebook® is a registered mark of Facebook, Inc.TwitterTM is a registered trademark of Twitter, Inc.WebMD® is a registered mark of WebMD, Inc.© 2014 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105

CMC0006118 (0414)

If you are ever dissatisfied with any aspect ofyour plan coverage, including the quality of careor service you have received, you, a doctor,other health care professional or authorizedrepresentative acting on your behalf (and withyour consent) may file an inquiry, complaint orappeal with Horizon Blue Cross Blue Shield ofNew Jersey.

Horizon BCBSNJ offers inquiry, complaint andappeal processes designed to provide a prompt response and resolution to all requests. Theseprocesses relate to:tMedical issues.tOur utilization management decisionmaking.

tOther nonutilization management issues.

If you file an appeal, Horizon BCBSNJ willprovide a timely, fair and full investigation andresolution of your appeal. For a completedescription of our internal appeals process,

please refer to your Member Benefit Booklet orcall Member Services at 1-800-355-BLUE (2583).If you file an appeal and are dissatisfied withthe resolution reached through our internalappeals process, you may call the New JerseyDepartment of Banking and Insurance at 1-888-393-1062.*

You may also write to:Office of Managed Care Consumer

Protection ServicesDepartment of Banking and Insurance

PO Box 329Trenton, NJ 08625-0329*

Any member who voices a concern, files acomplaint or pursues an appeal will not besubject to disenrollment, discrimination orpenalty by Horizon BCBSNJ.

* This applies to insured plans only. Speak with your plan’s benefits administrator for more information.

Voicing a concern

PRESORTED STANDARD

U S POSTAGE PAID

W. CALDWELL, NJ PERMIT NO. 55

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At Horizon Blue Cross Blue Shield of New Jersey, we’recommitted to making sure you receive access to quality care.Our Quality Improvement (QI) Program monitors and works toimprove the quality of care and services provided to you.

For more information on the QI Program and its progress,

please visit HorizonBlue.com, scroll down to CorporateSections and click Our Company, then click Company Reports.

If you don’t have access to the Internet, please call theQuality Management Department at 1-877-841-9629 torequest a copy of the information.



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