EXHIBIT 10.28
CONTRACT
BETWEEN
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
AND
University Health Plans, Inc., CONTRACTOR
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
AND
UNIVERSITY HEALTH PLANS, INC.
CONTRACT TO PROVIDE SERVICES
This risk comprehensive contract is entered into this _______ day of
_________, and is effective on the 1st day of October between the Department of
Human Services, which is in the executive branch of state government, the state
agency designated to administer the Medicaid program under Title XIX of the
Social Security Act, 42 U.S.C. 1396 et seq. pursuant to the New Jersey Medical
Assistance Act, N.J.S.A. 30:4D-1 et seq. and the State Child Health Insurance
Program under Title XXI of the Social Security Act, 42 U.S.C. 1397aa et seq.,
pursuant to the Children's Health Care Coverage Act, PL 1997, c.272 (also known
as "NJ KidCare"), pursuant to Family Care Health Coverage Act, P.L. 2000, c.71
(also known as "NJ FamilyCare") whose principal office is located at CN 712, in
the City of Trenton, New Jersey hereinafter referred to as the "Department" and
University Health Plans, Inc., a federally qualified/ state defined health
maintenance organization (HMO) which is a New Jersey, profit/non-profit
corporation, certified to operate as an HMO by the State of New Jersey
Department of Banking and Insurance and the State of New Jersey Department of
Health and Senior Services, and whose principal corporate office is located at
000 Xxxxx Xxxxxx, in the City of Newark, County of Essex, New Jersey,
hereinafter referred to as the "contractor".
WHEREAS, the contractor is engaged in the business of providing prepaid,
capitated comprehensive health care services pursuant to N.J.S.A. 26:2J-1 et
seq.; and
WHEREAS, the Department, as the state agency designated to administer a program
of medical assistance for eligible persons under Title XIX of the Social
Security Act (42 U.S.C. Sec. 1396, et seq., also known as "Medicaid"), for
eligible persons under the Family Care Health Coverage Act (P.L. 2000, c.71) and
for children under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa,
et seq., also known as "State Child Health Insurance Program"), is authorized
pursuant to the federal regulations at 42 C.F.R. 434 to provide such a program
through an HMO and is desirous of obtaining the contractor's services for the
benefit of persons eligible for Medicaid/NJ FamilyCare; and
WHEREAS, the Division of Medical Assistance and Health Services (DMAHS), is the
Division within the Department designated to administer the medical assistance
program, and the Department's functions as regards all Medicaid/NJ FamilyCare
program benefits provided through the contractor for Medicaid/NJ FamilyCare
eligibles enrolled in the contractor's plan.
NOW THEREFORE, in consideration of the contracts and mutual covenants herein
contained, the Parties hereto agree as follows:
PREAMBLE
Governing Statutory and Regulatory Provisions: This contract and all renewals
and modifications are subject to the following laws and all amendments thereof:
Title XIX and Title XXI of the Social Security Act, 42 U.S.C. 1396 et. seq., 42
U.S.C. 1397aa et seq., the New Jersey Medical Assistance Act and the Medicaid,
and NJ KidCare and NJ FamilyCare State Plans approved by HCFA (N.J.S.A. 30:4D-1
et seq.; 30:4I-1 et seq.; 30:4J-1 et seq.); federal and state Medicaid and State
Child Health Insurance, and NJ FamilyCare regulations, other applicable federal
and state statutes, and all applicable local laws and ordinances.
IN WITNESS WHEREOF, the parties hereto have caused this contract and Appendices
to be executed this 27th day of September, 2000. This contract and
Appendices are hereby accepted and considered binding in accordance with the
terms outlined in the preceding statements.
CONTRACTOR STATE OF NEW JERSEY
ADDRESS DEPARTMENT OF HUMAN SERVICES
DIRECTOR, DIVISION MEDICAL ASSISTANCE
AND HEALTH SERVICES
BY: /s/ Xxxxxxxxx X. XxXxxx BY: /s/ Xxxxxxxx X. Xxxxxx
TITLE: President & CEO TITLE: Director, DMAHS
DATE: 9/27/00 DATE:______________________
Approved As to Form
______________________
Deputy Attorney General
Date: _________________
TABLE OF CONTENTS
ARTICLE ONE: DEFINITIONS
ARTICLE TWO: CONDITIONS PRECEDENT
ARTICLE THREE: MANAGED CARE MANAGEMENT INFORMATION SYSTEM
3.1 GENERAL OPERATIONAL REQUIREMENTS FOR THE MCMIS......................... III-1
3.1.1 ONLINE ACCESS................................................. III-1
3.1.2 PROCESSING REQUIREMENTS....................................... III-1
3.1.3 REPORTING AND DOCUMENTATION REQUIREMENTS ..................... III-3
3.1.4 OTHER REQUIREMENTS............................................ III-3
3.2 ENROLLEE SERVICES...................................................... III-4
3.2.1 CONTRACTOR ENROLLMENT DATA.................................... III-4
3.2.2 ENROLLEE PROCESSING REQUIREMENTS ............................. III-5
3.2.3 CONTRACTOR ENROLLMENT VERIFICATION ........................... III-6
3.2.4 ENROLLEE COMPLAINT AND GRIEVANCE TRACKING SYSTEM ............. III-6
3.2.5 ENROLLEE REPORTING............................................ III-7
3.3 PROVIDER SERVICES...................................................... III-7
3.3.1 PROVIDER INFORMATION AND PROCESSING REQUIREMENTS ............. III-7
3.3.2 PROVIDER CREDENTIALING........................................ III-8
3.3.3 PROVIDER/ENROLLEE LINKAGE..................................... III-8
3.3.4 PROVIDER MONITORING .......................................... III-8
3.3.5 REPORTING REQUIREMENTS........................................ III-9
3.4 CLAIMS/ENCOUNTER PROCESSING ........................................... III-9
3.4.1 GENERAL REQUIREMENTS.......................................... III-9
3.4.2 COORDINATION OF BENEFITS...................................... III-10
3.4.3 REPORTING REQUIREMENTS........................................ III-11
3.5 PRIOR AUTHORIZATION, REFERRAL AND UTILIZATION MANAGEMENT............... III-11
3.5.1 FUNCTIONS AND CAPABILITIES ................................... II-12
3.5.2 REPORTING REQUIREMENTS........................................ III-12
3.6 FINANCIAL PROCESSING .................................................. III-12
3.6.1 FUNCTIONS AND CAPABILITIES ................................... II-13
3.6.2 REPORTING PRODUCTS............................................ III-14
3.7 QUALITY ASSURANCE...................................................... III-14
3.7.1 FUNCTIONS AND CAPABILITIES ................................... II-14
3.7.2 REPORTING PRODUCTS............................................ III-16
3.8 MANAGEMENT AND ADMINISTRATIVE REPORTING................................ III-16
3.8.1 GENERAL REQUIREMENTS.......................................... III-16
3.8.2 QUERY CAPABILITIES............................................ III-17
3.8.3 REPORTING CAPABILITIES........................................ III-17
3.9 ENCOUNTER DATA REPORTING............................................... III-17
3.9.1 REQUIRED ENCOUNTER DATA ELEMENTS.............................. III-18
i
3.9.2 SUBMISSION OF TEST ENCOUNTER DATA............................. III-18
3.9.3 SUBMISSION OF PRODUCTION ENCOUNTER DATA....................... III-19
3.9.4 REMITTANCE ADVICE ............................................ III-20
3.9.5 SUBCONTRACTS AND ENCOUNTER DATA REPORTING FUNCTION............ III-20
3.9.6 FUTURE ELECTRONIC ENCOUNTER SUBMISSION REQUIREMENTS........... III-20
ARTICLE FOUR: PROVISION OF HEALTH CARE SERVICES
4.1 COVERED SERVICES....................................................... IV-1
4.1.1 GENERAL PROVISIONS AND CONTRACTOR RESPONSIBILITIES............ IV-1
4.1.2 BENEFIT PACKAGE............................................... V-3
4.1.3 SERVICES REMAINING IN FEE-FOR-SERVICE PROGRAM AND MAY
NECESSITATE CONTRACTOR ASSISTANCE TO THE ENROLLEE TO ACCESS
THE SERVICES.................................................. IV-6
4.1.4 MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR.......... IV-8
4.1.5 INSTITUTIONAL FEE-FOR-SERVICE BENEFITS -- NO
COORDINATION BY THE CONTRACTOR................................ IV-9
4.1.6 BENEFIT PACKAGE FOR NJ FAMILYCARE PLAN D ..................... IV-9
4.1.7 SUPPLEMENTAL BENEFITS ........................................ IV-13
4.1.8 CONTRACTOR AND DMAHS SERVICE EXCLUSIONS ...................... IV-13
4.2 SPECIAL PROGRAM REQUIREMENTS........................................... IV-15
4.2.1 EMERGENCY SERVICES... ........................................ IV-15
4.2.2 FAMILY PLANNING SERVICES AND SUPPLIES ........................ IV-19
4.2.3 OBSTETRICAL SERVICES REQUIREMENTS/ISSUES...................... IV-20
4.2.4 PRESCRIBED DRUGS AND PHARMACY SERVICES........................ IV-20
4.2.5 LABORATORY SERVICES .......................................... IV-23
4.2.6 EPSDT SCREENING SERVICES ..................................... IV-23
4.2.7 IMMUNIZATIONS................................................. IV-32
4.2.8 CLINICAL TRIALS............................................... IV-32
4.2.9 HEALTH PROMOTION AND EDUCATION PROGRAMS ...................... IV-34
4.3 COORDINATION WITH ESSENTIAL COMMUNITY PROVIDERS ....................... IV-35
4.3.1 GENERAL ...................................................... IV-35
4.3.2 HEAD START PROGRAMS........................................... IV-35
4.3.3 SCHOOL-BASED YOUTH SERVICES PROGRAMS.......................... IV-36
4.3.4 LOCAL HEALTH DEPARTMENTS...................................... IV-38
4.3.5 WIC PROGRAM REQUIREMENTS/ISSUES .............................. IV-38
4.3.6 COMMUNITY LINKAGES ........................................... IV-38
4.4 COORDINATION WITH MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES .......... IV-39
4.5 ENROLLEES WITH SPECIAL NEEDS .......................................... IV-41
4.5.1 INTRODUCTION.................................................. IV-41
4.5.2 GENERAL REQUIREMENTS.......................................... IV-42
ii
4.5.3 PROVIDER NETWORK REQUIREMENTS ................................ IV-47
4.5.4 CARE MANAGEMENT AND COORDINATION OF CARE FOR PERSONS WITH
SPECIAL NEEDS ................................................ IV-48
4.5.5 CHILDREN WITH SPECIAL HEALTH CARE NEEDS....................... IV-50
4.5.6 CLIENTS OF THE DIVISION OF DEVELOPMENTAL DISABILITIES......... IV-52
4.5.7 PERSONS WITH HIV/AIDS......................................... IV-53
4.6 QUALITY MANAGEMENT SYSTEM.............................................. IV-54
4.6.1 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PLAN .......... IV-54
4.6.2 QAPI ACTIVITIES............................................... IV-56
4.6.3 REFERRAL SYSTEMS.............................................. IV-67
4.6.4 UTILIZATION MANAGEMENT ....................................... IV-69
4.6.5 CARE MANAGEMENT .............................................. IV-75
4.7 MONITORING AND EVALUATION.............................................. IV-78
4.7.1 GENERAL PROVISIONS............................................ IV-78
4.7.2 EVALUATION AND REPORTING - CONTRACTOR RESPONSIBILITIES ....... IV-80
4.7.3 MONITORING AND EVALUATION - DEPARTMENT ACTIVITIES ............ IV-82
4.7.4 INDEPENDENT EXTERNAL REVIEW ORGANIZATION REVIEWS.............. IV-83
4.8 PROVIDER NETWORK ...................................................... IV-84
4.8.1 GENERAL PROVISIONS............................................ IV-84
4.8.2 PRIMARY CARE PROVIDER REQUIREMENTS ........................... IV-86
4.8.3 PROVIDER NETWORK FILE REQUIREMENTS............................ IV-88
4.8.4 PROVIDER DIRECTORY REQUIREMENTS .............................. IV-88
4.8.5 CREDENTIALING/RECREDENTIALING REQUIREMENTS/ISSUES............. IV-89
4.8.6 LABORATORY SERVICE PROVIDERS.................................. IV-89
4.8.7 SPECIALTY PROVIDERS AND CENTERS .............................. IV-91
4.8.8 PROVIDER NETWORK REQUIREMENTS ................................ IV-92
4.8.9 DENTAL PROVIDER NETWORK REQUIREMENTS ......................... IV-102
4.8.10 GOOD FAITH NEGOTIATIONS ...................................... IV-103
4.8.11 PROVIDER NETWORK ANALYSIS .................................... IV-103
4.9 PROVIDER CONTRACTS AND SUBCONTRACTS.................................... IV-103
4.9.1 GENERAL PROVISIONS............................................ IV-103
4.9.2 CONTRACT SUBMISSION .......................................... IV-105
4.9.3 PROVIDER CONTRACT AND SUBCONTRACT TERMINATION................. IV-107
4.9.4 PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL
COMMUNICATIONS ............................................... IV-108
4.9.5 ANTIDISCRIMINATION ........................................... IV-109
4.10 EXPERT WITNESS REQUIREMENTS AND COURT OBLIGATIONS..................... IV-109
4.11 ADDITIONS, DELETIONS, AND/OR CHANGES ................................. IV-110
ARTICLE FIVE: ENROLLEE SERVICES
5.1 GEOGRAPHIC REGIONS..................................................... V-1
iii
5.2 AID CATEGORIES ELIGIBLE FOR CONTRACTOR ENROLLMENT...................... V-2
5.3 EXCLUSIONS AND EXEMPTIONS ............................................. V-2
5.3.1 ENROLLMENT EXCLUSIONS ........................................ V-3
5.3.2 ENROLLMENT EXEMPTIONS......................................... V-4
5.4 ENROLLMENT OF MANAGED CARE ELIGIBLES .................................. V-5
5.5 ENROLLMENT AND COVERAGE REQUIREMENTS .................................. V-6
5.6 VERIFICATION OF ENROLLMENT............................................. V-10
5.7 MEMBER SERVICES UNIT .................................................. V-10
5.8 ENROLLEE EDUCATION AND INFORMATION..................................... V-11
5.8.1 GENERAL REQUIREMENTS.......................................... V-11
5.8.2 ENROLLEE NOTIFICATION/HANDBOOK................................ V-12
5.8.3 ANNUAL INFORMATION TO ENROLLEES .............................. V-18
5.8.4 NOTIFICATION OF CHANGES IN SERVICES .......................... V-18
5.8.5 ID CARD....................................................... V-18
5.8.6 ORIENTATION AND WELCOME LETTER ............................... V-19
5.9 PCP SELECTION AND ASSIGNMENT .......................................... V-19
5.9.1 INITIAL SELECTION/ASSIGNMENT ................................. V-20
5.9.2 PCP CHANGES................................................... V-20
5.10 DISENROLLMENT FROM CONTRACTOR'S PLAN................................... V-22
5.10.1 GENERAL PROVISIONS............................................ V-22
5.10.2 DISENROLLMENT FROM THE CONTRACTOR'S PLAN AT THE ENROLLEE'S
REQUEST....................................................... V-23
5.10.3 DISENROLLMENT FROM THE CONTRACTOR'S PLAN AT THE CONTRACTOR'S
REQUEST ...................................................... V-24
5.10.4 TERMINATION .................................................. V-26
5.11 TELEPHONE ACCESS ...................................................... V-27
5.12 APPOINTMENT AVAILABILITY .............................................. V-28
5.13 APPOINTMENT MONITORING PROCEDURES...................................... V-30
5.14 CULTURAL AND LINGUISTIC NEEDS ......................................... V-31
5.15 ENROLLEE COMPLAINTS AND GRIEVANCES .................................... V-34
5.15.1 GENERAL REQUIREMENTS.......................................... V-34
5.15.2 NOTIFICATION TO ENROLLEES OF GRIEVANCE PROCEDURE.............. V-35
5.15.3 GRIEVANCE PROCEDURES.......................................... V-36
5.15.4 PROCESSING GRIEVANCES ........................................ V-37
5.15.5 RECORDS MAINTENANCE .......................................... V-38
5.16 MARKETING ............................................................. V-39
5.16.1 GENERAL PROVISIONS - CONTRACTOR'S RESPONSIBILITIES............ V-39
5.16.2 STANDARDS FOR MARKETING REPRESENTATIVES....................... V-43
ARTICLE SIX: PROVIDER INFORMATION
6.1 GENERAL................................................................ VI-1
6.2 PROVIDER PUBLICATIONS ................................................. VI-1
6.3 PROVIDER EDUCATION AND TRAINING........................................ VI-3
iv
6.4 PROVIDER TELEPHONE ACCESS.............................................. VI-3
6.5 PROVIDER GRIEVANCES AND APPEALS ....................................... VI-4
ARTICLE SEVEN: TERMS AND CONDITIONS (ENTIRE CONTRACT)
7.1 CONTRACT COMPONENTS ................................................... VII-1
7.2 GENERAL PROVISIONS .................................................... VII-1
7.3 STAFFING............................................................... VII-4
7.4 RELATIONSHIPS WITH DEBARRED OR SUSPENDED PERSONS PROHIBITED ........... VII-5
7.5 CONTRACTING OFFICER AND CONTRACTOR'S REPRESENTATIVE.................... VII-7
7.6 AUTHORITY OF THE STATE................................................. VII-8
7.7 EQUAL OPPORTUNITY EMPLOYER............................................. VII-8
7.8 NONDISCRIMINATION REQUIREMENTS......................................... VII-8
7.9 INSPECTION RIGHTS ..................................................... VII-10
7.10 NOTICES/CONTRACT COMMUNICATION......................................... VII-11
7.11 TERM................................................................... VII-11
7.11.1 CONTRACT DURATION AND EFFECTIVE DATE ......................... VII-11
7.11.2 AMENDMENT, EXTENSION, AND MODIFICATION........................ VII-11
7.12 TERMINATION ........................................................... VII-13
7.13 CLOSEOUT REQUIREMENTS.................................................. VII-15
7.14 MERGER/ACQUISITION REQUIREMENTS........................................ VII-19
7.15 SANCTIONS.............................................................. VII-22
7.16 LIQUIDATED DAMAGES PROVISIONS.......................................... VII-24
7.16.1 GENERAL PROVISIONS............................................ VII-24
7.16.2 MANAGED CARE OPERATIONS, TERMS AND CONDITIONS,
AND PAYMENT PROVISIONS........................................ VII-25
7.16.3 TIMELY REPORTING REQUIREMENTS................................. VII-26
7.16.4 ACCURATE REPORTING REQUIREMENTS .............................. VII-26
7.16.5 TIMELY PAYMENTS TO MEDICAL PROVIDERS.......................... VII-27
7.16.6 CONDITIONS FOR TERMINATION OF LIQUIDATED DAMAGES ............. VII-28
7.16.7 EPSDT PERFORMANCE STANDARDS .................................. VII-28
7.16.8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CIVIL MONEY PENALTIES. VII-31
7.16.8.1 FEDERAL STATUTES.............................................. VII-31
7.16.8.2 FEDERAL PENALTIES............................................. VII-31
7.17 STATE SANCTIONS ....................................................... VII-32
7.18 APPEAL PROCESS......................................................... VII-33
7.19 ASSIGNMENTS............................................................ VII-33
v
7.20 CONTRACTOR CERTIFICATIONS ............................................. VII-33
7.20.1 GENERAL PROVISIONS ........................................... VII-33
7.20.2 CERTIFICATION SUBMISSIONS .................................... VII-34
7.20.3 ENVIRONMENTAL COMPLIANCE...................................... VII-34
7.20.4 ENERGY CONSERVATION........................................... VII-34
7.20.5 INDEPENDENT CAPACITY OF CONTRACTOR ........................... VII-34
7.20.6 NO THIRD PARTY BENEFICIARIES.................................. VII-34
7.20.7 PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING ............. VII-34
7.21 REQUIRED CERTIFICATE OF AUTHORITY ..................................... VII-35
7.22 SUBCONTRACTS........................................................... VII-35
7.23 SET-OFF FOR STATE TAXES AND CHILD SUPPORT.............................. VII-36
7.24 CLAIMS ................................................................ VII-36
7.25 MEDICARE RISK CONTRACTOR............................................... VII-36
7.26 TRACKING AND REPORTING................................................. VII-36
7.27 FINANCIAL STATEMENTS................................................... VII-38
7.27.1 AUDITED FINANCIAL STATEMENTS (GAAP BASIS) .................... VII-38
7.27.2 FINANCIAL STATEMENTS (SAP).................................... VII-39
7.28 FEDERAL APPROVAL AND FUNDING .......................................... VII-39
7.29 CONFLICT OF INTEREST................................................... VII-39
7.30 RECORDS RETENTION ..................................................... VII-40
7.31 WAIVERS................................................................ VII-41
7.32 CHANGE BY THE CONTRACTOR .............................................. VII-41
7.33 INDEMNIFICATION........................................................ VII-41
7.34 INVENTIONS............................................................. VII-43
7.35 USE OF CONCEPTS........................................................ VII-43
7.36 PREVAILING WAGE ....................................................... VII-43
7.37 DISCLOSURE STATEMENT................................................... VII-44
7.38 FRAUD AND ABUSE........................................................ VII-45
7.38.1 ENROLLEES .................................................... VII-45
7.38.2 PROVIDERS..................................................... VII-46
7.38.3 NOTIFICATION TO DMAHS ........................................ VII-48
7.39 EQUALITY OF ACCESS AND TREATMENT/DUE PROCESS........................... VII-48
7.40 CONFIDENTIALITY........................................................ VII-48
7.41 SEVERABILITY........................................................... VII-49
7.42 CONTRACTING OFFICER AND CONTRACTOR'S REPRESENTATIVE...VII-50
ARTICLE EIGHT: FINANCIAL PROVISIONS
8.1 GENERAL INFORMATION ................................................... VIII-1
8.2 FINANCIAL REQUIREMENTS ................................................ VIII-1
8.2.1 COMPLIANCE WITH CERTAIN CONDITIONS ........................... VIII-1
8.2.2 SOLVENCY REQUIREMENTS......................................... VIII-1
8.2.3 GENERAL PROVISIONS AND CONTRACTOR COMPLIANCE ................. VIII-2
8.3 INSURANCE REQUIREMENTS ................................................ VIII-3
8.3.1 INSURANCE CANCELLATION AND/OR CHANGES ........................ VIII-3
vi
8.3.2 STOP-LOSS INSURANCE .......................................... VIII-3
8.4 MEDICAL COST RATIO..................................................... VIII-4
8.4.1 MEDICAL COST RATIO STANDARD................................... VIII-4
8.4.2 EXEMPTIONS.................................................... VIII-5
8.4.3 DAMAGES ...................................................... VIII-5
8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS................ VIII-6
8.5.1 REGIONS....................................................... VIII-6
8.5.2 AFDC/TANF AND NJ FAMILYCARE, PLAN A CHILDREN.................. VIII-6
8.5.3 NJ FAMILYCARE PLAN A PARENTS/CARETAKERS ...................... VIII-7
8.5.4 NJ FAMILYCARE PLAN A ADULTS WITHOUT DEPENDENT
CHILDREN UNDER 19 YEARS OF AGE................................ VIII-7
8.5.5 NJ FAMILYCARE PLANS B & C..................................... VIII-7
8.5.6 NJ FAMILYCARE PLAN D CHILDREN ................................ VIII-7
8.5.7 NJ FAMILYCARE PLAN D PARENTS/CARETAKERS ...................... VIII-8
8.5.8 NJ FAMILYCARE PLAN D ADULTS WITHOUT DEPENDENT
CHILDREN UNDER 19 YEARS OF AGE................................ VIII-8
8.5.9 PREMIUM GROUPS FOR DYFS AND AGING OUT XXXXXX CHILDREN......... VIII-8
8.5.10 ABDWITHOUT MEDICARE........................................... VIII-8
8.5.11 ABD WITH MEDICARE............................................. VIII-9
8.5.12 CLIENTS OF DDD................................................ VIII-9
8.5.13 PREMIUM GROUPS FOR ENROLLEES WITH AIDS ....................... VIII-9
8.5.14 SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME.................... VIII-10
8.5.15 PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS ................... VIII-10
8.5.16 PAYMENT FOR HIV/AIDS DRUGS.................................... VIII-10
8.5.17 EPSDT INCENTIVE PAYMENT ...................................... VIII-11
8.5.18 ADMINISTRATIVE COSTS.......................................... VIII-11
8.6 HEALTH BASED PAYMENT SYSTEM (HBPS) FOR THE ABD WITHOUT MEDICARE
POPULATION............................................................. VIII-11
8.7 THIRD PARTY LIABILITY.................................................. VIII-14
8.8 COMPENSATION/CAPITATION CONTRACTUAL REQUIREMENTS....................... VIII-19
8.9 CONTRACTOR ADVANCED PAYMENTS AND PIPS TO PROVIDERS .................... VIII-21
8.10 FEDERALLY QUALIFIED HEALTH CENTERS..................................... VIII-23
vii
ARTICLE ONE: DEFINITIONS
The following terms shall have the meaning stated, unless the context
clearly indicates otherwise.
ABUSE--means provider practices that are inconsistent with sound
fiscal, business, or medical practices, and result in an unnecessary
cost to the Medicaid/NJ FamilyCare program, or in reimbursement for
services that are not medically necessary or that fail to meet
professionally recognized standards for health care. It also includes
enrollee practices that result in unnecessary cost to the Medicaid/NJ
FamilyCare program. (See 42 C.F.R. Section 455.2)
ADDP--AIDS Drug Distribution Program, a Department of Health and Senior
Servicessponsored program which provides life-sustaining and
life-prolonging medications to persons who are HIV positive or who are
living with AIDS and meet certain residency and income criteria for
program participation.
ADJUDICATE--the point in the claims processing at which a final
decision is reached to pay or deny a claim.
ADMINISTRATIVE SERVICE(S)--the contractual obligations of the
contractor that include but may not be limited to utilization
management, credentialing providers, network management, quality
improvement, marketing, enrollment, member services, claims payment,
management information systems, financial management, and reporting.
ADVERSE EFFECT--medically necessary medical care has not been provided
and the failure to provide such necessary medical care has presented an
imminent danger to the health, safety, or well-being of the patient or
has placed the patient unnecessarily in a high-risk situation.
ADVERSE SELECTION--the enrollment with a contractor of a
disproportionate number of persons with high health care costs.
AFDC OR AFDC/TANF--Aid to Families with Dependent Children, established
by 42 U.S.C. Section 601 et seq., and N.J.S.A. 44:10-1 et seq., as a
joint federal/State cash assistance program administered by counties
under State supervision. For cash assistance, it is now called "TANF."
For Medicaid, the former AFDC rules still apply.
AFDC-RELATED--see "SPECIAL MEDICAID PROGRAMS" and "TANF"
AID CODES--the two-digit number which indicates the aid category under
which a person is eligible to receive Medicaid and NJ FamilyCare.
AMELIORATE--to improve, maintain, or stabilize a health outcome, or to
prevent or mitigate an adverse change in health outcome.
I-1
ANTICIPATORY GUIDANCE--the education provided to parents or authorized
individuals during routine prenatal or pediatric visits to prevent or
reduce the risk to their fetuses or children developing a particular
health problem.
ASSIGNMENT--the process by which a Medicaid enrollee in a New Jersey
Care 2000+ contractor receives a Primary Care Provider (PCP).
AT-RISK--any service for which the provider agrees to accept
responsibility to provide or arrange for in exchange for the capitation
payment.
AUTHORIZED PERSON--in general means a person authorized to make medical
determinations for an enrollee, including, but not limited to,
enrollment and disenrollment decisions and choice of a PCP.
For individuals who are eligible through the Division of Youth and
Family Services (DYFS), the authorized person is authorized to make
medical determinations, including but not limited to enrollment,
disenrollment and choice of a PCP, on behalf of or in conjunction with
individuals eligible through DYFS. These persons may include a xxxxxx
home parent, an authorized health care professional employee of a group
home, an authorized health care professional employee of a residential
center or facility, a DYFS employee, a pre-adoptive or adoptive parent
receiving subsidy from DYFS, a natural or biological parent, or a legal
caretaker.
For individuals who are eligible through the Division of Developmental
Disabilities (DD), the authorized person may be one of the following:
A. The enrollee, if he or she is an adult and has the
capacity to make medical decisions;
B. The parent or guardian of the enrollee, if the
enrollee is a minor, or the individual or agency
having legal guardianship if the enrollee is an adult
who lacks the capacity to make medical decisions;
C. The Bureau of Guardianship Services (BGS); or
D. A person or agency who has been duly designated by a
power of attorney for medical decisions made on
behalf of an enrollee.
Throughout the contract, information regarding enrollee rights and
responsibilities can be taken to include authorized persons, whether
stated as such or not.
AUTOMATIC ASSIGNMENT--the enrollment of an eligible person, for whom
enrollment is mandatory, in a managed care plan chosen by the New
Jersey Department of Human Services pursuant to the provisions of
Article 5.4 of this contract.
I-2
BASIC SERVICE AREA--the geographic area in which the contractor is
obligated to provide covered services for its Medicaid/NJ FamilyCare
enrollees under this contract.
BENEFICIARY--any person eligible to receive services in the New Jersey
Medicaid/NJ FamilyCare program.
BENEFITS PACKAGE--the health care services set forth in this contract,
for which the contractor has agreed to provide, arrange, and be held
fiscally responsible.
BILINGUAL--see "MULTILINGUAL"
BONUS--a payment the contractor makes to a physician or physician group
beyond any salary, fee-for-service payments, capitation, or returned
withholding amount.
CAPITATED SERVICE--any covered service for which the contractor
receives capitation payment.
CAPITATION--a contractual agreement through which a contractor agrees
to provide specified health care services to enrollees for a fixed
amount per month.
CAPITATION PAYMENTS--the amount prepaid monthly by DMAHS to the
contractor in exchange for the delivery of covered services to
enrollees based on a fixed Capitation Rate per enrollee,
notwithstanding (a) the actual number of enrollees who receive services
from the contractor, or (b) the amount of services provided to any
enrollee.
CAPITATION RATE--the fixed monthly amount that the contractor is
prepaid by the Department for each enrollee for which the contractor
provides the services included in the Benefits Package described in
this contract.
CARE MANAGEMENT--a set of enrollee-centered, goal-oriented, culturally
relevant, and logical steps to assure that an enrollee receives needed
services in a supportive, effective, efficient, timely, and
cost-effective manner. Care management emphasizes prevention,
continuity of care, and coordination of care, which advocates for, and
links enrollees to, services as necessary across providers and
settings. Care management functions include 1) early identification of
enrollees who have or may have special needs, 2) assessment of an
enrollees risk factors, 3) development of a plan of care, 4) referrals
and assistance to ensure timely access to providers, 5) coordination of
care actively linking the enrollee to providers, medical services,
residential, social, and other support services where needed, 6)
monitoring, 7) continuity of care, and 8) follow-up and documentation.
CERTIFICATE OF AUTHORITY--a license granted by the New Jersey
Department of Banking and Insurance and the New Jersey Department of
Health and Senior Services to operate an HMO in compliance with
N.J.S.A. 26:2J-1 et. seq.
I-3
CHILDREN'S HEALTH CARE COVERAGE PROGRAM--means the program established
by the "Children's Health Care Coverage Act", P.L. 1997, c.272 as a
health insurance program for targeted, low-income children.
CHILDREN WITH SPECIAL HEALTH CARE NEEDS--those children who have or are
at increased risk for chronic physical, developmental, behavioral, or
emotional conditions and who also require health and related services
of a type and amount beyond that required by children generally.
CHRONIC ILLNESS--a disease or condition of long duration (repeated
inpatient hospitalizations, out of work or school at least three months
within a twelve-month period, or the necessity for continuous health
care on an ongoing basis), sometimes involving very slow progression
and long continuance. Onset is often gradual and the process may
include periods of acute exacerbation alternating with periods of
remission.
CLINICAL PEER--a physician or other health care professional who holds
a non-restricted license in New Jersey and is in the same or similar
specialty as typically manages the medical condition, procedure, or
treatment under review.
CNM OR CERTIFIED NURSE MIDWIFE--a registered professional nurse who is
legally authorized under State law to practice as a nurse-midwife, and
has completed a program of study and clinical experience for
nurse-midwives or equivalent.
CNP OR CERTIFIED NURSE PRACTITIONER--a registered professional nurse
who is licensed by the New Jersey Board of Nursing and meets the
advanced educational and clinical practice requirements beyond the two
to four years of basic nursing education required of all registered
nurses.
CNS OR CLINICAL NURSE SPECIALIST--a person licensed to practice as a
registered professional nurse who is licensed by the New Jersey State
Board of Nursing or similarly licensed and certified by a comparable
agency of the state in which he/she practices.
COLD CALL MARKETING--any unsolicited personal contact with a potential
enrollee by an employee or agent of the contractor for the purpose of
influencing the individual to enroll with the contractor. Marketing by
an employee of the contractor is considered direct; marketing by an
agent is considered indirect.
COMMISSIONER--the Commissioner of the New Jersey Department of Human
Services or a duly authorized representative.
COMPLAINT--a protest by an enrollee as to the conduct by the contractor
or any agent of the contractor, or an act or failure to act by the
contractor or any agent of the contractor, or any other matter in which
an enrollee feels aggrieved by the contractor, that is communicated to
the contractor and that could be resolved by the contractor within the
same day/24 hours of receipt.
I-4
CONDITION--a disease, illness, injury, disorder, or biological or
psychological condition or status for which treatment is indicated.
CONTESTED CLAIM--a claim that is denied because the claim is an
ineligible claim, the claim submission is incomplete, the coding or
other required information to be submitted is incorrect, the amount
claimed is in dispute, or the claim requires special treatment.
CONTINUITY OF CARE--the plan of care for a particular enrollee that
should assure progress without unreasonable interruption.
CONTRACT--the written agreement between the State and the contractor,
and comprises the contract, any addenda, appendices, attachments, or
amendments thereto.
CONTRACTING OFFICER--the individual empowered to act and respond for
the State throughout the life of any contract entered into with the
State.
CONTRACTOR--the Health Maintenance Organization with a valid
Certificate of Authority in New Jersey that contracts hereunder with
the State for the provision of comprehensive health care services to
enrollees on a prepaid, capitated basis.
CONTRACTOR'S PLAN--all services and responsibilities undertaken by the
contractor pursuant to this contract.
CONTRACTOR'S REPRESENTATIVE--the individual legally empowered to bind
the contractor, using his/her signature block, including his/her title.
This individual will be considered the Contractor's Representative
during the life of any contract entered into with the State unless
amended in writing pursuant to Article 7.
COPAYMENT--the part of the cost-sharing requirement for NJ FamilyCare
Plan D enrollees in which a fixed monetary amount is paid for certain
services/items received from the contractor's providers.
COST AVOIDANCE--a method of paying claims in which the provider is not
reimbursed until the provider has demonstrated that all available
health insurance has been exhausted.
COVERED SERVICES--see "BENEFITS PACKAGE"
CREDENTIALING--the contractor's determination as to the qualifications
and ascribed privileges of a specific provider to render specific
health care services.
CULTURAL COMPETENCY--a set of interpersonal skills that allow
individuals to increase their understanding, appreciation, acceptance
of and respect for cultural differences and similarities within, among
and between groups and the sensitivity to how these differences
influence relationships with enrollees. This requires a willingness and
ability to draw on community-based values, traditions and customs, to
devise strategies to better
I-5
meet culturally diverse enrollee needs, and to work with knowledgeable
persons of and from the community in developing focused interactions,
communications, and other supports.
CWA OR COUNTY WELFARE AGENCY ALSO KNOWN AS COUNTY BOARD OF SOCIAL
SERVICES--the agency within the county government that makes
determination of eligibility for Medicaid and financial assistance
programs.
DAYS--calendar days unless otherwise specified.
DBI--the New Jersey Department of Banking and Insurance in the
executive branch of New Jersey State government.
DEFAULT--see "AUTOMATIC ASSIGNMENT"
DELIVERABLE--a document/report/manual to be submitted to the Department
by the contractor pursuant to this contract.
DENTAL DIRECTOR--the contractor's Director of dental services, who is
required to be a Doctor of Dental Science or a Doctor of Medical
Dentistry and licensed by the New Jersey Board of Dentistry, designated
by the contractor to exercise general supervision over the provision of
dental services by the contractor.
DEPARTMENT--the Department of Human Services (DHS) in the executive
branch of New Jersey State government. The Department of Human Services
includes the Division of Medical Assistance and Health Services (DMAHS)
and the terms are used interchangeably. The Department also includes
Division of Youth and Family Services (DYFS), the Division of Family
Development (DFD), the Division of Mental Health Services (DMHS), and
the Division of Developmental Disabilities (DDD).
DEVELOPMENTAL DISABILITY--a severe, chronic disability of a person
which is attributable to a mental or physical impairment or combination
of mental and physical impairments; is manifested before the person
attains age twenty-two (22); is likely to continue indefinitely;
results in substantial functional limitations in three or more of the
following areas of major life activity: self-care, receptive and
expressive language, learning, mobility, self-direction, capacity for
independent living and economic self-sufficiency; and reflects the
person's need for a combination and sequence of special,
interdisciplinary, or generic care, treatment, or other services which
are lifelong or of extended duration and are individually planned and
coordinated. Developmental disability includes but is not limited to
severe disabilities attributable to mental retardation, autism,
cerebral palsy, epilepsy, xxxxx bifida and other neurological
impairments where the above criteria are met.
DFD--the Division of Family Development, within the New Jersey
Department of Human Services that administers programs of financial and
administrative support for certain qualified individuals and families.
I-6
DIAGNOSTIC SERVICES--any medical procedures or supplies recommended by
a physician or other licensed practitioner of the healing arts, within
the scope of his or her practice under State law, to enable him or her
to identify the existence, nature, or extent of illness, injury, or
other health deviation in an enrollee.
DIRECTOR--the Director of the Division of Medical Assistance and Health
Services or a duly authorized representative.
DISABILITY--a physical or mental impairment that substantially limits
one or more of the major life activities for more than three months a
year.
DISABILITY IN ADULTS--for adults applying under New Jersey Care Special
Medicaid Programs and Title II (Social Security Disability Insurance
Program) and for adults applying under Title XVI (the Supplemental
Security Income [SSI] program), disability is defined as the inability
to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment(s) which can be
expected to result in death or which has lasted or can be expected to
last for a continuous period of not less than 12 months.
DISABILITY IN CHILDREN--a child under age 18 is considered disabled if
he or she has a medically determinable physical or mental impairment(s)
which results in marked and severe functional limitations that limit
the child's ability to function independently, appropriately, and
effectively in an age-appropriate manner, and can be expected to result
in death or which can be expected to last for 12 months or longer.
DISENROLLMENT--the removal of an enrollee from participation in the
contractor's plan, but not from the Medicaid program.
DIVISION OF DEVELOPMENTAL DISABILITIES (DDD)--a Division within the New
Jersey Department of Human Services that provides evaluation,
functional and guardianship services to eligible persons. Services
include residential services, family support, contracted day programs,
work opportunities, social supervision, guardianship, and referral
services.
DIVISION OR DMAHS--the New Jersey Division of Medical Assistance and
Health Services within the Department of Human Services which
administers the contract on behalf of the Department.
DHHS OR HHS--United States Department of Health and Human Services of
the executive branch of the federal government, which administers the
Medicaid program through the Health Care Financing Administration
(HCFA).
DHSS--the New Jersey Department of Health and Senior Services in the
executive branch of New Jersey State government, one of the regulatory
agencies of the managed care industry. Its role and functions are
delineated throughout the contract.
I-7
DURABLE MEDICAL EQUIPMENT (DME)--equipment, including assistive
technology, which: a) can withstand repeated use; b) is used to service
a health or functional purpose; c) is ordered by a qualified
practitioner to address an illness, injury or disability; and d) is
appropriate for use in the home or work place/school.
DYFS--the Division of Youth and Family Services, within the New Jersey
Department of Human Services, whose responsibility is to ensure the
safety of children and to provide social services to children and their
families. DYFS enrolls into Medicaid financially eligible children
under its supervision who reside in DYFS-supported substitute living
arrangements such as xxxxxx care and certain subsidized adoption
placements.
DYFS RESIDENTIAL FACILITIES--include Residential Facilities, Teaching
Family Homes, Juvenile Family In-Crisis Shelters, Children's Shelters,
Transitional Living Homes, Treatment Homes Programs, Alternative Home
Care Program, and Group Homes.
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT)--a Title
XIX mandated program that covers screening and diagnostic services to
determine physical and mental defects in enrollees under the age of 21,
and health care, treatment, and other measures to correct or ameliorate
any defects and chronic conditions discovered, pursuant to Federal
Regulations found in Title XIX of the Social Security Act.
EFFECTIVE DATE OF CONTRACT--shall be October 1, 2000.
EFFECTIVE DATE OF DISENROLLMENT--the last day of the month in which the
enrollee may receive services under the contractor's plan.
EFFECTIVE DATE OF ENROLLMENT--the date on which an enrollee can begin
to receive services under the contractor's plan pursuant to Article
Five of this contract.
ELDERLY PERSON--a person who is 65 years of age or older.
EMERGENCY MEDICAL CONDITION--a medical condition manifesting itself by
acute symptoms of sufficient severity, (including severe pain) such
that a prudent layperson, who possesses an average knowledge of
medicine and health, could reasonably expect the absence of immediate
medical attention to result in placing the health of the individual
(or, with respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy; serious impairment to bodily
functions; or serious dysfunction of any bodily organ or part.
EMERGENCY SERVICES--covered inpatient and outpatient services furnished
by any qualified provider that are necessary to evaluate or stabilize
an emergency medical condition.
I-8
ENCOUNTER--the basic unit of service used in accumulating utilization
data and/or a face-to-face contact between a patient and a health care
provider resulting in a service to the patient.
ENCOUNTER DATA--the record of the number and types of services rendered
to patients during a specific time period and defined in Article 3.9 of
this contract.
ENROLLEE--an individual who is eligible for Medicaid/NJ FamilyCare,
residing within the defined enrollment area, who elects or has had
elected on his or her behalf by an authorized person, in writing, to
participate in the contractor's plan and who meets specific Medicaid/NJ
FamilyCare eligibility requirements for plan enrollment agreed to by
the Department and the contractor. Enrollees include individuals in the
AFDC/TANF, AFDC/TANF-Related Pregnant Women and Children, SSI-Aged,
Blind and Disabled, DYFS, NJ FamilyCare, and Division of Developmental
Disabilities/Community Care Waiver (DDD/CCW) populations. See also
"Authorized Person."
ENROLLEE WITH SPECIAL NEEDS--for adults, special needs includes
complex/chronic medical conditions requiring specialized health care
services, including persons with physical, mental/substance abuse,
and/or developmental disabilities, including such persons who are
homeless. Children with special health care needs are those who have or
are at increased risk for a chronic physical, developmental,
behavioral, or emotional conditions and who also require health and
related services of a type or amount beyond that required by children
generally.
ENROLLMENT--the process by which an individual eligible for Medicaid
voluntarily or mandatorily applies to utilize the contractor's plan in
lieu of standard Medicaid benefits, and such application is approved by
DMAHS.
ENROLLMENT AREA--the geographic area bound by county lines from which
Medicaid/NJ FamilyCare eligible residents may enroll with the
contractor unless otherwise specified in the contract.
ENROLLMENT LOCK-IN PERIOD--the period between the first day of the
fourth (4th) month and the end of twelve (12) months after the
effective date of enrollment in the contractor's plan, during which the
enrollee must have good cause to disenroll or transfer from the
contractor's plan. This is not to be construed as a guarantee of
eligibility during the lock-in period. Lock-in provisions will not
apply to clients of DDD or SSI, New Jersey Care Special Medicaid
Program - Aged, Blind, Disabled, and DYFS enrollees.
ENROLLMENT PERIOD--the twelve (12) month period commencing on the
effective date of enrollment.
EPSDT--see "EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT"
I-9
EQUITABLE ACCESS--the concept that enrollees are given equal
opportunity and consideration for needed services without exclusionary
practices of providers or system design because of gender, age, race,
ethnicity, sexual orientation, health status, or disability.
EXCLUDED SERVICES--those services covered under the fee-for-service
Medicaid program that are not included in the contractor benefits
package.
EXTERNAL REVIEW ORGANIZATION (ERO)--an outside independent accredited
review organization under contract with the Department for the purposes
of conducting annual contractor operation assessments and quality of
care reviews for contractors.
FAIR HEARING--the appeal process available to all Medicaid Eligibles
pursuant to N.J.S.A. 30:4D-7 and administered pursuant to N.J.A.C.
10:49-10.1 et seq.
FEDERAL FINANCIAL PARTICIPATION--the funding contribution that the
federal government makes to the New Jersey Medicaid and NJ FamilyCare
programs.
FEDERALLY QUALIFIED HEALTH CENTER (FQHC)--an entity that provides
outpatient health programs pursuant to 42 U.S.C. Section 201 et seq.
FEDERALLY QUALIFIED HMO--an HMO that has been found by the Secretary of
the federal Department of Health and Human Services to provide "basic"
and "supplemental" health services to its enrollees in accordance with
the Health Maintenance Organization Act of 1973, as amended (Title XIII
of the Public Health Service Act, 42 U.S.C. Section 300e), and to meet
the other requirements of that Act relating to fiscal assurance
mechanisms, continuing education for staff, and membership
representation on the HMO's board of directors.
FEE-FOR-SERVICE OR FFS--a method for reimbursement based on payment for
specific services rendered to an enrollee.
FRAUD--an intentional deception or misrepresentation made by a person
with the knowledge that the deception could result in some unauthorized
benefit to him/herself or some other person. It includes any act that
constitutes fraud under applicable federal or State law. (See 42 C.F.R.
Section 455.2)
FULL TIME EQUIVALENT--the number of personnel with the same job title
and responsibilities who, in the aggregate, perform work equivalent to
a singular individual working a 40-hour work week.
GA--means General Assistance, established by N.J.S.A. 10:90-1 et seq.,
as a State cash assistance program administered by counties and
municipalities under State supervision.
GAAP--Generally Accepted Accounting Principles.
I-10
GOOD CAUSE--reasons for disenrollment or transfer that include failure
of the contractor to provide services including physical access to the
enrollee in accordance with contract terms, enrollee has filed a
grievance and has not received a response within the specified time
period or enrollee has filed a grievance and has not received
satisfaction. See Article 5.10.2 for more detail.
GOVERNING BODY--a managed care organization's Board of Directors or,
where the Board's participation with quality improvement issues is not
direct, a designated committee of the senior management of the managed
care organization.
GRIEVANCE--means any complaint that is submitted in writing, or that is
orally communicated and could not be resolved within the same day of
receipt.
GROUP MODEL--a type of HMO operation similar to a group practice except
that the group model must meet the following criteria: (a) the group is
a separate legal entity, (i.e. administrative entity) apart from the
HMO; (b) the group is usually a corporation or partnership; (c) members
of the group must pool their income; (d) members of the group must
share medical equipment, as well as technical and administrative staff;
(e) members of the group must devote at least 50 percent of their time
to the group; and (f) members of the group must have "substantial
responsibility" for delivery of health services to HMO members, within
four years of qualification. After that period, the group may request
additional time or a waiver in accordance with federal regulations at
42 C.F.R. Section 110.104(2), Subpart A.
HCFA--the Health Care Financing Administration within the U.S.
Department of Health and Human Services.
HEALTH BENEFITS COORDINATOR (HBC)--the external organization under
contract with the Department whose primary responsibility is to assist
Medicaid eligible individuals in contractor selection and enrollment.
HEALTH CARE PROFESSIONAL--a physician or other health care professional
if coverage for the professional's services is provided under the
contractor's contract for the services. It includes podiatrists,
optometrists, chiropractors, psychologists, dentists, physician
assistants, physical or occupational therapists and therapy assistants,
speech-language pathologists, audiologists, registered or licensed
practical nurses (including nurse practitioners, clinical nurse
specialists, certified registered nurses, registered nurse
anesthetists, and certified nurse midwives), licensed certified social
workers, registered respiratory therapists, and certified respiratory
therapy technicians.
HEALTH CARE SERVICES--are all preventive and therapeutic medical,
dental, surgical, ancillary (medical and non-medical) and supplemental
benefits provided to enrollees to diagnose, treat, and maintain the
optimal well-being of enrollees provided by physicians, other health
care professionals, institutional, and ancillary service providers.
I-11
HEALTH INSURANCE--private insurance available through an individual or
group plan that covers health services. It is also referred to as Third
Party Liability.
HEALTH MAINTENANCE ORGANIZATION (HMO)--any entity which contracts with
providers and furnishes at least basic comprehensive health care
services on a prepaid basis to enrollees in a designated geographic
area pursuant to N.J.S.A. 26:2J-1 et seq., and with regard to this
contract is either:
A. A Federally Qualified HMO; or
B. Meets the State Plan's definition of an HMO which
includes, at a minimum, the following requirements:
1. It is organized primarily for the purpose of
providing health care services;
2. It makes the services it provides to its
Medicaid enrollees as accessible to them (in
terms of timeliness, amount, duration, and
scope) as the services are to non-enrolled
Medicaid eligible individuals within the
area served by the HMO;
3. It makes provision, satisfactory to the
Division and Departments of Banking and
Insurance and Health and Senior Services,
against the risk of insolvency, and assures
that Medicaid enrollees will not be liable
for any of the HMO's debts if it does become
insolvent; and
4. It has a Certificate of Authority granted by
the State of New Jersey to operate in all or
selected counties in New Jersey.
HEDIS--Health Plan Employer Data and Information Set.
INDICATORS--the objective and measurable means, based on current
knowledge and clinical experience, used to monitor and evaluate each
important aspect of care and service identified.
INDIVIDUAL HEALTH CARE PLAN (IHCP)--a multi-disciplinary plan of care
for enrollees with special needs who qualify for a higher level of care
management based on a Complex Needs Assessment. IHCPs specify short-
and long-term goals, identify needed medical services and relevant
social/support services, specialized transportation and communication,
appropriate outcomes, and barriers to effective outcomes, and
timelines. The IHCP is implemented and monitored by the care manager.
INQUIRY--means a request for information by an enrollee, or a verbal
request by an enrollee for action by the contractor that is so clearly
contrary to the Medicaid Managed Care Program or the contractor's
operating procedures that it may be construed as a factual
misunderstanding, provided that the issue can be immediately explained
and resolved by the contractor. Inquiries need not be treated or
reported as complaints or grievances.
I-12
INSOLVENT--unable to meet or discharge financial liabilities pursuant
to N.J.S.A. 17B:32- 33.
INSTITUTIONALIZED--residing in a nursing facility, psychiatric
hospital, or intermediate care facility/mental retardation (ICF/MR);
this does not include admission in an acute care or rehabilitation
hospital setting.
IPN OR INDEPENDENT PRACTITIONER NETWORK--one type of HMO operation
where member services are normally provided in the individual offices
of the contracting physicians.
LIMITED-ENGLISH-PROFICIENT POPULATIONS--individuals with a primary
language other than English who must communicate in that language if
the individual is to have an equal opportunity to participate
effectively in and benefit from any aid, service or benefit provided by
the health provider.
MAINTENANCE SERVICES--include physical services provided to allow
people to maintain their current level of functioning. Does not include
habilitative and rehabilitative services.
MANAGED CARE--a comprehensive approach to the provision of health care
which combines clinical preventive, restorative, and emergency services
and administrative procedures within an integrated, coordinated system
to provide timely access to primary care and other medically necessary
health care services in a cost effective manner.
MANAGED CARE ENTITY--a managed care organization described in Section
1903(m)(1)(A) of the Social Security Act, including Health Maintenance
Organizations (HMOs), organizations with Section 1876 or
Medicare+Choice contracts, provider sponsored organizations, or any
other public or private organization meeting the requirements of
Section 1902(w) of the Social Security Act, which has a risk
comprehensive contract and meets the other requirements of that
Section.
MANDATORY--the requirement that certain DMAHS beneficiaries, delineated
in Article 5, must select, or be assigned to a contractor in order to
receive Medicaid services.
MANDATORY ENROLLMENT--the process whereby an individual eligible for
Medicaid/NJ FamilyCare is required to enroll in a contractor, unless
otherwise exempted or excluded, to receive the services described in
the standard benefits package as approved by the Department of Human
Services through necessary federal waivers.
MARKETING--any activity by the contractor, its employees or agents, or
on behalf of the contractor by any person, firm or corporation by which
information about the contractor's plan is made known to Medicaid or NJ
FamilyCare Eligible Persons for enrollment purposes.
MAXIMUM PATIENT CAPACITY--the estimated maximum number of active
patients that could be assigned to a specific provider within mandated
access-related requirements.
I-13
MCMIS--managed care management information system, an automated
information system designed and maintained to integrate information
across the enterprise. The State recommends that the system include,
but not necessarily be limited to, the following functions:
- Enrollee Services
- Provider Services
- Claims and Encounter Processing
- Prior Authorization, Referral and Utilization Management
- Financial Processing
- Quality Assurance
- Management and Administrative Reporting
- Encounter Data Reporting to the State
MEDICAID--the joint federal/State program of medical assistance
established by Title XIX of the Social Security Act, 42 U.S.C. Section
1396 et seq., which in New Jersey is administered by DMAHS in DHS
pursuant to N.J.S.A. 30:4D-1 et seq.
MEDICAID ELIGIBLE--an individual eligible to receive services under the
New Jersey Medicaid program.
MEDICAID EXPANSION--means the expansion of the New Jersey
Care...Special Medicaid Programs, incorporates NJ FamilyCare Plan A,
that will extend coverage to uninsured children below the age of 19
years with family incomes up to and including 133 percent of the
federal poverty level. (See NJ FamilyCare Plan A)
MEDICAID RECIPIENT OR MEDICAID BENEFICIARY--an individual eligible for
Medicaid who has applied for and been granted Medicaid benefits by
DMAHS, generally through a CWA or Social Security District Office.
MEDICAL COMMUNICATION--any communication made by a health care provider
with a patient of the health care provider (or, where applicable, an
authorized person) with respect to:
A. The patient's health status, medical care, or
treatment options;
B. Any utilization review requirements that may affect
treatment options for the patient; or
C. Any financial incentives that may affect the
treatment of the patient.
The term "medical communication" does not include a communication by a
health care provider with a patient of the health care provider (or,
where applicable, an authorized person) if the communication involves a
knowing or willful misrepresentation by such provider.
I-14
MEDICAL DIRECTOR--the licensed physician, in the State of New Jersey,
i.e. Medical Doctor (MD) or Doctor of Osteopathy (DO), designated by
the contractor to exercise general supervision over the provision of
health service benefits by the contractor.
MEDICAL GROUP--a partnership, association, corporation, or other group
which is chiefly composed of health professionals licensed to practice
medicine or osteopathy, and other licensed health professionals who are
necessary for the provision of health services for whom the group is
responsible.
MEDICALLY DETERMINABLE IMPAIRMENT--an impairment that results from
anatomical, physiological, or psychological abnormalities which can be
shown by medically acceptable clinical and laboratory diagnostic
techniques. A physical or mental impairment must be established by
medical evidences consisting of signs, symptoms, and laboratory
findings -- not only the individual's statement of symptoms.
MEDICAL RECORDS--the complete, comprehensive records, accessible at the
site of the enrollee's participating primary care physician or
provider, that document all medical services received by the enrollee,
including inpatient, ambulatory, ancillary, and emergency care,
prepared in accordance with all applicable DHS rules and regulations,
and signed by the medical professional rendering the services.
MEDICAL SCREENING--an examination 1) provided on hospital property, and
provided for that patient for whom it is requested or required, and 2)
performed within the capabilities of the hospital's emergency room (ER)
(including ancillary services routinely available to its ER), and 3)
the purpose of which is to determine if the patient has an emergency
medical condition, and 4) performed by a physician (M.D. or D.O.)
and/or by a nurse practitioner, or physician assistant as permitted by
State statutes and regulations and hospital bylaws.
MEDICALLY NECESSARY SERVICES--services or supplies necessary to
prevent, diagnose, correct, prevent the worsening of, alleviate,
ameliorate, or cure a physical or mental illness or condition; to
maintain health; to prevent the onset of an illness, condition, or
disability; to prevent or treat a condition that endangers life or
causes suffering or pain or results in illness or infirmity; to prevent
the deterioration of a condition; to promote the development or
maintenance of maximal functioning capacity in performing daily
activities, taking into account both the functional capacity of the
individual and those functional capacities that are appropriate for
individuals of the same age; to prevent or treat a condition that
threatens to cause or aggravate a handicap or cause physical deformity
or malfunction, and there is no other equally effective, more
conservative or substantially less costly course of treatment available
or suitable for the enrollee. The services provided, as well as the
type of provider and setting, must be reflective of the level of
services that can be safely provided, must be consistent with the
diagnosis of the condition and appropriate to the specific medical
needs of the enrollee and not solely for the convenience of the
enrollee or provider of service and in accordance with standards of
good medical practice and generally recognized by the medical
scientific community as
I-15
effective. Course of treatment may include mere observation or, where
appropriate, no treatment at all. Experimental services or services
generally regarded by the medical profession as unacceptable treatment
are not medically necessary for purposes of this contract.
Medically necessary services provided must be based on peer-reviewed
publications, expert pediatric, psychiatric, and medical opinion, and
medical/pediatric community acceptance.
In the case of pediatric enrollees, this definition shall apply with
the additional criteria that the services, including those found to be
needed by a child as a result of a comprehensive screening visit or an
inter-periodic encounter whether or not they are ordinarily covered
services for all other Medicaid enrollees, are appropriate for the age
and health status of the individual and that the service will aid the
overall physical and mental growth and development of the individual
and the service will assist in achieving or maintaining functional
capacity.
MEDICALLY NEEDY (MN) PERSON OR FAMILY--a person or family receiving
services under the Medically Needy Program.
MEDICARE--the program authorized by Title XVIII of the Social Security
Act to provide payment for health services to federally defined
populations.
MEDICARE+CHOICE ORGANIZATION--an entity that contracts with HCFA to
offer a Medicare+Choice plan pursuant to 42 U.S.C. Section 1395w-27.
MEMBER--an enrolled participant in the contractor's plan; also means
enrollee.
MINORITY POPULATIONS--Asian/Pacific Islanders, African-American/Black,
Hispanic/ Latino, and American Indians/Alaska Natives.
MIS--management information system.
MULTILINGUAL--at a minimum, English and Spanish and any other language
which is spoken by 200 enrollees or five percent of the enrolled
Medicaid population of the contractor's plan, whichever is greater.
NCQA--the National Committee for Quality Assurance.
NEWBORN--an infant born to a mother enrolled in a contractor at the
time of birth.
NEW JERSEY STATE PLAN OR STATE PLAN--the DHS/DMAHS document, filed with
and approved by HCFA, that describes the New Jersey Medicaid program.
N.J.A.C.--New Jersey Administrative Code.
I-16
NJ FAMILYCARE PLAN A--means the State-operated program which provides
comprehensive managed care coverage to:
- Uninsured children below the age of 19 with family incomes up to
and including 133 percent of the federal poverty level;
- Children under the age of one year and pregnant women eligible
under the New Jersey Care...Special Medicaid Programs;
- Pregnant women up to 200 percent of the federal poverty level;
- AFDC eligibles with incomes up to and including 133 percent of the
federal poverty level;
- Parents/caretaker relatives with children below the age of 19
years who do not qualify for AFDC Medicaid and have family incomes
up to and including 133 percent of the federal poverty level;
- Uninsured single adults/couples without dependent children with
family incomes up to and including 50 percent of the federal
poverty level; and
- General Assistance eligibles.
In addition to covered managed care services, eligibles under this
program may access certain other services which are paid
fee-for-service and not covered under this contract.
NJ FAMILYCARE PLAN B--means the State-operated program which provides
comprehensive managed care coverage, including all benefits provided
through the New Jersey Care... Special Medicaid Programs, to uninsured
children below the age of 19 with family incomes above 133 percent and
up to and including 150 percent of the federal poverty level. In
addition to covered managed care services, eligibles under this program
may access certain other services which are paid fee-for-service and
not covered under this contract.
NJ FAMILYCARE PLAN C--means the State-operated program which provides
comprehensive managed care coverage, including all benefits provided
through the New Jersey Care... Special Medicaid Programs, to uninsured
children below the age of 19 with family incomes above 150 percent and
up to and including 200 percent of the federal poverty level. Eligibles
are required to participate in cost-sharing in the form of monthly
premiums and a personal contribution to care for most services. In
addition to covered managed care services, eligibles under this program
may access certain other services which are paid fee-for-service and
not covered under this contract.
NJ FAMILYCARE PLAN D--means the State-operated program which provides
managed care coverage to uninsured:
- Adults and couples without dependent children under the age of 19
with family incomes above 50% and up to and including 100 percent
of the federal poverty level;
- Adults and couples without dependent children under the age of 23
years with family incomes up to and including 250% of the federal
poverty level;
I-17
- Parents/caretakers with children below the age of 19 who do not
qualify for AFDC Medicaid with family incomes up to and including
200 percent of the federal poverty level;
- Parents/caretakers with children below the age of 23 years and
children from the age of 19 through 22 years who are full time
students who do not qualify for AFDC Medicaid with family incomes
up to and including 250% of the federal poverty level; and
- Children below the age of 19 with family incomes between 201
percent and up to and including 350 percent of the federal poverty
level.
Eligibles with incomes above 150 percent of the federal poverty level
are required to participate in cost sharing in the form of monthly
premiums and copayments for most services. These groups are identified
by Program Status Codes (PSCs) on the eligibility system as indicated
below. For clarity, the codes related to Plan D non-cost sharing groups
are also listed.
Cost Sharing No Cost Sharing
------------ ---------------
493 497
494 763
495 300
498 700
301
701
In addition to covered managed care services, eligibles under these
programs may access certain services which are paid fee-for-service and
not covered under this contract.
N.J.S.A.--New Jersey Statutes Annotated.
NON-COVERED CONTRACTOR SERVICES--services that are not covered in the
contractor's benefits package included under the terms of this
contract.
NON-COVERED MEDICAID SERVICES--all services that are not covered by the
New Jersey Medicaid State Plan.
NON-PARTICIPATING PROVIDER--a provider of service that does not have a
contract with the contractor.
OIT--the New Jersey Office of Information Technology.
OTHER HEALTH COVERAGE--private non-Medicaid individual or group
health/dental insurance. It may be referred to as Third Party Liability
(TPL) or includes Medicare.
OUT OF AREA SERVICES--all services covered under the contractor's
benefits package included under the terms of the Medicaid contract
which are provided to enrollees outside the defined basic service area.
I-18
OUTCOMES--the results of the health care process, involving either the
enrollee or provider of care, and may be measured at any specified
point in time. Outcomes can be medical, dental, behavioral, economic,
or societal in nature.
OUTPATIENT CARE--treatment provided to an enrollee who is not admitted
to an inpatient hospital or health care facility.
P FACTOR (P7)--the grade of service for the telephone system. The digit
following the P (e.g., 7) indicates the number of calls per hundred
that are or can be blocked from the system. In this sample, P7 means
seven (7) calls in a hundred may be blocked, so the system is designed
to meet this criterion. Typically, the grade of service is designed to
meet the peak busy hour, the busiest hour of the busiest day of the
year.
PARTICIPATING PROVIDER--a provider that has entered into a provider
contract with the contractor to provide services.
PARTIES--the DMAHS, on behalf of the DHS, and the contractor.
PATIENT--an individual who is receiving needed professional services
that are directed by a licensed practitioner of the healing arts toward
the maintenance, improvement, or protection of health, or lessening of
illness, disability, or pain.
PAYMENTS--any amounts the contractor pays physicians or physician
groups or subcontractors for services they furnished directly, plus
amounts paid for administration and amounts paid (in whole or in part)
based on use and costs of referral services (such as withhold amounts,
bonuses based on referral levels, and any other compensation to the
physician or physician groups or subcontractor to influence the use of
referral services). Bonuses and other compensation that are not based
on referral levels (such as bonuses based solely on quality of care
furnished, patient satisfaction, and participation on committees) are
not considered payments for purposes of the requirements pertaining to
physician incentive plans.
PEER REVIEW--a mechanism in quality assurance and utilization review
where care delivered by a physician, dentist, or nurse is reviewed by a
panel of practitioners of the same specialty to determine levels of
appropriateness, effectiveness, quality, and efficiency.
PERSONAL CONTRIBUTION TO CARE (PCC)--means the portion of the
cost-sharing requirement for NJ FamilyCare Plan C enrollees in which a
fixed monetary amount is paid for certain services/items received from
contractor providers.
PERSONAL INJURY (PI)--a program designed to recover the cost of medical
services from an action involving the tort liability of a third party.
I-19
PHYSICIAN GROUP--a partnership, association, corporation, individual
practice association, or other group that distributes income from the
practice among members. An individual practice association is a
physician group only if it is composed of individual physicians and has
no subcontracts with physician groups.
PHYSICIAN INCENTIVE PLAN--any compensation arrangement between a
contractor and a physician or physician group that may directly or
indirectly have the effect of reducing or limiting services furnished
to Medicaid beneficiaries enrolled in the organization.
POST-STABILIZATION SERVICES--services subsequent to an emergency that a
treating physician views as medically necessary after an emergency
medical condition has been stabilized.
PREPAID HEALTH PLAN--an entity that provides medical services to
enrollees under a contract with the DHS and on the basis of prepaid
capitation fees, but does not necessarily qualify as an MCE.
PREVENTIVE SERVICES--services provided by a physician or other licensed
practitioner of the healing arts within the scope of his or her
practice under State law to:
A. Prevent disease, disability, and other health
conditions or their progression;
B. Treat potential secondary conditions before they
happen or at an early remediable stage;
C. Prolong life; and
D. Promote physical and mental health and efficiency
PRIMARY CARE DENTIST (PCD)--a licensed dentist who is the health care
provider responsible for supervising, coordinating, and providing
initial and primary dental care to patients; for initiating referrals
for specialty care; and for maintaining the continuity of patient care.
PRIMARY CARE PROVIDER (PCP)--a licensed medical doctor (MD) or doctor
of osteopathy (DO) or certain other licensed medical practitioner who,
within the scope of practice and in accordance with State
certification/licensure requirements, standards, and practices, is
responsible for providing all required primary care services to
enrollees, including periodic examinations, preventive health care and
counseling, immunizations, diagnosis and treatment of illness or
injury, coordination of overall medical care, record maintenance, and
initiation of referrals to specialty providers described in this
contract and the Benefits Package, and for maintaining continuity of
patient care. A PCP shall include general/family practitioners,
pediatricians, internists, and may include specialist physicians,
physician assistants, CNMs or CNPs/CNSs, provided that the practitioner
is
I-20
able and willing to carry out all PCP responsibilities in accordance
with these contract provisions and licensure requirements.
PRIOR AUTHORIZATION (ALSO KNOWN AS "PRE-AUTHORIZATION" OR "APPROVAL")--
authorization granted in advance of the rendering of a service after
appropriate medical/dental review.
PROVIDER--means any physician, hospital, facility, or other health care
professional who is licensed or otherwise authorized to provide health
care services in the state or jurisdiction in which they are furnished.
PROVIDER CAPITATION--a set dollar payment per patient per unit of time
(usually per month) that the contractor pays a provider to cover a
specified set of services and administrative costs without regard to
the actual number of services.
PROVIDER CONTRACT--any written contract between the contractor and a
provider that requires the provider to perform specific parts of the
contractor's obligations for the provision of health care services
under this contract.
QAPI--Quality Assessment and Performance Improvement.
QARI--Quality Assurance Reform Initiative.
QIP--Quality Improvement Project.
QISMC--Quality Improvement System for Managed Care.
QUALIFIED INDIVIDUAL WITH A DISABILITY--an individual with a disability
who, with or without reasonable modifications to rules, policies, or
practices, the removal of architectural, communication, or
transportation barriers, or the provision of auxiliary aids and
services, meets the essential eligibility requirements for the receipt
of services or the participation in programs or activities provided by
a public entity (42 U.S.C. Section 12131).
REASSIGNMENT--the process by which an enrollee's entitlement to receive
services from a particular Primary Care Practitioner/Dentist is
terminated and switched to another PCP/PCD.
REFERRAL SERVICES--those health care services provided by a health
professional other than the primary care practitioner and which are
ordered and approved by the primary care practitioner or the
contractor.
Exception A: An enrollee shall not be required to obtain a
referral or be otherwise restricted in the choice of the
family planning provider from whom the enrollee may receive
family planning services.
I-21
Exception B: An enrollee may access services at a Federally
Qualified Health Center (FQHC) in a specific enrollment area
without the need for a referral when neither the contractor
nor any other contractor has a contract with the Federally
Qualified Health Center in that enrollment area and the cost
of such services will be paid by the Medicaid fee-for-service
program.
REINSURANCE--an agreement whereby the reinsurer, for a consideration,
agrees to indemnify the contractor, or other provider, against all or
part of the loss which the latter may sustain under the enrollee
contracts which it has issued.
RISK OR UNDERWRITING RISK--the possibility that a contractor may incur
a loss because the cost of providing services may exceed the payments
made by the Department to the contractor for services covered under the
contract.
RISK COMPREHENSIVE CONTRACT--for purposes of this contract, a risk
contract for furnishing comprehensive health care services, i.e.,
inpatient hospital services and any three of the following services or
groups of services:
A. Outpatient hospital services and rural health
clinical services;
B. Other laboratory and diagnostic and therapeutic
radiologic services;
C. Skilled nursing facility services, EPSDT, and family
planning;
D. Physician services; and
E. Home health services.
RISK THRESHOLD--the maximum liability, if the liability is based on
referral services, to which a physician or physician group may be
exposed under a physician incentive plan without being at substantial
financial risk.
ROUTINE CARE--treatment of a condition which would have no adverse
effects if not treated within 24 hours or could be treated in a less
acute setting (e.g., physician's office) or by the patient.
SAFETY-NET PROVIDERS OR ESSENTIAL COMMUNITY PROVIDERS--public-funded or
government-sponsored clinics and health centers which provide
specialty/specialized services which serve any individual in need of
health care whether or not covered by health insurance and may include
medical/dental education institutions, hospital-based programs,
clinics, and health centers.
SAP--Statutory Accounting Principles.
SCOPE OF SERVICES--those specific health care services for which a
provider has been credentialed, by the plan, to provide to enrollees.
I-22
SCREENING SERVICES--any encounter with a health professional practicing
within the scope of his or her profession as well as the use of
standardized tests given under medical direction in the examination of
a designated population to detect the existence of one or more
particular diseases or health deviations or to identify for more
definitive studies individuals suspected of having certain diseases.
SECRETARY--the Secretary of the United States Department of Health and
Human Services.
SEMI--Special Education Medicaid Initiative, a federal Medicaid program
that allows for reimbursement to local education agencies for certain
special education related services (e.g., physical therapy,
occupational therapy, and speech therapy).
SERVICE AREA--the geographic area or region comprised of those counties
as designated in the contract.
SERVICE LOCATION/SERVICE SITE--any location at which an enrollee
obtains any health care service provided by the contractor under the
terms of the contract.
SHORT TERM--a period of 30 calendar days or less.
SIGNING DATE--the date on which the parties sign this contract. In no
event shall the signing date be later than 5 P.M. Eastern Standard Time
on March 17, 2000.
SPECIAL MEDICAID PROGRAMS--programs for: (a) AFDC/TANF-related family
members who do not qualify for cash assistance, and (b) SSI-related
aged, blind and disabled individuals whose incomes or resources exceed
the SSI Standard.
For AFDC/TANF, they are:
Medicaid Special: covers children ages 19 to 21 using AFDC
standards; New Jersey Care: covers pregnant women and children
up to age 1 with incomes at or below 185 percent of the
federal poverty level (FPL); children up to age 6 at 133
percent of FPL; and children up to age 13 (the age range
increases annually, pursuant to federal law until children up
to age 18 are covered) at 100 percent of FPL.
For SSI-related, they are:
Community Medicaid Only-provides full Medicaid benefits for
aged, blind and disabled individuals who meet the SSI age and
disability criteria, but do not receive cash assistance,
including former SSI recipients who receive Medicaid
continuation;
I-23
New Jersey Care-provides full Medicaid benefits for all
SSI-related Aged, Blind, and Disabled individuals with income
below 100 percent of the federal poverty level and resources
at or below 200 percent of the SSI resource standard.
SSI--the Supplemental Security Income program, which provides cash
assistance and full Medicaid benefits for individuals who meet the
definition of aged, blind, or disabled, and who meet the SSI financial
needs criteria.
STAFF MODEL--a type of HMO operation in which HMO employees are
responsible for both administrative and medical functions of the plan.
Health professionals, including physicians, are reimbursed on a salary
or fee-for-service basis. These employees are subject to all policies
and procedures of the HMO. In addition, the HMO may contract with
external entities to supplement its own staff resources (e.g., referral
services of specialists).
STANDARD SERVICE PACKAGE--see "COVERED SERVICES" and "BENEFITS PACKAGE"
STATE--the State of New Jersey.
STATE PLAN--see "NEW JERSEY STATE PLAN"
STOP-LOSS--the dollar amount threshold above which the contractor
insures the financial coverage for the cost of care for an enrollee
through the use of an insurance underwritten policy.
SUBCONTRACT--any written contract between the contractor and a third
party to perform a specified part of the contractor's obligations under
this contract.
SUBCONTRACTOR--any third party who has a written contract with the
contractor to perform a specified part of the contractor's obligations
under this contract.
SUBCONTRACTOR PAYMENTS--any amounts the contractor pays a provider or
subcontractor for services they furnish directly, plus amounts paid for
administration and amounts paid (in whole or in part) based on use and
costs of referral services (such as withhold amounts, bonuses based on
referral levels, and any other compensation to the physician or
physician group to influence the use of referral services). Bonuses and
other compensation that are not based on referral levels (such as
bonuses based solely on quality of care furnished, patient
satisfaction, and participation on committees) are not considered
payments for purposes of physician incentive plans.
SUBSTANTIAL CONTRACTUAL RELATIONSHIP--any contractual relationship that
provides for one or more of the following services: 1) the
administration, management, or provision of medical services; and 2)
the establishment of policies, or the provision of operational support,
for the administration, management, or provision of medical services.
I-24
TANF--Temporary Assistance for Needy Families, which replaced the
federal AFDC program.
TARGET POPULATION--the population of individuals eligible for
Medicaid/NJ FamilyCare residing within the stated enrollment area and
belonging to one of the categories of eligibility found in Article Five
from which the contractor may enroll, not to exceed any limit specified
in the contract.
TDD--Telecommunication Device for the Deaf.
TT--Tech Telephone.
TERMINAL ILLNESS--a condition in which it is recognized that there will
be no recovery, the patient is nearing the "terminus" of life and
restorative treatment is no longer effective.
THIRD PARTY--any person, institution, corporation, insurance company,
public, private or governmental entity who is or may be liable in
contract, tort, or otherwise by law or equity to pay all or part of the
medical cost of injury, disease or disability of an applicant for or
recipient of medical assistance payable under the New Jersey Medical
Assistance and Health Services Act N.J.S.A. 30:4D-1 et seq.
THIRD PARTY LIABILITY--the liability of any individual or entity,
including public or private insurance plans or programs, with a legal
or contractual responsibility to provide or pay for medical/dental
services. Third Party is defined in N.J.S.A. 30:4D-3m.
TRADITIONAL PROVIDERS--those providers who have historically delivered
medically necessary health care services to Medicaid enrollees and have
maintained a substantial Medicaid portion in their practices.
TRANSFER--an enrollee's change from enrollment in one contractor's plan
to enrollment of said enrollee in a different contractor's plan.
UNCONTESTED CLAIM--a claim that can be processed without obtaining
additional information from the provider of the service or third party.
URGENT CARE--treatment of a condition that is potentially harmful to a
patient's health and for which his/her physician determined it is
medically necessary for the patient to receive medical treatment within
24 hours to prevent deterioration.
UTILIZATION--the rate patterns of service usage or types of service
occurring within a specified time.
UTILIZATION REVIEW--procedures used to monitor or evaluate the clinical
necessity, appropriateness, efficacy, or efficiency of health care
services, procedures or settings, and includes ambulatory review,
prospective review, concurrent review, second opinions, care
management, discharge planning, or retrospective review.
I-25
VOLUNTARY ENROLLMENT--the process by which a Medicaid eligible
individual voluntarily enrolls in a contractor.
WIC--A special supplemental food program for Women, Infants, and
Children.
WITHHOLD--a percentage of payments or set dollar amounts that a
contractor deducts from a practitioner's service fee, capitation, or
salary payment, and that may or may not be returned to the physician,
depending on specific predetermined factors.
I-26
ARTICLE TWO: CONDITIONS PRECEDENT
A. This contract shall be with qualified, established HMOs
operating in New Jersey through a Certificate of Authority for
Medicaid lines of business approved by the New Jersey
Department of Banking and Insurance and Department of Health
and Senior Services. The contractor shall receive all
necessary authorizations and approvals of governmental or
regulatory authorities to operate in the service/enrollment
areas as of the effective date of operations.
B. The contractor shall ensure continuity of care and full access
to primary, specialty, and ancillary care as required under
this contract and access to full administrative programs and
support services offered by the contractor for all its lines
of business and/or otherwise required under this contract.
C. The contractor shall, by the effective date, have received all
necessary authorizations and approvals of governmental or
regulatory authorities including an approved Certificate of
Authority (COA) to operate in all counties in a geographic
region as defined in Article 5.1 or shall have an approved (by
DMAHS) county phase-in plan defined in Section H. This Article
does not and is not intended to require the contractor to
obtain COAs in all three geographic regions.
D. Documentation. Subsequent to the signing date by the
contractor but prior to contract execution by the Department,
the Department shall review and approve the materials listed
in Section B.2.2 of the Appendices.
E. Readiness Review. The Department will, prior to the signing
date, conduct a readiness review of the areas set forth in
Section B.2.3 of the Appendices to generally assess the
contractor's readiness to begin operations and issue a letter
to the contractor that conveys its findings and any changes
required before contracting with the Department.
F. This contract, as well as any attachments or appendices hereto
shall only be effective, notwithstanding any provisions in
such contract to the contrary, upon the receipt of federal
approval and approval as to form by the Office of the Attorney
General for the State of New Jersey.
G. The contractor shall remain in compliance with the following
conditions which shall satisfy the Departments of Banking and
Insurance, Health and Senior Services, and Human Services
prior to this contract becoming effective:
1. The contractor shall maintain an approved certificate
of authority to operate as a health maintenance
organization in New Jersey from the Department of
Banking and Insurance and the Department of Health
and Senior Services for the Medicaid population.
II-1
2. The contractor shall comply with and remain in
compliance with minimum net worth and fiscal solvency
and reporting requirements of the Department of
Banking and Insurance, the Department of Human
Services, the federal government, and this contract.
3. The contractor shall provide written certification of
new written contracts for all providers other than
FQHCs and shall provide copies of fully executed
contracts for new contracts with FQHCs on a quarterly
basis.
4. If insolvency protection arrangements change, the
contractor shall notify the DMAHS sixty (60) days
before such change takes effect and provide written
copy of DOBI approval.
H. County Expansion Phase-In Plan. If the contractor does not
have an approved COA for each of the counties in a designated
region, the contractor shall submit to DMAHS a county
expansion phase-in plan for review and approval by DMAHS prior
to the execution of this contract. The plan shall include
detailed information of:
- The region and names of the counties targeted for
expansion;
- Anticipated dates of the submission of the COA
modification to DOBI and DHSS (with copies to DMAHS);
- Anticipated date of approval of the COA;
- Anticipated date for full operations in the region;
- Anticipated date for initial beneficiary enrollment
in each county
The phase-in plan shall indicate that full expansion into a
region shall be completed by June 30, 2001. The contractor
shall maintain full coverage for each county in each region in
which the contractor operates for the duration of this
contract.
I. No court order, administrative decision, or action by any
other instrumentality of the United States Government or the
State of New Jersey or any other state is outstanding which
prevents implementation of this contract.
J. Net Worth
1. The contractor shall maintain a minimum net worth in
accordance with N.J.A.C. Title 8:38-11 et seq.
2. The Department shall have the right to conduct
targeted financial audits of the contractor's
Medicaid line of business. The contractor shall
provide
II-2
the Department with financial data, as requested by
the Department, within a timeframe specified by the
Department.
K. The contractor shall comply with the following financial
operations requirements:
1. A contractor shall establish and maintain:
a. An office in New Jersey, and
b. Premium and claims accounts in a bank with a
principal office in New Jersey.
2. The contractor shall have a fiscally sound operation
as demonstrated by:
a. Maintenance of a minimum net worth in
accordance with DOBI requirements (total
line of business) and the requirements
outlined in G and J above and Article 8.2.
b. Maintenance of a net operating surplus for
Medicaid line of business. If the contractor
fails to earn a net operating surplus during
the most recent calendar year or does not
maintain minimum net worth requirements on a
quarterly basis, it shall submit a plan of
action to DMAHS within the time frame
specified by the Department. The plan is
subject to the approval of DMAHS. It shall
demonstrate how and when minimum net worth
will be replenished and present marketing
and financial projections. These shall be
supported by suitable back-up material. The
discussion shall include possible alternate
funding sources, including invoking of
corporate parental guarantee. The plan will
include:
i. A detailed marketing plan with
enrollment projections for the next
two years.
ii. A projected balance sheet for the
next two years.
iii. A projected statement of revenues
and expenses on an accrual basis
for the next two years.
iv. A statement of cash flow projected
for the next two years.
v. A description of how to maintain
capital requirements and replenish
net worth.
vi. Sources and timing of capital shall
be specifically identified.
3. The contractor may be required to obtain prior to
this contract and maintain "Stop-Loss" insurance,
pursuant to provisions in Article 8.3.2.
II-3
4. The contractor shall obtain prior to this contract
and maintain for the duration of this contract, any
extension thereof or for any period of liability
exposure, protection against insolvency pursuant to
provisions in G above and Article 8.2.
II-4
ARTICLE THREE: MANAGED CARE MANAGEMENT INFORMATION SYSTEM
The contractor's MCMIS shall provide certain minimum functional capabilities as
described in this contract. The contractor shall have sophisticated information
systems capabilities that cannot only support the specific requirements of this
contract, but also respond to future program requirements. The DHS shall provide
the contractor with what the DHS, in its sole discretion, believes is sufficient
lead time to make system changes.
The various components of the contractor's MCMIS shall be sufficiently
integrated to effectively and efficiently support the requirements of this
contract. The contractor's MCMIS shall also be a collection point and repository
for all data required under this contract and shall provide comprehensive
information retrieval capabilities. Contractors with multiple systems and/or
subcontracted health care services shall integrate the data, at a minimum, to
provide for combined reporting and, as required, to support the required
processing functions.
3.1 GENERAL OPERATIONAL REQUIREMENTS FOR THE MCMIS
The following requirements apply to the contractor's MCMIS. Any
reference to "systems" in this Article shall mean contractor's MCMIS
unless otherwise specified. If the contractor subcontracts any MCMIS
functions, then these requirements apply to the subcontractor's
systems. For example, if the contractor contracts with a dental network
to provide services and pay claims/collect encounters, then these
requirements shall apply to the dental network's systems. However, if
the contractor contracts with a dental network only to provide dental
services, then these requirements do not apply.
3.1.1 ONLINE ACCESS
The system(s) shall provide online access for contractor use to all
major files and data elements within the MIS including enrollee
demographic and enrollment information, provider demographic and
enrollment data, processed claims and encounters, prior approvals,
referrals, reference files, and payment and financial transactions.
3.1.2 PROCESSING REQUIREMENTS
A. Timely Processing. The contractor shall provide for timely
updates and edits for all transactions on a schedule that
allows the contractor to meet the State's performance
requirements. In general, the State expects the following
schedule:
1. Enrollee and provider file updates to be daily
2. Reference file updates to be at least weekly or as
needed
3. Prior authorizations and referral updates to be daily
4. Claims and encounters to be processed (entered and
edited) daily
5. Claim payments to be at a minimum biweekly
6. Capitation payments to be monthly
III-1
Specific update schedule requirements are identified in the remaining
subarticles of this Article.
B. Error Tracking and Audit Trails. The update and edit processes for each
transaction shall provide for the monitoring of errors incurred by type
of error and frequency. The system shall maintain information
indicating the errors failed, the person making the corrections, when
the correction was made, and if the error was overridden on all
critical transactions (e.g., terminating enrollment or denying a
claim). The major update processes shall maintain sufficient audit
trails to allow reconstruction of the processing events.
C. Comprehensive Edits and Audits. The contractor's system shall provide
for a comprehensive set of automated edits and audits that will ensure
the data are valid, the benefits are covered and appropriate, the
payments are accurate and timely, other insurance is maximized, and all
of the requirements of this contract are met.
D. System Controls and Balancing. The contractor's system shall provide
adequate control totals for balancing and ensuring that all inputs are
accounted for. The contractor shall have operational procedures for
balancing and validating all outputs and processes. Quality checkpoints
should be as automated as possible.
E. Multimedia Input Capability. The system shall support a variety of
input media formats including hardcopy, diskette, tape, clearing house,
direct entry, electronic transmission or other means, as defined by all
federal and State laws and regulations. The contractor may use any
clearing house(s) and/or alternatively provide for electronic
submissions directly from the provider to the contractor. These
requirements apply to claims/encounter and prior authorization (PA),
referral, and UM subsystems. Provider/vendor data must be routed
through the contractor when submitting data/information to the State.
F. Backup/Restore and Archiving. The contractor shall provide for periodic
backup of all key processing and transaction files such that there will
be a minimum of interruption in the event of a disaster. Unless
otherwise agreed by the State, key processes must be restored as
follows:
1. Enrollment verification - twenty-four (24) hours
2. Enrollment update process - twenty-four (24) hours
3. Prior authorization/referral processing - twenty-four (24)
hours
4. Claims/encounter processing - seventy-two (72) hours
5. Encounter submissions to State - one (1) week
6. Other functions - two (2) weeks
The contractor shall demonstrate its restore capabilities at least once
a year. The contractor shall also provide for permanent archiving of
all major files for a
III-2
period of no less than seven (7) years. The contractor's backup/recover
plan must be approved by State.
3.1.3 REPORTING AND DOCUMENTATION REQUIREMENTS
A. Regular Reporting. The contractor's system shall provide
sufficient reports to meet the requirements of this contract
as well as to support the efficient and effective operation of
its business functions. The required reports, including time
frames and format requirements, are in Section A of the
Appendices.
B. Ad Hoc Reporting. The contractor shall have the capability to
support ad hoc reporting requests, in addition to those listed
in this contract, both from its own organization and from the
State in a reasonable time frame. The time frame for
submission of the report will be determined by DMAHS with
input from the contractor based on the nature of the report.
DMAHS shall at its option request six (6) to eight (8) reports
per year, hardcopy or electronic reports and/or file extracts.
This does not preclude or prevent DMAHS from requiring, or the
contractor from providing, additional reports that are
required by State or federal governmental entities or any
court of competent jurisdiction.
C. System Documentation. The contractor shall update
documentation on its system(s) within 30 days of
implementation of the changes. The contractor's documentation
must include a system introduction, program overviews,
operating environment, external interfaces, and data element
dictionary. For each of the functional components, the
documentation should include where applicable program
narratives, processing flow diagrams, forms, screens, reports,
files, detailed logic such as claims pricing algorithms and
system edits. The documentation should also include job
descriptions and operations instructions. The contractor shall
have available current documentation on-site for State audit
as requested.
3.1.4 OTHER REQUIREMENTS
A. Future Changes. The system shall be easily modifiable to
accommodate future system changes/enhancements to claims
processing or other related systems at the same time as
changes take place in the State's MMIS. In addition, the
system shall be able to accommodate all future requirements
based upon federal and State statutes, policies and
regulations. Unless otherwise agreed by the State, the
contractor shall be responsible for the costs of these
changes.
B. Year 2000. The MCMIS shall meet the Office of Information
Technology (OIT) standards for Year 2000 compliance unless
otherwise approved by the Department. The OIT standards may be
accessed on the Internet at
xxxx://xxx.xxxxx.xx.xx/xxxxxxxx/xxxxxxxx/xxx0000x.xxx.
III-3
3.2 ENROLLEE SERVICES
The MCMIS shall support all of the enrollee services as specified in
Article 5 of this contract. The system shall:
A. Capture and maintain contractor enrollment data
electronically.
B. Provide information so that the contractor can send plan
materials and information to enrollees.
C. Capture electronically the Primary Care Provider (PCP)
selections by enrollees.
D. Provide contractor enrollment and Medicaid information to
providers.
E. Maintain an enrollee complaint and grievance tracking system
for Medicaid and NJ FamilyCare enrollees.
F. Produce the required enrollee data reports.
The enrollee module(s) shall interface with all other required modules
and permit the access, search, and retrieval of enrollee data by key
fields, including date-sensitive information.
3.2.1 CONTRACTOR ENROLLMENT DATA
A. Enrollee Data. The contractor shall maintain a complete
history of enrollee information, including contractor
enrollment, primary care provider assignment, third party
liability coverage, and Medicare coverage. In addition, the
contractor shall capture demographic information relating to
the enrollee (age, sex, county, etc.), information related to
family linkages, information relating to benefit and service
limitations, and information related to health care for
enrollees with special needs.
B. Updates. The contractor shall accept and process a weekly
enrollment and eligibility file (the managed care register
files; See Section B.3.2 of the Appendices) within 48 hours of
receipt from the Department. The system shall provide reports
that identify all errors encountered, count all transactions
processed, and provide for a complete audit trail of the
update processes. The MCMIS shall accommodate the following
specific Medicaid/NJ FamilyCare requirements.
1. The contractor shall be able to access and identify
all enrollees by their Medicaid/NJ FamilyCare
Identification Number. This number shall be readily
cross-referenced to the contractor's enrollee number
and the enrollee's social security number. For DYFS
cases, it is important that the contractor's system
be able to distinguish the DYFS enrolled children
III-4
from other cases and that mailings to the DYFS
enrolled children not be consolidated based on the
first 10 digits of the Medicaid ID number because the
family members may not be residing together.
2. The system shall be able to link family members for
on-line inquiry access and for consolidated mailings
based on the first ten-digits of the Medicaid ID
number.
3. The system shall be able to identify newborns from
the date of birth, submit the proper eligibility form
to the State, and link the newborn record to the NJ
FamilyCare/Medicaid eligibility and enrollment data
when these data are received back from the State.
4. The system shall capture and maintain all of the data
elements provided by the Department on the weekly
update files.
5. The system shall allow for day-specific enrollment
into the contractor.
3.2.2 ENROLLEE PROCESSING REQUIREMENTS
The contractor's system shall support the enrollee processing
requirements of this contract. The system shall be modified/enhanced as
required to meet the contract requirements in an efficient manner and
ensure that each requirement is consistently and accurately
administered by the contractor. Materials shall be sent to the enrollee
or authorized representative, as applicable.
A. Enrollee Notification. The contractor shall issue contractor
plan materials and information to all new enrollees prior to
the effective date of enrollment or within seven (7) calendar
days following the receipt of weekly enrollment file specified
above, or, in case of retroactive enrollment, issue the
materials by the 1st of the subsequent month or within seven
(7) calendar days following receipt of the weekly enrollment
file. The specifications for the contractor plan materials and
information are listed in Article 5.8.
B. ID Cards. The contractor shall issue an Identification Card to
all new enrollees within ten (10) calendar days following
receipt of the weekly enrollment file specified above but no
later than seven (7) calendar days after the effective date of
enrollment.
The specifications for Identification Cards are in Article
5.8.5. The system shall produce ID cards that include the
information required in that Article. The contractor shall
also be able to produce replacement cards on request.
III-5
C. PCP Selection. The contractor shall provide the enrollee with
the opportunity to select a PCP. If no selection is made by
the enrollee, the contractor shall assign the PCP for the
enrollee according to the timeframes specified in Article 5.9.
If the enrollee selects a PCP, the contractor shall process
the selection. The contractor is responsible for monitoring
the PCP capacity and limitations prior to assignment of an
enrollee to a PCP. The contractor shall notify the enrollee
accordingly if a selected PCP is not available.
The contractor shall notify the PCP of newly assigned
enrollees or any other enrollee roster changes that affect the
PCP monthly by the second working day of the month.
D. Other Enrollee Processing. The contractor's enrollee
processing shall also support the following:
1. Notification of State of any enrollee demographic
changes including date of death, change of address,
newborns, and commercial enrollment.
2. Generation of correspondence to enrollees based on
variable criteria, including PCP and demographic
information.
3.2.3 CONTRACTOR ENROLLMENT VERIFICATION
A. Electronic Verification System. The contractor shall provide a
system that supports the electronic verification of contractor
enrollment to network providers via the telephone 24 hours a
day and 365 days a year or on a schedule approved by the
State. This capability should require the enrollee's
contractor Identification Number, the Medicaid/NJ FamilyCare
Identification Number, or the Social Security Number. The
system should provide information on the enrollee's current
PCP as well as the enrollment information.
B. Telephone Enrollment Inquiry. The contractor shall provide
telephone operator personnel (both member services and
provider services) to verify contractor enrollment during
normal business hours. The contractor's telephone operator
personnel should have the capability to electronically verify
contractor enrollment based on a variety of fields, including
contractor Identification Number, Medicaid/NJ FamilyCare
Identification Number, Social Security Number, Enrollee Name,
Date of Birth, etc.
The contractor shall ensure that a recorded message is
available to providers when enrollment capability is
unavailable for any reason.
3.2.4 ENROLLEE COMPLAINT AND GRIEVANCE TRACKING SYSTEM
The contractor shall develop an electronic system to capture and track
the content and
III-6
resolution of enrollee complaints or grievances.
A. Data Requirements. The system shall capture, at a minimum, the
enrollee, the reason of the complaint or grievance, the date
the complaint or grievance was reported, the operator who
talked to the enrollee, the explanation of the resolution, the
date the complaint or grievance was resolved, the person who
resolved the complaint or grievance, referrals to other
departments, and comments including general information and/or
observations. See Article 5.15.
B. Processing and Reporting. The contractor shall identify trends
in complaint and grievance reasons and responsiveness to the
complaints or grievances. The system shall provide detail
reports to be used in tracking individual complaints and
grievances. The system shall also produce summary reports that
include statistics indicating the number of complaints and
grievances, the types, the dispositions, and the average time
for dispositioning, broken out by category of eligibility. See
Article 5.15.
3.2.5 ENROLLEE REPORTING
The contractor shall produce all of the reports according to the
timeframes and specifications outlined in Section A of the Appendices.
The contractor shall provide the State with a monthly file of enrollees
(See Section A.3.1 of the Appendices). The State's fiscal agent will
reconcile this file with the State's Recipient File. The contractor
shall provide for reconciling any differences and taking the
appropriate corrective action.
3.3 PROVIDER SERVICES
The contractor's system shall collect, process, and maintain current
and historical data on program providers. This information shall be
accessible to all parts of the MCMIS for editing and reporting.
3.3.1 PROVIDER INFORMATION AND PROCESSING REQUIREMENTS
A. Provider Data. The contractor shall maintain individual and
group provider network information with basic demographics,
EIN or tax identification number, professional credentials,
license and/or certification numbers and dates, sites, risk
arrangements (i.e., individual and group risk pools), services
provided, payment methodology and/or reimbursement schedules,
group/individual provider relationships, facility linkages,
number of grievances and/or complaints.
For PCPs, the contractor shall maintain identification as
traditional or safety net provider, specialties, enrollees
with beginning and ending effective dates, capacity, emergency
arrangements or contact, other limitations or restrictions,
languages spoken, address, office hours, disability access.
See Article 5.
III-7
The contractor shall maintain provider history files and
provide for easy data retrieval. The system should maintain
audit trails of key updates.
Providers should be identified with a unique number. The
contractor shall be able to cross-reference its provider
number with the provider's EIN or tax number, the provider's
license number, UPIN, Medicaid provider number, and Medicare
provider number where applicable.
B. Updates. The contractor shall apply updates to the provider
file daily.
C. Complaint Tracking System. The system shall provide for the
capabilities to track and report provider complaints as
specified in Article 6.5. The contractor shall provide detail
reports identifying open complaints and summary statistics by
provider on the types of complaints, resolution, and average
time for resolution.
3.3.2 PROVIDER CREDENTIALING
A. Credentialing. The contractor shall credential and
re-credential each network provider as specified in Article
4.6.1. The system should provide a tracking and reporting
system to support this process.
B. Review. The contractor shall be able to flag providers for
review based on problems identified during credentialing,
information received from the State, information received from
HCFA, complaints, and in-house utilization review results.
Flagging providers should cause all claims to deny as
appropriate.
3.3.3 PROVIDER/ENROLLEE LINKAGE
A. Enrollee Rosters. The contractor shall generate electronic
and/or hard copy enrollee rosters to its PCPs each month by
the second business day of the month. The rosters shall
indicate all enrollees that are assigned to the PCP and should
provide the provider with basic demographic and enrollment
information related to the enrollee.
B. Provider Capacity. The contractor's system shall support the
provider network requirements described in Article 4.8.
III-8
3.3.4 PROVIDER MONITORING
The contractor's system shall support monitoring and tracking of
provider/enrollee complaints, grievances and appeals from receipt to
disposition. The system shall be able to produce provider reports for
quality of medical and dental care analysis, flag and identify
providers with restrictive conditions (e.g., fraud monitoring), and
identify the confidentiality level of information (i.e., to manage who
has access to the information).
3.3.5 REPORTING REQUIREMENTS
The contractor shall produce all of the reports identified in Section A
of the Appendices. In addition, the system shall provide ongoing and
periodic reports to monitor provider activity, support provider
contracting, and provide administrative and management information as
required for the contractor to effectively operate.
3.4 CLAIMS/ENCOUNTER PROCESSING
The system shall capture and adjudicate all claims and encounters
submitted by providers. The major functions of this module(s) include
enrollee enrollment verification, provider enrollment verification,
claims and encounter edits, benefit determination, pricing, medical
review and claims adjudication, and claims payment. Once claims and
encounters are processed, the system shall maintain the
claims/encounter history file that supports the State's encounter
reporting requirements as well as all of the utilization management and
quality assurance functions and other reporting requirements of the
contractor.
3.4.1 GENERAL REQUIREMENTS
The contractor shall have an automated claims and encounter processing
system that will support the requirements of this contract and ensure
the accurate and timely processing of claims and encounters. The
contractor shall offer its providers an electronic payment option.
A. Input Processing. The contractor shall support both hardcopy
and electronic submission of claims and encounters for all
claim types (hospital, medical, dental, pharmacy, etc.). The
contractor should also support hardcopy and electronic
submission of referral and authorization documents, claim
inquiry forms, and adjustment claims and encounters. Providers
shall be afforded a choice between an electronic or a hardcopy
submission. Electronic submissions include diskette, tape,
clearinghouse, electronic transmission, and direct entry. The
contractor must process all standard electronic formats
recognized by the State. The contractor may use any
clearinghouse(s) and/or alternatively provide for electronic
submission directly from providers to the contractor.
III-9
The system shall maintain the receipt date for each document
(claim, encounter, referral, authorization, and adjustment)
and track the processing time from date of receipt to final
disposition.
B. Edits and Audits. The system shall perform sufficient edits to
ensure the accurate payment of claims and ensure the accuracy
and completeness of encounters that are submitted. Edits
should include, but not be limited to, verification of member
enrollment, verification of provider eligibility, field edits,
claim/encounter crosscheck and consistency edits, validation
of code values, duplicate checks, authorization checks, checks
for service limitations, checks for service inconsistencies,
medical review, and utilization management. Pharmacy claim
edits shall include prospective drug utilization review
(ProDUR) checks.
The contractor shall comply with New Jersey law and
regulations to process records in error. (Note: Uncontested
payments to providers and uncontested portions of contested
claims should not be withheld pending final adjudication.)
C. Benefit and Reference Files. The system shall provide
file-driven processing for benefit determination, validation
of code values, pricing (multiple methods and schedules), and
other functions as appropriate. Files should include code
descriptions, edit criteria, and effective dates. The system
shall support the State's procedure and diagnosis coding
schemes and other codes that shall be submitted on the
hardcopy and electronic reports and files.
The system shall provide for an automated update to the
National Drug Code file including all product, packaging,
prescription, and pricing information.
The system shall provide online access to reference file
information. The system should maintain a history of the
pricing schedules and other significant reference data.
D. Claims/Encounter History Files. The contractor shall maintain
two (2) years active history of adjudicated claims and
encounter data for verifying duplicates, checking service
limitations, and supporting historical reporting. For drug
claims, the contractor may maintain nine (9) months of active
history of adjudicated claims/encounter data if it has the
ability to restore such information back to two (2) years and
provide for permanent archiving in accordance with Article
3.1.2F. Provisions should be made to maintain permanent
history by service date for those services identified as
"once-in-a-lifetime" (e.g., hysterectomy). The system should
readily provide access to all types of claims and encounters
(hospital, medical, dental, pharmacy, etc.) for combined
reporting of claims and encounters. Archive requirements are
described in Article 3.1.2F.
3.4.2 COORDINATION OF BENEFITS
The contractor shall exhaust all other sources of payment prior to
remitting payment for a
III-10
Medicaid enrollee.
A. Other Coverage Information. The contractor shall maintain
other coverage information for each enrollee. The contractor
shall verify the other coverage information provided by the
State pursuant to Article 8.13 and develop a system to include
additional other coverage information when it becomes
available. The contractor shall provide a periodic file of
updates to other coverage back to the State as specified in
Article 8.7.
B. Cost Avoidance. As provided in Article 8.13, except in certain
cases, the contractor shall attempt to avoid payment in all
cases where there is other insurance.
The system should have edits to identify potential other
coverage situations and flag the claims accordingly. The edits
should include looking for accident indicators, other coverage
information from the claims, other coverage information on
file for the enrollee, and potential accident/injury
diagnoses.
C. Postpayment Recoupments. Where other insurance is discovered
after the fact, for the exceptions identified in 8.13, and for
encounters, recoveries shall be initiated on a postpayment
basis.
D. Personal Injury Cases. These cases should be referred to the
Department for recovery.
E. Medicare. The contractor's system shall provide for
coordinating benefits on enrollees that are also covered by
Medicare. See Article 8.13.
F. Reporting and Tracking. The contractor's system shall identify
and track potential collections. The system should produce
reports indicating open receivables, closed receivables,
amounts collected, and amounts written off.
3.4.3 REPORTING REQUIREMENTS
A. General. The contractor's operational reports shall be
created, maintained and made available for audit by State
personnel and will include, but will not be limited to, the
following:
1. Claims Processing Statistics
2. Inventory and Claims Aging Statistics
3. Error Reports
4. Contested Claims and Encounters
5. Aged Claims and Encounters
6. Checks and EOB(s)
7. Lag Factors and IBNR
III-11
B. The contractor shall produce reports according to the
timeframes and specification outlined in Section A of the
Appendices.
3.5 PRIOR AUTHORIZATION, REFERRAL AND UTILIZATION MANAGEMENT
The prior authorization/referral and utilization management functions
shall be an integrated component of the MCMIS. It shall allow for
effective management of delivery of care. It shall provide a
sophisticated environment for managing the monitoring of both inpatient
and outpatient care on a proactive basis.
3.5.1 FUNCTIONS AND CAPABILITIES
A. Prior Authorizations. The contractor shall provide an
automated system that includes the following:
1. Enrollee eligibility, utilization, and case
management information.
2. Edits to ensure enrollee is eligible, provider is
eligible, and service is covered.
3. Predefined treatment criteria to aid in adjudicating
the requests.
4. Notification to provider of approval or denial.
5. Notification to enrollees of any denials or cutbacks
of service.
6. Interface with claims processing system for editing.
B. Referrals. The contractor shall provide an automated system
that includes the following:
1. Ability for providers to enter referral information
directly, fax information to the contractor, or call
in on dedicated phone lines.
2. Interface with claims processing system for editing.
C. Utilization Management. The contractor should provide an
automated system that includes the following:
1. Provides case tracking, notifies the case worker of
outstanding actions.
2. Provide case history of all activity.
3. Provide online access to cases by enrollee and
provider numbers.
4. Includes an automated correspondence generator for
letters to clients and network providers.
5. Reports for case analysis, concurrent review, and
case follow up including hospital admissions,
discharges, and census reports.
D. Fraud and Abuse. The contractor shall have a system that
supports the requirements in Article 7.40 to identify
potential and/or actual instances of fraud, abuse,
underutilization and/or overutilization and shall meet the
REPORTING requirements in Section A of the Appendices.
III-12
3.5.2 REPORTING REQUIREMENTS
The contractor's system shall support the reporting requirements as
described in Section A of the Appendices.
3.6 FINANCIAL PROCESSING
The contractor's system shall provide for financial processing to
support the requirements of the contract and the contractor's
operations.
3.6.1 FUNCTIONS AND CAPABILITIES
A. General. The system shall provide the necessary data for all
accounting functions including claims payment, capitation
payment, capitation reconciliation, recoupments, recoveries,
accounts receivable, accounts payable, general ledger, and
bank reconciliation. The financial module shall provide the
contractor's management with information to demonstrate the
contractor is meeting, exceeding or falling short of its
fiscal and level of risk goals. It shall interface with other
relevant modules. The information shall provide management
with the necessary tools to monitor financial performance,
make prompt payments on financial obligations, monitor
accounts receivables, and keep accurate and complete financial
records.
Reports should:
1. Provide information useful in making business and
economic decisions.
2. Provide information that will allow the Department to
monitor the future cash flow of the contractor
resulting from this contract.
3. Provide information relative to an enterprise's
economic resources, the claims on those resources,
and the effects of transactions, events and
circumstances that change resources and claims to
resources.
4. Generate data to evaluate the contractor's operations
(i.e., indicators of risk, efficiency,
capitalization, and profitability).
5. Provide support for detailed actuarial analysis of
the operations performed under the contract resulting
from this contract.
6. Provide other information that is useful in
evaluating important past events or predicting
meaningful future events.
B. Specific Functions. The contractor's system shall provide for
integration of the financial system with the claims and
encounter system. At a minimum the system shall:
III-13
1. Update the specific claim records in the claims
history if payments are voided or refunded.
2. Update the specific claims records in the claims
history if amounts are recovered.
3. Update capitation history if payments are voided or
refunded.
4. Provide for liens and withholds of payments to
providers.
5. Provide for reissuing lost or stolen checks.
6. Provide for automatic recoupment if a claim is
adjusted and results in a negative payment.
3.6.2 REPORTING PRODUCTS
Report descriptions and criteria required by the State for the
financial portion of the system are set forth in Section A of the
Appendices.
3.7 QUALITY ASSURANCE
The contractor's system shall produce reports for analysis that focus
on the review and assessment of quality of care given, the detection of
over- and under-utilization, the development of user-defined criteria
and standards of care, and the monitoring of corrective actions.
3.7.1 FUNCTIONS AND CAPABILITIES
A. General. The system shall provide data to assist in the
definition and establishment of contractor performance
measurement standards, norms and service criteria.
1. The system shall provide reports to monitor and
identify deviations of patterns of treatment from
established standards or norms and established
baselines. These reports shall profile utilization of
providers and enrollees and compare them against
experience and norms for comparable individuals.
2. The system should provide cost utilization reports by
provider and service in various arrays.
3. It should maintain data for medical and dental
assessments and evaluations.
4. It should collect, integrate, analyze, and report
data necessary to
III-14
implement the Quality Assessment and Performance
Improvement (QAPI) program.
5. It should collect data on enrollee and provider
characteristics and on services furnished to
enrollees, as needed to guide the selection of
performance improvement project topics and to meet
the data collection requirements for such projects.
6. It should collect data in standardized formats to the
extent feasible and appropriate. The contractor must
review and ensure that data received from providers
are accurate, timely, and complete.
7. Reports should facilitate at a minimum monthly
tracking and trending of enrollee care issues to
monitor and assess contractor and provider
performance and services provided to enrollees.
8. Reports should monitor xxxxxxxx for evidence of a
pattern of inappropriate xxxxxxxx, services, and
assess potential mispayments as a result of such
practices.
9. Reports should support tracking utilization control
function(s) and monitoring activities for out-of-area
and emergency services.
B. Specific Capabilities. The system should:
1. Include a database for utilization, referrals,
tracking function for utilization controls, and
consultant services.
2. Accommodate and apply standard norms/criteria and
medical and dental policy standards for quality of
care and utilization review.
3. Include all types of claims and encounters data along
with service authorizations and referrals.
4. Include pharmacy utilization data from MH/SA
providers.
5. Interface, as applicable, with external utilization
and quality assurance/measurement software programs.
6. Include tracking of coordination requirements with
MH/SA providers.
7. Include ability to protect patient confidentiality
through the use of masked identifiers and other
safeguards as necessary.
C. Measurement Functions. The system should include:
III-15
1. Ability to track review committee(s) functions when
case requires next review and/or follow-up.
2. Track access, use and coordination of services.
3. Provide patient satisfaction data through use of
enrollee surveys, grievance, complaint/appeals
processes, etc.
4. Generate HEDIS reports in the version specified by
the State.
3.7.2 REPORTING PRODUCTS
The system shall support the reporting requirements and other functions
described in Article 4 and Section A of the Appendices.
3.8 MANAGEMENT AND ADMINISTRATIVE REPORTING
The MCMIS shall have a comprehensive reporting capability to support
the reporting requirements of this contract and the management needs
for all of the contractor operations.
3.8.1 GENERAL REQUIREMENTS
A. Purpose. The reports should provide information to determine
and review fiscal viability, to evaluate the appropriateness
of care rendered, and to identify reporting/billing problems
and provider practices that are at variance with the norm, and
measure overall performance.
B. General Capabilities. MCMIS reporting capabilities shall
include the capabilities to access relatively small amounts of
data very quickly as well as to generate comprehensive reports
using multiple years of historical claims and encounter data.
The contractor shall provide a management and administrative
reporting system that allows full access to all of the
information utilized in the MCMIS. The contractor shall
provide a solution that makes all data contained in any
subcontractor's MIS available to authorized users through the
use of the various software that provides the capabilities
detailed in the following Articles.
C. Regular Reports. The system shall generate a comprehensive set
of management and administrative management reports that
facilitate the oversight, evaluation, and management of this
program as well as the contractor's other operations.
The system should provide the capability for pre-defined,
parameter driven report/trend alerts. The system shall have
the capability to select important and specific parameters of
utilization, and have specified users alerted when these
parameters are being exceeded. For example, the State may want
to monitor the use of a specific drug as treatment for a
specific condition.
III-16
D. The contractor shall acquire the capability to receive and
transmit data in a secure manner electronically to and from
the State's data centers, which are operated by OIT. The
standard data transfer software that OIT utilizes for
electronic data exchange is Connect: Direct. Both mainframe
and PC versions are available. A dedicated line is preferred,
but at a minimum connectivity software can be used for the
connection.
3.8.2 QUERY CAPABILITIES
The contractor's MCMIS should have a sophisticated, query tool with
access to all major files for the users.
A. General. The system should provide a user-friendly, online
query language to construct database queries to data available
across all of the database(s), down to raw data elements. It
should provide options to select query output to be displayed
on-line, in a formatted hard-copy report, or downloaded to
disk for PCbased analysis.
B. Unduplicated Counts. The system should provide the capability
to execute queries that perform unduplicated counts (e.g.,
unduplicated count of original beneficiary ID number),
duplicated counts (e.g., total number of services provided for
a given aid category), or a combination of unduplicated and
duplicated counts.
3.8.3 REPORTING CAPABILITIES
The contractor should provide reporting tools with its MCMIS that
facilitate ad hoc, user, and special reporting. The MCMIS should
provide flexible report formatting/editing capabilities that meet the
contractor's business requirements and support the Department's
information needs. For example, it should provide the ability to
import, export and manipulate data files from spreadsheet, word
processing and database management tools as well as the database(s) and
should provide the capability to indicate header information, date and
run time, and page numbers on reports. The system should provide
multiple pre-defined report types and formats that are easily selected
by users.
III-17
3.9 ENCOUNTER DATA REPORTING
The contractor shall collect, process, format, and submit electronic
encounter data for all services delivered for which the contractor is
responsible. The contractor shall capture all required encounter data
elements using coding structures recognized by the Department. The
contractor shall process the encounter data, integrating any manual or
automated systems to validate the adjudicated encounter data. The
contractor shall interface with any systems or modules within its
organization to obtain the required encounter data elements. The
contractor shall submit the encounter data to the Department's fiscal
agent electronically, via diskette, tape, or electronic transmission,
according to specifications in the Electronic Media Claims (EMC) Manual
found in Section B.3.3 of the Appendices. The encounter data processing
system shall have a data quality assurance plan to include timely data
capture, accurate and complete encounter records, and internal data
quality audit procedures. If DMAHS determines that changes are
required, the contractor shall be given advance notice and time to make
the change according to the extent and nature of the required change.
3.9.1 REQUIRED ENCOUNTER DATA ELEMENTS
A. All Types of Claims. The contractor shall capture all required
encounter data elements for each of the eight claim types:
Inpatient, Outpatient, Professional, Home Health,
Transportation, Vision, Dental, and Pharmacy.
B. Data Elements. The required data elements are provided in
Section A.7.11 and Section B.3.3 of the Appendices. Note that
New Jersey-specific Medicaid codes are required in some
fields. Providers shall be identified using the provider's EIN
or tax identification number. Inpatient hospital claims and
encounters shall be combined into a single stay when the
enrollee's dates of services are consecutive.
C. Contractor Encounter. The contractor shall submit encounter
data for claims and encounters received by the contractor. The
contractor shall identify a capitated arrangement versus a
"fee-for-service" arrangement for each of its network
providers. For noncapitated arrangements, the contractor shall
report the actual payment made to the provider for each
encounter. For capitated arrangements, the contractor may
report a zero payment for each encounter. However, a monthly
"Capitation Summary Record" shall be required for each
provider type, beneficiary capitation category, and service
month combination. The specifications for the submission of
monthly capitation summary records is further detailed in the
EMC Manual, found in Section B.3.3 of the Appendices.
3.9.2 SUBMISSION OF TEST ENCOUNTER DATA
A. Submitter ID. The contractor shall make application in order
to obtain a Submitter Identification Number, according to the
instructions listed in the EMC Manual found in Section B.3.3
of the Appendices.
III-18
B. Test Requirement. The contractor shall be required to pass a
testing phase for each of the eight encounter claim types
before production encounter data will be accepted. The
contractor shall pass the testing phase for all encounter
claim type submissions within twelve (12) calendar weeks from
the award date of the contract. Contractors with prior
contracting experience with DHS who have successfully passed
test phases and have successfully submitted approved
production data may be exempted at DHS's option.
The contractor shall submit the test encounter data to the
Department's fiscal agent electronically, via diskette, tape,
or electronic transmission, according to the specifications of
the Electronic Media Claims (EMC) Manual found in Section
B.3.3 of the Appendices.
The contractor shall be responsible for passing a two-phased
test for each encounter claim type. The first phase requires
that each submitted file follows the prescribed format, that
header and trailer records are present and correctly located
within the file, and that the key fields are present. The
second phase requires that the required data elements are
present and properly valued.
Following each submission, an error report will be forwarded
to the contractor identifying the file and record location of
each error encountered for both testing phases. The contractor
shall analyze the report, complete the necessary corrections,
and re-submit the encounter data test file(s).
The contractor shall utilize production encounter data,
systems, tables, and programs when processing encounter test
files. The contractor shall submit errorfree production data
once testing has been approved for all of the encounter claims
types.
3.9.3 SUBMISSION OF PRODUCTION ENCOUNTER DATA
A. Adjudicated Claims and Encounters. The contractor shall submit
all adjudicated encounter data for all services provided for
which the contractor is responsible. Adjudicated encounter
data are defined as data from claims and encounters that the
contractor has processed as paid or denied. The contractor is
not responsible for submitting contested claims or encounters
until final adjudication has been determined.
III-19
B. Schedule. Encounter data shall be submitted per the schedule
established by the Department. Each submission shall include
encounter data that were adjudicated in the prior period and
any adjustments for encounter data previously submitted.
C. Two-Phase Process. Similar to testing, the contractor shall be
responsible for passing a two-phased test for all production
encounter data submitted. The first phase requires each
submitted file follow the prescribed format, that header and
trailer records are present and correctly located within the
file, and that the key fields are present. The second phase
requires that the required data elements are present and
properly valued.
D. Phase One Errors. If all or part of a production encounter
file(s) rejects during phase one, an error report will be
forwarded to the contractor identifying the file and record
location of each error encountered. The contractor shall
analyze the report, complete the necessary corrections, and
re-submit the "rejected" encounter production data within
forty-five (45) calendar days from the date the contractor
receives the notice of error(s).
E. The contractor shall not be permitted to provide services
under this contract nor shall the contractor receive
capitation payment until it has passed the testing and
production submission of encounter data.
3.9.4 REMITTANCE ADVICE
A. Remittance Advice File Processing Report. The Department's
fiscal agent shall produce a Remittance Advice File on a
monthly basis that itemizes all processed encounters. The
contractor shall be responsible for the acceptance and
processing of a Remittance Advice (RA) File according to the
specifications listed in the EMC Manual found in Section B.3.3
of the Appendices. The Remittance Advice File is produced on
magnetic tape and contains all submitted encounter data that
passed phase one testing. The disposition (paid or denied)
shall be reported for each encounter along with the "phase
two" errors for those claims that New Jersey Medicaid denied.
B. Reconciliation. The contractor shall be responsible for
matching the encounters on the Remittance Advice File against
the contractor's data files(s). The contractor shall correct
any encounters that denied improperly and/or any other
discrepancies noted on the file. Corrections shall be
resubmitted within thirty (30) calendar days from the date the
contractor receives the Remittance Advice File.
All corrections to "denied" encounter data, as reported on the
Remittance Advice File, shall be resubmitted as "full record"
adjustments, according to the requirements listed in the EMC
Manual found in Section B.3.3 of the Appendices.
III-20
3.9.5 SUBCONTRACTS AND ENCOUNTER DATA REPORTING FUNCTION
A. Interfaces. All encounter data shall be submitted to the
Department directly by the contractor. DMAHS shall not accept
any encounter data submissions or correspondence directly from
any subcontractors, and DMAHS shall not forward any electronic
media, reports or correspondence directly to a subcontractor.
The contractor shall be required to receive all electronic
files and hardcopy material from the Department, or its
appointed fiscal agent, and distribute them within its
organization or to its subcontractors appropriately.
B. Communication. The contractor and its subcontractors shall be
represented at all DMAHS meetings scheduled to discuss any
issue related to the encounter function requirements.
3.9.6 FUTURE ELECTRONIC ENCOUNTER SUBMISSION REQUIREMENTS
At the present time, the Health Care Financing Administration (HCFA) is
pursuing a standardization of all electronic health care information,
including encounter data. The contractor shall be responsible for
completing and paying for any modifications required to submit
encounter data electronically, according to the same specifications and
timeframes outlined by HCFA for the New Jersey MMIS.
III-21
ARTICLE FOUR: PROVISION OF HEALTH CARE SERVICES
4.1 COVERED SERVICES
For enrollees who are eligible through Title XIX or the NJ FamilyCare
program the contractor shall provide or arrange to have provided
comprehensive, preventive, and diagnostic and therapeutic, health care
services to enrollees that include all services that Medicaid
beneficiaries are entitled to receive under Medicaid, subject to any
limitations and/or excluded services as specified in this Article.
Provision of these services shall be equal in amount, duration, and
scope as established by the Medicaid program, in accordance with
medical necessity and without any predetermined limits, unless
specifically stated, and as set forth in 42 C.F.R. Part 440; 42 C.F.R.
Part 434; the Medicaid State Plan; the Medicaid Provider Manuals: The
New Jersey Administrative Code, Title 10, Department of Human Services
Division of Medical Assistance and Health Services; Medicaid/NJ
FamilyCare Alerts; Medicaid/NJ FamilyCare Newsletters; and all
applicable federal and State statutes, rules, and regulations.
4.1.1 GENERAL PROVISIONS AND CONTRACTOR RESPONSIBILITIES
A. With the exception of certain emergency services described in
Article 4.2.1 of this contract, all care covered by the
contractor pursuant to the benefits package must be provided,
arranged, or authorized by the contractor or a participating
provider.
B. The contractor and its providers shall furnish all covered
services required to maintain or improve health in a manner
that maximizes coordination and integration of services, and
in accordance with professionally recognized standards of
quality and shall ensure that the care is appropriately
documented to encompass all health care services for which
payment is made.
C. For beneficiaries eligible solely through the NJ FamilyCare
Plan A the contractor shall provide the same managed care
services and products provided to enrollees who are eligible
through Title XIX. For beneficiaries eligible solely through
the NJ FamilyCare Plans B and C the contractor shall provide
the same managed care services and products provided to
enrollees who are eligible through Title XIX with the
exception of limitations on EPSDT coverage as indicated in
Articles 4.1.2A.3 and 4.2.6A.2. NJ FamilyCare Plan D and other
plans have a different service package specified in Article
4.1.6.
D. Out-of-Area Coverage. The contractor shall provide or arrange
for out-of-area coverage of contracted benefits in emergency
situations and non-emergency situations when travel back to
the service area is not possible, is impractical, or when
medically necessary services could only be provided elsewhere.
The contractor shall not be responsible for out-of-state
coverage for routine care if the enrollee resides out-of-state
for more than 30 days. For full time students attending school
and residing out of the country, the contractor shall not be
responsible for health care benefits while the individual is
in school.
IV-1
E. Existing Plans of Care. The contractor shall honor and pay for
plans of care for new enrollees, including prescriptions,
durable medical equipment, medical supplies, prosthetic and
orthotic appliances, and any other on-going services initiated
prior to enrollment with the contractor. Services shall be
continued until the enrollee is evaluated by his/her primary
care physician and a new plan of care is established with the
contractor.
The contractor shall use its best efforts to contact the new
enrollee or, where applicable, authorized person and/or
contractor care manager. However, if after documented,
reasonable outreach (i.e., mailers, certified mail, use of
MEDM system provided by the State, contact with the Medicaid
District Office (MDO), DDD, or DYFS to confirm addresses
and/or to request assistance in locating the enrollee) the
enrollee fails to respond within 20 working days of certified
mail, the contractor may cease paying for the pre-existing
service until the enrollee or, where applicable, authorized
person, contacts the contractor for re-evaluation.
F. Routine Physicals. The contractor shall provide for routine
physical examinations required for employment, school, camp or
other entities/programs that require such examinations as a
condition of employment or participation.
G. Non-Participating Providers. The contractor shall pay for
services furnished by non-participating providers to whom an
enrollee was referred, even if erroneously referred, by
his/her PCP or network specialist. Under no circumstances
shall the enrollee bear the cost of such services when
referral errors by the contractor or its providers occur. It
is the sole responsibility of the contractor to provide
regular updates on complete network information to all its
providers as well as appropriate policies and procedures for
provider referrals.
H. The contractor shall have policies and procedures on the use
of enrollee selfreferred services.
I. The contractor shall have policies and procedures on how it
will provide for genetic testing and counseling.
J. Second Opinions. The contractor shall have a Second Opinion
program that can be utilized at the enrollee's option for
diagnosis and treatment of serious medical conditions, such as
cancer and for elective surgical procedures. The program shall
include at a minimum: hernia repair (simple) for adults (18
years or older), hysterectomy (elective procedures), spinal
fusion (except for children under 18 years of age with a
diagnosis of scoliosis or xxxxx bifida), and laminectomy
(except for children under 18 years of age with a diagnosis of
scoliosis). The plan shall be incorporated into the
contractor's medical procedures. The exceptions noted do not
require second surgical opinion before surgery can be
performed. The Second Opinion program shall be incorporated
into the contractor's medical procedures and submitted to
DMAHS for review and approval.
IV-2
K. Unless otherwise required by this contract, the contractor
shall make no distinctions with regard to the provision of
services to Medicaid and NJ FamlyCare enrollees and the
provision of services provided to the contractor's
non-Medicaid/NJ FamilyCare enrollees.
L. DMAHS may intercede on an enrollee's behalf when DMAHS deems
it appropriate for the provision of medically necessary
services and to assist enrollees with the contractor's
operations and procedures which may cause undue hardship for
the enrollee. In the event of a difference in interpretation
of contractually required service provision between the
Department and the contractor, the Department's interpretation
shall prevail until a formal decision is reached, if
necessary.
M. A New Jersey Care 2000+ enrollee who seeks self-initiated care
from a nonparticipating provider without
referral/authorization shall be held responsible for the cost
of care. The enrollee shall be fully informed of the
requirement to seek care when it is available within the
network and the consequences of obtaining unauthorized
out-of-network care for covered services.
N. Protection of Enrollee - Provider Communications. Health care
professionals may not be prohibited from advising their
patients about their health status or medical care or
treatment, regardless of whether this care is covered as a
benefit under the contract.
O. Medical or Dental Procedures. For procedures that may be
considered either medical or dental such as surgical
procedures for fractured jaw or removal of cysts, the
contractor shall establish written policies and procedures
clearly and definitively delineated for all providers and
administrative staff, indicating that either a physician
specialist or oral surgeon may perform the procedure and when,
where, and how authorization, if needed, shall be promptly
obtained.
4.1.2 BENEFIT PACKAGE
A. The following categories of services shall be provided by the
contractor for all Medicaid and NJ FamilyCare Plans A, B, and
C enrollees, except where indicated. See Section B.4.1 of the
Appendices for complete definitions of the covered services.
1. Primary and Specialty Care by physicians and, within
the scope of practice and in accordance with State
certification/licensure requirements, standards and
practices, by Certified Nurse Midwives, Certified
Nurse Practitioners, Clinical Nurse Specialists, and
Physician Assistants
2. Preventive Health Care and Counseling and Health
Promotion
IV-3
3. Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) Program Services
For NJ FamilyCare Plans B and C participants,
coverage includes early and periodic screening and
diagnosis medical examinations, dental, vision,
hearing, and lead screening services. It includes
only those treatment services identified through the
examination that are available under the contractor's
benefit package or specified services under the FFS
program.
4. Emergency Medical Care
5. Inpatient Hospital Services including acute care
hospitals, rehabilitation hospitals, and special
hospitals
6. Outpatient Hospital Services
7. Laboratory Services [Except routine testing related
to administration of Clozapine and the other
psychotropic drugs listed in Article 4.1.4B for
non-DDD clients.]
8. Radiology Services - diagnostic and therapeutic
9. Prescription Drugs (legend and non-legend covered by
the Medicaid program) - For payment method for
Protease Inhibitors, certain other antiretrovirals,
blood clotting factors VIII and IX, and coverage of
protease inhibitors and certain other anti-
retrovirals under NJ FamilyCare, see Article 8.
10. Family Planning Services and Supplies
11. Audiology
12. Inpatient Rehabilitation Services
13. Podiatrist Services
14. Chiropractor Services
15. Optometrist Services
16. Optical Appliances
17. Hearing Aid Services
18. Home Health Agency Services - Not a
contractor-covered benefit for the non-dually
eligible ABD population. All other services provided
to any
IV-4
enrollee in the home, including but not limited to
pharmacy and DME services, are the contractor's
fiscal and medical management responsibility.
19. Hospice Agency Services
20. Durable Medical Equipment (DME)/Assistive Technology
Devices in accordance with existing Medicaid
regulations
21. Medical Supplies
22. Prosthetics and Orthotics including certified shoe
provider
23. Dental Services
24. Organ Transplants
25. Transportation Services for any contractor-covered
service or noncontractor covered service including
ambulance, mobile intensive care units (MICUs) and
invalid coach (including lift equipped vehicles)
26. Post-acute Care
27. Mental Health/Substance Abuse Services for enrollees
who are clients of the Division of Developmental
Disabilities
B. Conditions Altering Mental Status. Those diagnoses which are
categorized as altering the mental status of an individual but
are of organic origin shall be part of the contractor's
medical, financial and care management responsibilities for
all categories of enrollees. These include the diagnoses in
the following ICD-9-CM Series:
1. 290.0 Senile dementia, simple type
2. 290.1 Presenile dementia
3. 290.3 Senile dementia with acute confusional state
4. 290.4 Arteriosclerotic dementia uncomplicated
5. 290.8 Other
6. 290.9 Unspecified
7. 291.1 Korsakov's psychosis, alcoholic
8. 291.2 Other alcoholic dementia
9. 292.82 Drug induced dementia
10. 292.9 Unspecified drug induced mental disorders
11. 293.0 Acute delirium
12. 293.1 Subacute delirium
13. 294.0 Amnestic syndrome
14. 294.1 Dementia in conditions classified elsewhere
IV-5
15. 294.8 Other specified organic brain syndromes
(chronic)
16. 294.9 Unspecified organic brain syndrome (chronic)
17. 305.1 Non-dependent abuse of drugs - tobacco
18. 310.0 Frontal lobe syndrome
19. 310.2 Postconcussion syndrome
20. 310.8 Other specified nonpsychotic mental disorder
following organic brain damage
21. 310.9 Unspecified nonpsychotic mental disorder
following organic brain damage
In addition, the contractor shall retain responsibility for
delivering all covered Medicaid mental health/substance abuse
services to enrollees who are clients of the Division of
Developmental Disabilities (referred to as "clients of DDD").
Articles Four and Five contain further information regarding
clients of DDD.
4.1.3 SERVICES REMAINING IN FEE-FOR-SERVICE PROGRAM AND MAY NECESSITATE
CONTRACTOR ASSISTANCE TO THE ENROLLEE TO ACCESS THE SERVICES
A. The following services provided by the New Jersey Medicaid
program under its State plan shall remain in the
fee-for-service program but may require medical orders by the
contractor's PCPs/providers. These services shall not be
included in the contractor's capitation.
1. Personal Care Assistant Services (not covered for NJ
FamilyCare Plans B and C)
2. Medical Day Care (not cove red for NJ FamilyCare
Plans B and C)
3. Outpatient Rehab - Physical therapy, occupational
therapy, and speech pathology services (For NJ
FamilyCare Plans B & C enrollees, limited to 60 days
per therapy per year)
4. Abortions and related services including surgical
procedure, cervical dilation, insertion of cervical
dilator, anesthesia including para cervical block,
history and physical examination on day of surgery;
lab tests including PT, PTT, OB Panel (includes
hemogram, platelet count, hepatitis B surface
antigen, rubella antibody, VDRL, blood typing ABO and
Rh, CBC and differential), pregnancy test, urinalysis
and urine drug screen, glucose and electrolytes;
routine venapuncture; ultrasound, pathological
examination of aborted fetus; Rhogam and its
administration.
5. Transportation - lower mode (not covered for NJ
FamilyCare Plans B and C)
6. Sex Abuse Examinations
IV-6
7. Services Provided by New Jersey MH/SA and DYFS
Residential Treatment Facilities or Group Homes. For
enrollees living in residential facilities or group
homes where ongoing care is provided, contractor
shall cooperate with the medical, nursing, or
administrative staff person designated by the
facility to ensure that the enrollees have timely and
appropriate access to contractor providers as needed
and to coordinate care between those providers and
the facility's employed or contracted providers of
health services. Medical care required by these
residents remains the contractor's responsibility
providing the contractor's provider network and
facilities are utilized.
8. Family Planning Services and Supplies when furnished
by a nonparticipating provider
9. Home health agency services for the non-dually
eligible ABD population
B. Dental Services. For those dental services specified below
that are initiated by a Medicaid non-New Jersey Care 2000+
provider prior to first time New Jersey Care 2000+ enrollment,
an exemption from contractor-covered services based on the
initial managed care enrollment date will be provided and the
services paid by Medicaid FFS. The exemption shall only apply
to those beneficiaries who have initially received these
services during the 60 or 120 day period immediately prior to
the initial New Jersey Care 2000+ enrollment date.
1. Procedure Codes to be paid by Medicaid FFS up to 60
days after first time New Jersey Care
2000+ enrollment:
02710 02792 03430
02720 02950 05110
02721 02952 05120
02722 02954 05211
02750 03310 05211-52
02751 03320 05212
02752 03330 05212-52
02790 03410-22 05213
02791 03411 05214
2. Procedure Codes to be paid by Medicaid FFS up to 120
days from date of last preliminary extractions after
patient enrolls in New Jersey Care 2000+ (applies to
tooth codes 5 - 12 and 21 - 28 only):
05130
05130-22
05140
05140-22
IV-7
3. Extraction Procedure Codes to be paid by Medicaid FFS
up to 120 days from last date of preliminary
extractions after first time New Jersey Care 2000+
enrollment in conjunction with the following codes
(05130, 05130-22, 05140, 05140-22):
07110
07130
07210
4.1.4 MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR
A. Mental Health/Substance Abuse. The following mental
health/substance abuse services (except for the conditions
listed in 4.1.2.B) will be managed by the State or its agent
for non-DDD enrollees, including all NJ FamilyCare enrollees.
(The contractor will retain responsibility for furnishing
mental health/substance abuse services, excluding the cost of
the drugs listed below, to Medicaid enrollees who are clients
of the Division of Developmental Disabilities).
- Substance Abuse Services--diagnosis, treatment, and
detoxification
- Costs for Methadone and its administration
- Mental Health Services
B. Drugs. The following drugs will be paid fee-for-service by the
Medicaid program for all DMAHS enrollees:
- Clozapine
- Risperidone
- Olanzapine
- Ziprasidone
- Quetiapine
- Methadone - cost and its administration. Except as
provided in Article 4.4, the contractor will remain
responsible for the medical care of enrollees
requiring substance abuse treatment
- Generically-equivalent drug products of the drugs
listed in this section.
C. Up to twelve (12) inpatient hospital days required for social
necessity
D. DDD/CCW waiver services: individual supports (which includes
personal care and training), habilitation, case management,
respite, and Personal Emergency Response Systems (PERS).
IV-8
4.1.5 INSTITUTIONAL FEE-FOR-SERVICE BENEFITS - NO COORDINATION BY THE
CONTRACTOR
The following institutional services shall remain in the
fee-for-service program without requiring coordination by the
contractor. In addition, Medicaid beneficiaries participating in a
waiver (except the Division of Developmental Disabilities Community
Care Waiver) or demonstration program or admitted for long term care
treatment in one of the following shall be disenrolled from the
contractor's plan on the date of admission to institutionalized care.
A. Nursing Facility care (if the admission is only for inpatient
rehabilitation/postacute care services and is less than 30
days, the enrollee will not be disenrolled).
B. Inpatient psychiatric services (except for RTCs) for
individuals under age 21 and 65 and over - Services that are
provided:
1. Under the direction of a physician;
2. In a facility or program accredited by the Joint
Commission on Accreditation of Health Care
Organizations; and
3. Meet the federal and State requirements.
C. Intermediate Care Facility/Mental Retardation Services - Items
and services furnished in an intermediate care facility for
the mentally retarded.
D. Waiver (except Division of Developmental Disabilities
Community Care Waiver) and demonstration program services.
4.1.6 BENEFIT PACKAGE FOR NJ FAMILYCARE PLAN D
A. Services Included In The Contractor's Benefits Package for NJ
FamilyCare Plan D. The following services shall be provided
and case managed by the contractor:
1. Primary Care
a. All physicians services, primary and
specialty
b. In accordance with state
certification/licensure requirements,
standards, and practices, primary care
providers shall also include access to
certified nurse midwifes, certified nurse
practitioners, clinical nurse specialists,
and physician assistants
c. Services rendered at independent clinics
that provide ambulatory services
IV-9
d. Federally Qualified Health Center primary
care services
2. Emergency room services
3. Family Planning Services, including medical history
and physical examinations (including pelvic and
breast), diagnostic and laboratory tests, drugs and
biologicals, medical supplies and devices,
counseling, continuing medical supervision,
continuity of care and genetic counseling
Services provided primarily for the diagnosis and
treatment of infertility, including sterilization
reversals, and related office (medical and clinic)
visits, drugs, laboratory services, radiological and
diagnostic services and surgical procedures are not
covered by the NJ FamilyCare program. Obtaining
family planning services from providers outside the
contractor's provider network is not available to NJ
FamilyCare Plan D enrollees.
4. Home Health Care Services -- Limited to skilled
nursing for a home bound beneficiary which is
provided or supervised by a registered nurse, and
home health aide when the purpose of the treatment is
skilled care; and medical social services which are
necessary for the treatment of the beneficiary's
medical condition
5. Hospice Services
6. Inpatient Hospital Services, including general
hospitals, special hospitals, and rehabilitation
hospitals. The contractor shall not be responsible
when the primary admitting diagnosis is mental health
or substance abuse related.
7. Outpatient Hospital Services, including outpatient
surgery
8. Laboratory Services -- All laboratory testing sites
providing services under this contract must have
either a Clinical Laboratory Improvement Act (CLIA)
certificate of waiver or a certificate of
registration along with a CLIA identification number.
Those providers with certificates of waiver shall
provide only the types of tests permitted under the
terms of their waiver. Laboratories with certificates
of registration may perform a full range of
laboratory services.
9. Radiology Services -- Diagnostic and therapeutic
10. Optometrist Services, including one routine eye
examination per year
IV-10
11. Optical appliances -- Limited to one pair of glasses
(or cont act lenses) per 24 month period or as
medically necessary
12. Organ transplant services which are non-experimental
or non-investigational
13. Prescription drugs, excluding over-the-counter drugs
Exception: See Article 8 regarding Protease
Inhibitors and other antiretrovirals.
14. Dental Services -- Limited to preventive dental
services for children under the age of 12 years,
including oral examinations, oral prophylaxis, and
topical application of fluorides
15. Podiatrist Services -- Excludes routine hygienic care
of the feet, including the treatment of corns and
calluses, the trimming of nails, and other hygienic
care such as cleaning or soaking feet, in the absence
of a pathological condition
16. Prosthetic appliances -- Limited to the initial
provision of a prosthetic device that temporarily or
permanently replaces all or part of an external body
part lost or impaired as a result of disease, injury,
or congenital defect. Repair and replacement services
are covered when due to congenital growth.
17. Private duty nursing -- Only when authorized by the
contractor
18. Transportation Services -- Limited to ambulance for
medical emergency only
19. Well child care including immunizations, lead
screening and treatments
20. Maternity and related newborn care
21. Diabetic supplies and equipment
B. Services Available To NJ FamilyCare Plan D Under
Fee-For-Service. The following services are available to NJ
FamilyCare Plan D enrollees under fee-for-service:
1. Abortion services
2. Skilled nursing facility services
IV-11
3. Outpatient Rehabilitation Services -- Physical
therapy, Occupational therapy, and Speech therapy for
non-chronic conditions and acute illnesses and
injuries. Limited to treatment for a 60-day
consecutive period per incident of illness or injury
beginning with the first day of treatment per
contract year. Speech therapy services rendered for
treatment of delays in speech development, unless
resulting from disease, injury or congenital defects
are not covered
4. Inpatient hospital services for mental health,
including psychiatric hospitals, limited to 35 days
per year
5. Outpatient benefits for short-term, outpatient
evaluative and crisis intervention, or home health
mental health services, limited to 20 visits per year
a. When authorized by the Division of Medical
Assistance and Health Services, one (1)
mental health inpatient day may be exchanged
for up to four (4) home health visits or
four (4) outpatient services, including
partial care. This is limited to an exchange
of up to a maximum of 10 inpatient days for
a maximum of 40 additional outpatient
visits.
b. When authorized by the Division of Medical
Assistance and Health Services, one (1)
mental health inpatient day may be exchanged
for two (2) days of treatment in partial
hospitalization up to the maximum number of
covered inpatient days.
6. Inpatient and outpatient services for substance abuse
are limited to detoxification.
C. Exclusions. The following services not covered for NJ
FamilyCare Plan D participants either by the contractor or the
Department include, but are not limited to:
1. Non-medically necessary services.
2. Intermediate Care Facilities/Mental Retardation
3. Private duty nursing unless authorized by the
contractor
4. Personal Care Assistant Services
5. Medical Day Care Services
6. Chiropractic Services
7. Dental services except preventive dentistry for
children under age 12
8. Orthotic devices
9. Targeted Case Management for the chronically ill
10. Residential treatment center psychiatric programs
11. Religious non-medical institutions care and services
IV-12
12. Durable Medical Equipment
13. Early and Periodic Screening, Diagnosis and Treatment
(EPSDT) services (except for well child care,
including immunizations and lead screening and
treatments)
14. Transportation Services, including non-emergency
ambulance, invalid coach, and lower mode
transportation
15. Hearing Aid Services
16. Blood and Blood Plasma, except administration of
blood, processing of blood, processing fees and fees
related to autologous blood donations are covered.
17. Cosmetic Services
18. Custodial Care
19. Special Remedial and Educational Services
20. Experimental and Investigational Services
21. Medical Supplies (except diabetic supplies)
22. Infertility Services
23. Rehabilitative Services for Substance Abuse
24. Weight reduction programs or dietary supplements,
except surgical operations, procedures or treatment
of obesity when approved by the contractor
25. Acupuncture and acupuncture therapy, except when
performed as a form of anesthesia in connection with
covered surgery
26. Temporomandibular joint disorder treatment, including
treatment performed by prosthesis placed directly in
the teeth
27. Recreational therapy
28. Sleep therapy
29. Court-ordered services
30. Thermograms and thermography
31. Biofeedback
32. Radial keratotomy
4.1.7 SUPPLEMENTAL BENEFITS
Any service, activity or product not covered under the State Plan may
be provided by the contractor only through written approval by the
Department and the cost of which shall be borne solely by the
contractor.
4.1.8 CONTRACTOR AND DMAHS SERVICE EXCLUSIONS
Neither the contractor nor DMAHS shall be responsible for the
following:
A. All services not medically necessary, provided, approved or
arranged by a contractor's physician or other provider (within
his/her scope of practice) except emergency services.
B. Cosmetic surgery except when medically necessary and approved.
IV-13
C. Experimental organ transplants.
D. Services provided primarily for the diagnosis and treatment of
infertility, including sterilization reversals, and related
office (medical or clinic), drugs, laboratory services,
radiological and diagnostic services and surgical procedures.
E. Rest cures, personal comfort and convenience items, services
and supplies not directly related to the care of the patient,
including but not limited to, guest meals and accommodations,
telephone charges, travel expenses other than those services
not in Article 4.1 of this contract, take home supplies and
similar cost. Costs incurred by an accompanying parent(s) for
an out-of-state medical intervention are covered under EPSDT
by the contractor.
F. Services involving the use of equipment in facilities, the
purchase, rental or construction of which has not been
approved by applicable laws of the State of New Jersey and
regulations issued pursuant thereto.
G. All claims arising directly from services provided by or in
institutions owned or operated by the federal government such
as Veterans Administration hospitals.
H. Services provided in an inpatient psychiatric institution,
that is not an acute care hospital, to individuals under 65
years of age and over 21 years of age.
I. Services provided to all persons without charge. Services and
items provided without charge through programs of other public
or voluntary agencies (for example, New Jersey State
Department of Health and Senior Services, New Jersey Heart
Association, First Aid Rescue Squads, and so forth) shall be
utilized to the fullest extent possible.
J. Services or items furnished for any sickness or injury
occurring while the covered person is on active duty in the
military.
K. Services provided outside the United States and territories.
L. Services or items furnished for any condition or accidental
injury arising out of and in the course of employment for
which any benefits are available under the provisions of any
workers' compensation law, temporary disability benefits law,
occupational disease law, or similar legislation, whether or
not the Medicaid beneficiary claims or receives benefits
thereunder, and whether or not any recovery is obtained from a
third-party for resulting damages.
M. That part of any benefit which is covered or payable under any
health, accident, or other insurance policy (including any
benefits payable under the New Jersey no-fault automobile
insurance laws), any other private or governmental health
benefit
IV-14
system, or through any similar third-party liability, which
also includes the provision of the Unsatisfied Claim and
Judgment Fund.
N. Any services or items furnished for which the provider does
not normally charge.
O. Services furnished by an immediate relative or member of the
Medicaid beneficiary's household.
P. Services billed for which the corresponding health care
records do not adequately and legibly reflect the requirements
of the procedure described or procedure code utilized by the
billing provider.
Q. Services or items reimbursed based upon submission of a cost
study when there are no acceptable records or other evidence
to substantiate either the costs allegedly incurred or
beneficiary income available to offset those costs. In the
absence of financial records, a provider may substantiate
costs or available income by means of other evidence
acceptable to the Division.
4.2 SPECIAL PROGRAM REQUIREMENTS
4.2.1 EMERGENCY SERVICES
A. For purposes of this contract, "emergency" means an onset of a
medical or behavioral condition, the onset of which is sudden,
that manifests itself by symptoms of sufficient severity,
including severe pain, that a prudent layperson, who possesses
an average knowledge of medicine and health, could reasonably
expect the absence of immediate medical attention to result
in:
1. Placing the health of the person or others in serious
jeopardy;
2. Serious impairment to such person's bodily functions;
3. Serious dysfunction of any bodily organ or part of
such person; or
4. Serious disfigurement of such person.
With respect to a pregnant woman who is having contractions,
an emergency exists where there is inadequate time to effect a
safe transfer to another hospital before delivery or the
transfer may pose a threat to the health or safety of the
woman or the unborn child.
B. The contractor shall be responsible for emergency services,
both within and outside the contractor's enrollment area, as
required by an enrollee in the case of an emergency. Emergency
services shall also include:
1. Medical examination at an Emergency Room which is
required by N.J.A.C. 10:122D-2.5(b) when a xxxxxx
home placement of a child occurs after business
hours.
IV-15
2. Examinations at an Emergency Room for suspected
physical/child abuse and/or neglect.
3. Post-Stabilization of Care. The contractor shall
comply with 42 C.F.R. 422.100(b)(iv). The contractor
must cover post-stabilization services without
requiring authorization and regardless of whether the
enrollee obtains the services within or outside the
contractor's network if:
a. The services were pre-approved by the
contractor or its providers; or
b. The services were not pre-approved by the
contractor because the contractor did not
respond to the provider of
post-stabilization care services' request
for pre-approval within one (1) hour after
being requested to approve such care; or
c. The contractor could not be contacted for
pre-approval.
C. Access Standards. The contractor shall ensure that all covered
services, that are required on an emergency basis are
available to all its enrollees, twenty-four (24) hours per
day, seven (7) days per week, either in the contractor's own
provider network or through arrangements approved by DMAHS.
The contractor shall maintain twenty-four (24) hours per day,
seven (7) days per week on-call telephone coverage, including
Telecommunication Device for the Deaf (TDD)/Tech Telephone
(TT) systems, to advise enrollees of procedures for emergency
and urgent care and explain procedures for obtaining
non-emergent/ non-urgent care during regular business hours
within the enrollment area as well as outside the enrollment
area.
D. Non-Participating Providers. The contractor shall be
responsible for developing and advising its enrollees and
where applicable, authorized persons of procedures for
obtaining emergency services, including emergency dental
services, when it is not medically feasible for enrollees to
receive emergency services from or through a participating
provider, or when the time required to reach the participating
provider would mean risk of permanent damage to the enrollee's
health. The contractor shall bear the cost of providing
emergency service through non-participating providers.
E. Emergency Care Prior Authorization. Prior authorization shall
not be required for emergency services. This applies to
out-of-network as well as to in-network providers.
F. Medical Screenings/Urgent Care. Prior authorization shall not
be required for medical screenings or in urgent care
situations at the hospital emergency room. The hospital
emergency room physician may determine the necessity for
IV-16
contacting the PCP or the contractor for information about an
enrollee who presents with an urgent condition.
G. The contractor shall pay for all medical screening services
rendered to its enrollees by hospitals and emergency room
physicians. The amount and method of reimbursement for medical
screenings shall be subject to negotiation between the
contractor and the hospital and directly with non-hospital
salaried emergency room physicians and shall include
reimbursement for urgent care and non-urgent care rates.
Non-participating hospitals may be reimbursed for hospital
costs at Medicaid rates or other mutually agreeable rates for
medical screening services. Additional fees for additional
services may be included at the discretion of the contractor
and the hospital.
1. The contractor shall not retroactively deny a claim
for an emergency medical screening exam because the
condition, which appeared to be an emergency medical
condition under the prudent layperson standard, was
subsequently determined to be non-emergency in
nature.
H. The contractor shall be liable for payment for the following
emergency services provided to an enrollee:
1. If the screening examination leads to a clinical
determination by the examining physician that an
actual emergency medical condition exists, the
contractor shall pay for both the services involved
in the screening exam and the services required to
stabilize the patient.
2. All emergency services which are medically necessary
until the clinical emergency is stabilized. This
includes all treatment that is necessary to assure,
within reasonable medical probability, that no
material deterioration of the patient's condition is
likely to result from, or occur during, discharge of
the patient or transfer of the patient to another
facility.
If there is a disagreement between a hospital and the
contractor concerning whether the patient is stable
enough for discharge or transfer, or whether the
medical benefits of an unstabilized transfer outweigh
the risks, the judgment of the attending physician(s)
actually caring for the enrollee at the treating
facility prevails and is binding on the contractor.
The contractor may establish arrangements with
hospitals whereby the contractor may send one of its
physicians with appropriate ER privileges to assume
the attending physician's responsibilities to
stabilize, treat, or transfer the patient.
3. If the screening examination leads to a clinical
determination by the examining physician that an
actual emergency medical condition does not exist,
but the enrollee had acute symptoms of sufficient
severity at the time of presentation to warrant
emergency attention under the prudent
IV-17
layperson standard, the contractor shall pay for all
services related to the screening examination.
4. The enrollee's PCP or other contractor representative
instructs the enrollee to seek emergency care
in-network or out-of-network, whether or not the
patient meets the prudent layperson definition.
I. The contractor may utilize a common list of symptom-based
presenting complaints that will reasonably substantiate that
an emergent/urgent medical condition existed. Some examples
include but are not limited to:
1. Severe pain of any kind.
2. Altered mental status, sustained or transient, for
any reason.
3. Abrupt change in neurological status, sustained or
transient, for any reason.
4. Complications of pregnancy.
5. Chest pain.
6. Acute allergic reactions.
7. Shortness of breath.
8. Abdominal pain.
9. Multiple episodes of vomiting or diarrhea, any age.
10. Fever greater than 102.5oF in any age group.
11. Fever greater than 100.4oF in infants three months or
younger.
12. Injuries with active bleeding.
13. Injuries with functional loss of any body part.
14. All patients arriving at the hospital by ambulance
after an injury with any body part immobilized.
15. All patients arriving at the hospital by paramedic
ambulance.
16. Symptoms of substance abuse.
17. Psychiatric disturbances.
J. Women who arrive at any emergency room in active labor shall
be considered as an emergency situation and the contractor
shall reimburse providers of care accordingly.
K. If within thirty (30) minutes after receiving a request from a
hospital emergency department for a specialty consultation,
the contractor fails to identify an appropriate specialist who
is available and willing to assume the care of the enrollee,
the emergency department may arrange for medically necessary
emergency services by an appropriate specialist, and the
contractor shall not deny coverage for these services due to
lack of prior authorization. The contractor shall not require
prior authorization for specialty care emergency services for
treatment of any immediately life-threatening medical
condition.
L. The contractor shall establish and maintain policies and
procedures for emergency dental services for all enrollees.
IV-18
1. Within the contractor's Enrollment/Service Area, the
contractor will ensure that:
a. Enrollees shall have access to emergency
dental services on a twenty-four (24) hour,
seven (7) day a week basis.
b. The contractor shall bear full
responsibility for the provision of
emergency dental services, and shall assure
the availability of a back-up provider in
the event that an on-call provider is
unavailable.
2. Outside the contractor's Service Area, the contractor
shall ensure that:
a. Enrollees shall be able to seek emergency
dental services from any licensed dental
provider without the need for prior
authorization from the contractor while
outside the Service Area (including out-of-
state services covered by the Medicaid
program).
M. The contractor shall reimburse ambulance and MICU
transportation providers responding to "911" calls whether or
not the patient's condition is determined, retrospectively, to
be an emergency.
4.2.2 FAMILY PLANNING SERVICES AND SUPPLIES
A. General. Except where specified in Section 4.1, the
contractor's enrollees are permitted to obtain family planning
services and supplies from either the contractor's family
planning provider network or from any other qualified Medicaid
family planning provider. The DMAHS shall reimburse family
planning services provided by non-participating providers
based on the Medicaid fee schedule.
B. Non-Participating Providers. The contractor shall cooperate
with nonparticipating family planning providers accessed at
the enrollee's option by establishing cooperative working
relationships with such providers for accepting referrals from
them for continued medical care and management of complex
health care needs and exchange of enrollee information, where
appropriate, to assure provision of needed care within the
scope of this contract. The contractor shall not deny coverage
of family planning services for a covered diagnostic,
preventive or treatment service solely on the basis that the
diagnosis was made by a non-participating provider.
IV-19
4.2.3 OBSTETRICAL SERVICES REQUIREMENTS/ISSUES
A. Obstetrical services shall be provided in the same amount,
duration, and scope as the Medicaid HealthStart program.
Guidelines, standards, and required program provisions are
found in Section B.4.2 of the Appendices.
B. The contractor shall not limit benefits for postpartum
hospital stays to less than forty-eight (48) hours following a
normal vaginal delivery or less than ninety-six (96) hours
following a cesarean section, unless the attending provider,
in consultation with the mother, makes the decision to
discharge the mother or the newborn before that time and the
provisions of N.J.S.A. 26:2J-4.9 are met.
1. The contractor shall not provide monetary payments or
rebates to mothers to encourage them to accept less
than the minimum protections provided for in this
Article.
2. The contractor shall not penalize, reduce, or limit
the reimbursement of an attending provider because
the provider provided care in a manner consistent
with this Article.
4.2.4 PRESCRIBED DRUGS AND PHARMACY SERVICES
A. General. The contractor shall provide all medically necessary
legend and non-legend drugs which are also covered by the
Medicaid program and ensure the availability of quality
pharmaceutical services for all enrollees including drugs
prescribed by Mental Health/Substance Abuse providers. See
Article 4.4C for additional information pertaining to MH/SA
pharmacy benefits.
B. Use of Formulary. The contractor may use a formulary as long
as the following minimum requirements are met:
1. The contractor shall only exclude coverage of drugs
or drug categories permitted under 1927(d) of the
Social Security Act as amended by OBRA 1993. In
addition, the contractor shall include in its
formulary, if it chooses to operate a formulary, any
FDA-approved drugs that may allow for clinical
improvement or are clinically advantageous for the
management of a disease or condition.
2. The contractor's formulary shall be developed by a
Pharmacy and Therapeutics (P&T) Committee that shall
represent the needs of all its enrollees including
enrollees with special needs. Network physicians and
dentists shall have the opportunity to participate in
the development of the formulary and, prior to any
changes to a drug formulary, to review, consider and
comment on proposed changes. The formulary shall be
reviewed in its entirety and updated at least
annually.
IV-20
3. The formulary for the DMAHS pharmacy benefit and any
revision thereto shall be reviewed and approved by
DMAHS.
4. The formulary shall include only FDA approved drug
products. For each Specific Therapeutic Drug (STD)
class, the selection of drugs included for each drug
class shall be sufficient to ensure the availability
of covered drugs with the least need for prior
authorization to be initiated by providers of
pharmaceutical services and include FDA approved
drugs to best serve the medical needs of enrollees
with special needs. In addition, the formulary shall
be revised periodically to assure compliance with
this requirement.
5. The contractor shall authorize the provision of a
drug not on the formulary requested by the PCP or
referral provider on behalf of the enrollee if the
approved prescriber certifies medical necessity for
the drug to the contractor for a determination.
Medically accepted indications shall be consistent
with Section 1927(k)(6) of the Social Security Act.
The contractor shall have in place a DMAHS-approved
prior approval process for authorizing the dispensing
of such drugs. In addition:
a. Any prior approval issued by the contractor
shall take into consideration prescription
refills related to the original pharmacy
service.
b. A formulary shall not be used to deny
coverage of any Medicaid covered outpatient
drug determined medically necessary through
the review and appeal process. The prior
approval process shall be used to ensure
drug coverage consistent with the policies
of the New Jersey Medicaid program.
c. Prior approval may be used for covered drug
products under the following conditions:
i. For prescribing and dispensing
medically necessary non-formulary
drugs.
ii. To limit drug coverage consistent
with the policies of the Medicaid
program.
iii. To minimize potential drug
over-utilization.
iv. To accommodate exceptions to
Medicaid drug utilization review
standards related to proper
maintenance drug therapy.
d. Except for the use of approved generic drug
substitution of brand drugs, under no
circumstances shall the contractor permit
the therapeutic substitution of a prescribed
drug without a prescriber's authorization.
IV-21
e. The contractor shall not penalize the
prescriber or enrollee, financially or
otherwise, for such requests and approvals.
f. Determinations shall be made within
twenty-four (24) hours of receipt of all
necessary information. A seventy-two
(72)-hour supply of medication shall be
permitted without prior authorization in
emergency situations or if a determination
has not been made within the required
timeframe.
g. Denials of off-formulary requests or
offering of an alternative medication shall
be provided to the prescriber and/or
enrollee in writing. All denials shall be
reported to the DMAHS quarterly.
6. The contractor shall publish and distribute hard copy
or on-line, at least annually, its current formulary
(if the contractor uses a formulary) to all
prescribing providers and pharmacists. Updates to the
formulary shall be distributed in all formats within
sixty (60) days of the changes.
7. If the formulary includes generic equivalents, the
contractor shall provide for a brand name exception
process for prescribers to use when medically
necessary.
8. The contractor shall establish and maintain a
procedure, approved by DMAHS, for internal review and
resolution of complaints, such as timely access and
coverage issues, drug utilization review, and claim
management based on standards of drug utilization
review.
C. Pharmacy Lock-In Program. The contractor may implement a
pharmacy lock-in program including policies, procedures and
criteria for establishing the need for the lock-in which must
be prior approved by DMAHS and must include the following
components to the program:
1. Enrollees shall be notified prior to the lock-in and
must be permitted to choose or change pharmacies for
good cause.
2. A seventy-two (72)-hour emergency supply of
medication at pharmacies other than the designated
lock-in pharmacy shall be permitted to assure the
provision of necessary medication required in an
interim/urgent basis when the assigned pharmacy does
not immediately have the medication.
3. Care management and education reinforcement of
appropriate medication/pharmacy use shall be
provided. A plan for an education program for
enrollees shall be developed and submitted for review
and approval.
IV-22
4. The continued need for lock-in shall be periodically
(at least every two years) evaluated by the
contractor for each enrollee in the program.
5. Prescriptions from all participating prescribers
shall be honored and may not be required to be
written by the PCP only.
6. The contractor shall fill medications prescribed by
mental health/substance abuse providers, subject to
the limitations described in Article 4.4C.
7. The contractor shall submit quarterly reports on
Pharmacy Lock-in participants. See Section A.7.17 of
the Appendices (Table 15).
D. The contractor shall develop criteria and protocols to avoid
enrollee injury due to the prescribing of drugs by more than
one provider.
4.2.5 LABORATORY SERVICES
A. Urgent/Emergent Results. The contractor shall develop policies
and procedures to require providers to notify enrollees of
laboratory and radiology results within twenty-four (24) hours
of receipt of results in urgent or emergent cases. The
contractor may allow its providers to arrange an appointment
to discuss laboratory/radiology results within 24 hours of
receipt of results when it is deemed face-to-face discussion
with the enrollee/authorized person may be necessary.
Urgent/emergency appointment standards must be followed (see
Article 5.12). Rapid strep test results must be available to
the enrollee within 24 hours of the test.
B. Routine Results. The contractor shall assure that its
providers establish a mechanism to notify enrollees of
non-urgent or non-emergent laboratory and radiology results
within ten business days of receipt of the results.
C. The contractor shall reimburse, on a fee-for service basis,
PCPs and other providers for blood drawing in the office for
lead screening.
4.2.6 EPSDT SCREENING SERVICES
A. The contractor shall comply with EPSDT program requirements
and performance standards found below.
1. The contractor shall provide EPSDT services.
2. NJ FamilyCare Plans B and C. For children eligible
solely through NJ FamilyCare Plans B and C, coverage
includes all preventive screening and diagnostic
services, medical examinations, immunizations,
dental, vision, lead screening and hearing services.
Includes only those treatment services identified
through the examination that are included under the
contractor's benefit package or specified services
through the FFS
IV-23
program. Other services identified through an EPSDT
examination that are not included in the New Jersey
Care 2000+ covered benefits package are not covered.
3. Enrollee Notification. The contractor shall provide
written notification to its enrollees under
twenty-one (21) years of age when appropriate
periodic assessments or needed services are due and
must coordinate appointments for care.
4. Missed Appointments. The contractor shall implement
policies and procedures and shall monitor its
providers to provide follow up on missed appointments
and referrals for problems identified through the
EPSDT exams. Reasonable outreach shall be documented
and must consist of: mailers, certified mail as
necessary; use of MEDM system provided by the State;
and contact with the Medicaid District Office (MDO),
DDD, or DYFS regional offices in the case of DYFS
enrollees to confirm addresses and/or to request
assistance in locating an enrollee.
5. PCP Notification. The contractor shall provide each
PCP, on a calendar quarter basis, a list of the PCP's
enrollees who have not had an encounter during the
past year and/or who have not complied with the EPSDT
periodicity and immunization schedules for children.
Primary care sites/PCPs and/or the contractor shall
be required to contact these enrollees to arrange an
appointment. Documentation of the outreach efforts
and responses is required.
6. Reporting Standards. The contractor shall submit
quarterly reports, hard copy and on diskette, of
EPSDT services. See Section A.7.16 of the Appendices
(Table 14).
B. Section 1905(r) of the Social Security Act (42 U.S.C. 1396d)
and federal regulation 42 C.F.R. 441.50 et seq. requires EPSDT
services to include:
1. EPSDT Services which include:
a. A comprehensive health and developmental
history including assessments of both
physical and mental health development and
the provision of all diagnostic and
treatment services that are medically
necessary to correct or ameliorate a
physical or mental condition identified
during a screening visit. The contractor
shall have procedures in place for referral
to the State or its agent for non-covered
mental health/substance abuse services.
b. A comprehensive unclothed physical
examination including:
- Vision and hearing screening;
IV-24
- Dental inspection; and
- Nutritional assessment.
c. Appropriate immunizations according to age,
health history and the schedule established
by the Advisory Committee on Immunization
Practices (ACIP) for pediatric vaccines (See
Section B.4.3 of the Appendices). Contractor
and its providers must adjust for periodic
changes in recommended types and schedule of
vaccines. Immunizations must be reviewed at
each screening examination as well as during
acute care visits and necessary
immunizations must be administered when not
contraindicated. Deferral of administration
of a vaccine for any reason must be
documented.
d. Appropriate laboratory tests: A recommended
sequence of screening laboratory
examinations must be provided by the
contractor. The following list of screening
tests is not all inclusive:
- Hemoglobin/hematocrit/EP
- Urinalysis
- Tuberculin test - intradermal,
administered annually and when
medically indicated
- Lead screening using blood lead level
determinations must be done for every
Medicaid-eligible and NJ FamilyCare
child:
- between nine (9) months and
eighteen (18) months,
preferably at twelve (12)
months of age
- at 18-26 months, preferably at
twenty-four (24) months of age
- test any child between
twenty-seven (27) to
seventy-two (72) months of age
not previously tested
- Additional laboratory tests may be
appropriate and medically indicated
(e.g., for ova and parasites) and shall
be obtained as necessary.
e. Health education/anticipatory guidance.
f. Referral for further diagnosis and treatment
or follow-up of all abnormalities which are
treatable/correctable or require maintenance
therapy uncovered or suspected (referral may
be to the provider conducting the screening
examination, or to another provider, as
appropriate.)
g. EPSDT screening services shall reflect the
age of the child and be provided
periodically according to the following
schedule:
IV-25
- Neonatal exam
- Under six (6) weeks
- Two (2) months
- Four (4) months
- Six (6) months
- Nine (9) months
- Twelve (12) months
- Fifteen (15) months
- Eighteen (18) months
- Twenty-four (24) months
- Annually through age twenty (20)
2. Vision Services. At a minimum, include diagnosis and
treatment for defects in vision, including
eyeglasses. Vision screening in an infant means, at a
minimum, eye examination and observation of responses
to visual stimuli. In an older child, screening for
distant visual acuity and ocular alignment shall be
done for each child beginning at age three.
3. Dental Services. Dental services may not be limited
to emergency services. Dental screening in this
context means, at a minimum, observation of tooth
eruption, occlusion pattern, presence of caries, or
oral infection. A referral to a dentist at or after
one year of age is recommended. A referral to a
dentist is mandatory at three years of age and
annually thereafter through age twenty (20) years.
4. Hearing Services. At a minimum, include diagnosis and
treatment for defects in hearing, including hearing
aids. For infants identified as at risk for hearing
loss through the New Jersey Newborn Hearing Screening
Program, hearing screening should be conducted prior
to three months of age using professionally
recognized audiological assessment techniques. For
all other children, hearing screening means, at a
minimum, observation of an infant's response to
auditory stimuli and audiogram for a child three (3)
years of age and older. Speech and hearing assessment
shall be a part of each preventive visit for an older
child.
5. Mental Health/Substance Abuse. Include a mental
health/substance abuse assessment documenting
pertinent findings. When there is an indication of
possible MH/SA issues, a mental health/substance
abuse screening tool(s) found in Section B.4.9 of the
Appendices or a DHS - approved equivalent shall be
used to evaluate the enrollee.
6. Such other necessary health care, diagnostic
services, treatment, and other measures to correct or
ameliorate defects, and physical and mental/substance
abuse illnesses and conditions discovered by the
screening services.
IV-26
7. Lead Screening. The contractor shall provide a
screening program for the presence of lead toxicity
in children which shall consist of two components:
verbal risk assessment and blood lead testing.
a. Verbal Risk Assessment - The provider shall
perform a verbal risk assessment for lead
toxicity at every periodic visit between the
ages of six (6) and seventy-two (72) months
as indicated on the schedule. The verbal
risk assessment includes, at a minimum, the
following types of questions:
i. Does your child live in or
regularly visit a house built
before 1960? Does the house have
chipping or peeling paint?
ii. Was your child's day care
center/preschool/babysitter's home
built before 1960? Does the house
have chipping or peeling paint?
iii. Does your child live in or
regularly visit a house built
before 1960 with recent, ongoing,
or planned renovation or
remodeling?
iv. Have any of your children or their
playmates had lead poisoning?
v. Does your child frequently come in
contact with an adult who works
with lead? Examples include
construction, welding, pottery, or
other trades practiced in your
community.
vi. Do you give your child home or folk
remedies that may contain lead?
Generally, a child's level of risk for
exposure to lead depends upon the answers to
the above questions. If the answer to all
questions are negative, a child is
considered at low risk for high doses of
lead exposure. If the answers to any
question is affirmative or "I don't know," a
child is considered at high risk for high
doses of lead exposure. Regardless of risk,
each child must be tested between nine (9)
months and eighteen (18) months, preferably
at twelve (12) months of age, at 18-26
months, preferably at two (2) years, and any
child between twenty-seven (27) and
seventy-two (72) months of age not
previously tested. A child's risk category
can change with each administration of the
verbal risk assessment.
IV-27
b. Blood Lead Testing - All screening must be
done through a blood lead level
determination. The contractor must implement
a screening program to identify and treat
high-risk children for leadexposure and
toxicity. The screening program shall
include blood level screening, diagnostic
evaluation and treatment with follow-up care
of children whose blood lead levels are
elevated. The EP test is no longer
acceptable as a screening test for lead
poisoning; however, it is still valid as a
screening test for iron deficiency anemia.
Screening blood lead testing may be
performed by either a capillary sample
(fingerstick) or a venous sample. However,
all elevated blood levels (equal to or
greater than ten (10) micrograms per one (1)
deciliter) obtained through a capillary
sample must be confirmed by a venous sample.
The blood lead test must be performed by a
New Jersey Department of Health and Senior
Services licensed laboratory. The frequency
with which the blood test is to be
administered depends upon the results of the
verbal risk assessment. For children
determined to be at low risk for high doses
of lead exposure, a screening blood lead
test must be performed once between the ages
of nine (9) and eighteen (18) months,
preferably at twelve (12) months, once
between 18-26 months, preferably at
twenty-four (24) months, and for any child
between twenty-seven (27) and seventy-two
(72) months not previously tested. For
children determined to be at high risk for
high doses of lead exposure, a screening
blood test must be performed at the time a
child is determined to be a high risk
beginning at six months of age if there is
pertinent information or evidence that the
child may be at risk at younger ages than
stated in 4.2.6B.1.d.
i. If the initial blood lead test
results are less than ten (10)
micrograms per deciliter, a verbal
risk assessment is required at
every subsequent periodic visit
through seventytwo (72) months of
age, with mandatory blood lead
testing performed according to the
schedule in 4.2.6B.7.
ii. If the child is found to have a
blood lead level equal to or
greater than ten (10) micrograms
per deciliter, providers should use
their professional judgment, in
accordance with the CDC guidelines
regarding patient management and
treatment, as well as follow-up
blood test.
iii. If a child between the ages of
twenty-four (24) months and
seventy-two (72) months has not
received a screening blood lead
test, the child must receive the
blood lead test immediately,
regardless of whether the child is
determined
IV-28
to be a low or high risk according
to the answers to the above-listed
questions.
iv. When a child is found to have a
blood lead level equal to or
greater than twenty (20) ug/dl, the
contractor shall ensure its PCPs
cooperate with the local health
department in whose jurisdiction
the child resides to facilitate the
environmental investigation to
determine and remediate the source
of lead. This cooperation shall
include sharing of information
regarding the child's care,
including the scheduling and
results of follow-up blood lead
tests.
v. When laboratory results are
received, the contractor shall
require PCPs to report to the
contractor all children with blood
lead levels > than = to 10 ug/dl.
Conversely, when a provider other
than the PCP has reported the lead
screening test to the contractor,
the contractor shall ensure that
this information is transmitted to
the PCP.
c. On a semi-annual basis, the contractor shall
outreach, via letters and informational
materials to parents/custodial caregivers of
all children enrolled in the contractor's
plan who have not been screened, educating
them as to the need for a lead screen and
informing them how to obtain lead screening
and transportation to the screening
location.
i. The contractor shall provide to
DMAHS, 45 days after the end of
each semi-annual reporting period,
documentation of all lead outreach
activities including the
distribution of the letters and
informational materials indicated
above.
ii. The contractor shall implement a
corrective action plan, which
describes the interventions to be
taken to outreach
parents/caregivers who do not
respond to the letters and outreach
indicated above. Corrective actions
may include interventions such as
telephone follow-up, home visits,
or other actions proposed by the
contractor and incorporated in the
corrective action plan for review
and approval by DMAHS.
d. On an annual basis, the contractor shall
send letters to PCPs who have lead screening
rates of less than 80% for two consecutive
six-month periods, educating them on the
need and their responsibility to provide
lead screening services.
IV-29
i. The contractor shall provide to
DMAHS documentation as to the
efforts made to educate providers
with low screening rates.
ii. The contractor shall implement
corrective action plans that
describe interventions to be taken
to identify and correct
deficiencies and impediments to the
screening and how the effectiveness
of its interventions will be
measured.
e. On a quarterly basis, the contractor shall
submit to DMAHS a report of all
lead-burdened children who are receiving
treatment and case management services.
f. Lead Case Management Program. The contractor
shall establish a Lead Case Management
Program (LCMP) and have written policies and
procedures for the enrollment of children
with blood lead levels > than = to 10 ug/dl
and members of the same household who are
between six months and six years of age,
into the contractor's LCMP.
i. Lead Case Management shall consist
of, at a minimum:
1) Follow-up of a child in need
of lead screening, or who has
been identified with an
elevated blood lead level >
than = to 10 ug/dl. At
minimum, follow-up shall
include:
A) For a child with an
elevated blood lead
level > than = to 10
ug/dl, the Plan's LCM
shall ascertain if the
blood lead level has
been confirmed by a
venous blood
determination. In the
absence of confirmatory
test results, the LCM
will arrange for a
test.
B) For a child with a
confirmed blood
(venous) lead level of
> than = to 10 ug/dl,
the contractor's LCM
shall notify and
provide to the local
health department the
child's name, primary
health care provider's
name, the confirmed
blood lead level, and
any other pertinent
information.
2) Education of the family
about all aspects of lead
hazard and toxicity.
Materials shall explain the
sources of lead exposure,
the consequences of elevated
blood levels, preventive
measures,
IV-30
including housekeeping,
hygiene, and appropriate
nutrition. The reasons why
it is necessary to follow a
prescribed medical regimen
shall also be explained.
3) Communication among all
interested parties.
4) Development of a written
case management plan with
the PCP and the child's
family and other interested
parties. The case management
plan shall be reviewed and
updated on an ongoing basis.
5) Coordination of the various
aspects of the affected
child's care, e.g., WIC,
support groups, and
community resources, and
6) Aggressively pursuing
non-compliance with follow-
up tests and appointments,
and document these
activities in the LCMP.
ii. Active case management may be
discontinued if one of the
following criteria has been met:
1) The child has two confirmed
blood lead levels < 10 ug/dl
drawn at least three months
apart and all other children
under the age of six years
living in the household who
have been tested and their
blood levels are < 10 ug/dl,
and the sources of lead have
been identified and reduced,
or
2) The family has been
permanently relocated to a
lead-safe house, or
3) The parent/guardian has
given a written refusal of
service, or
4) The LCM is unable to locate
the child after a minimum of
three documented attempts,
using the assistance of
County Board of Social
Services, and the LHD. The
child's PCP will be notified
in writing.
IV-31
4.2.7 IMMUNIZATIONS
A. General. The contractor shall ensure that its providers
furnish immunizations to its enrollees in accordance with the
most current recommendations for vaccines and periodicity
schedule of the Advisory Committee on Immunization Practices
(ACIP) (See Section B.4.3 of the Appendices) and any
subsequent revision to the schedule as formally recommended by
the ACIP, whether or not included as a contract amendment. To
the extent possible, the State will provide copies of updated
schedules and vaccine recommendations.
B. New Vaccines. New vaccines and/or new scheduling or method of
administration shall be provided as recommended by the ACIP.
The contractor shall monitor periodic recommendations and
disseminate updated instruction to its providers and assure
appropriate payment adjustment to its providers.
C. The contractor shall build in provisions for appropriate
reimbursement for catch-up immunizations its providers shall
provide for those pediatric enrollees who have missed
age-appropriate vaccines.
D. Vaccines for Children Program
1. Contractor's providers must enroll with the
Department of Health and Senior Services' Vaccines
for Children (VFC) Program and use the free vaccine
for its enrollees if the vaccine is covered by VFC.
(See Section B.4.4 of the Appendices for list of
vaccines to be covered by the NJ DHSS VFC program.)
The contractor shall not receive from DHS any
reimbursement for the cost of VFC-covered vaccines.
2. For non-VFC vaccines the contractor shall reimburse
its providers for the cost of both administration and
the vaccines.
E. To the extent possible, and as permitted by New Jersey
statutes and regulations, the contractor and its network
providers shall participate in the Statewide immunization
registry database, when it becomes fully operational.
F. The contractor shall provide immunizations recommended by
local health departments based on local epidemiological
conditions.
4.2.8 CLINICAL TRIALS
A. The contractor shall permit participation in an approved
clinical trial to a qualified enrollee (as defined in 4.2.8B),
and the contractor:
1. May not deny the enrollee participation in the
clinical trial referred to in 4.2.8B.2.
IV-32
2. Subject to 4.2.8C, may not deny (or limit or impose
additional conditions on) the coverage of routine
patient costs for items and services furnished in
connection with participation in the trial.
3. May not discriminate against the enrollee on the
basis of the enrollee's participation in such trial.
B. Qualified Enrollee Defined. For purposes of this Article, the
term "qualified enrollee" means an enrollee under the
contractor's coverage who meets the following conditions:
1. The enrollee has a life-threatening or serious
illness for which no standard treatment is effective;
2. The enrollee is eligible to participate in an
approved clinical trial with respect to treatment of
such illness;
3. The enrollee and the referring physician conclude
that the enrollee's participation in such trial would
be appropriate; and
4. The enrollee's participation in the trial offers
potential for significant clinical benefit for the
enrollee.
C. Payment. The contractor shall provide for payment for medical
problems/complications and for routine patient costs described
in Article 4.2.8A2 but is not required to pay for costs of
items and services that are reasonably expected to be paid for
by the sponsors of an approved clinical trial.
D. Approved Clinical Trial. For purposes of this Article, the
term "approved clinical trial" means a clinical research study
or clinical investigation that meets the following
requirements:
1. The trial is approved and funded by one or more of
the following:
a. The National Institutes of Health
b. A cooperative group or center of the
National Institutes of Health
c. The Department of Veterans Affairs
d. The Department of Defense
e. The Food and Drug Administration, in the
form of an investigational new drug (IND)
exemption
2. The facility and personnel providing the treatment
are capable of doing so by virtue of their experience
or training.
3. There is no alternative noninvestigational therapy
that is clearly superior.
IV-33
4. The available clinical or preclinical data provide a
reasonable expectation that the protocol treatment
will be at least as effective as the
noninvestigational alternative.
E. Coverage of Investigational Treatment. The contractor should
make a determination for coverage/denial of experimental
treatment for a terminal condition based on the following:
1. The treating physician refers the case to a
contractor internal review group not associated with
the case or referral center.
2. If the internal review group denies the referral, a
second, ad hoc group with two or more experts in the
field and not involved with the case must review the
case.
F. Experimental treatments for rare disorders shall not be
automatically excluded from coverage but decisions regarding
their medical necessity should be considered by a medical
review board established by the contractor. Routine costs
associated with investigational procedures that are part of an
approved research trial are considered medically appropriate.
Under no circumstances shall the contractor implement a
medical necessity standard that arbitrarily limits coverage on
the basis of the illness or condition itself.
4.2.9 HEALTH PROMOTION AND EDUCATION PROGRAMS
The contractor shall identify relevant community issues (such as TB
outbreaks, violence) and health education needs of its enrollees, and
implement plans that are culturally appropriate to meet those needs,
issues relevant to each of the target population groups of enrollees
served, as defined in Article 5.2, and the promotion of health. The
contractor shall use community-based needs assessments and other
relevant information available from State and local governmental
agencies and community groups. Health promotion activities shall be
made available in formats and presented in ways that meet the needs of
all enrollee groups including elderly enrollees and enrollees with
special needs, including enrollees with cognitive impairments. The
contractor shall comply with all applicable State and federal statutes
and regulations on health wellness programs. The contractor shall
submit a written description of all planned health education activities
and targeted implementation dates for DMAHS' approval, prior to
implementation, including culturally and linguistically appropriate
materials and materials developed to accommodate each of the enrolled
target population groups. Thereafter, the plan shall be reviewed,
revised, and pre-approved by the Department annually.
Health promotion topics shall include, but are not limited to, the
following:
A. General health education classes
IV-34
B. Smoking cessation programs, with targeted outreach for
adolescents and pregnant women
C. Childbirth education classes
D. Nutrition counseling, with targeted outreach for pregnant
women, elderly enrollees, and enrollees with special needs
E. Signs and symptoms of common diseases and complications
F. Early intervention and risk reduction strategies to avoid
complications of disability and chronic illness
G. Prevention and treatment of alcohol and substance abuse
H. Coping with losses resulting from disability or aging
I. Self care training, including self-examination
J. Need for clear understanding of how to take over-the-counter
and prescribed medications and the importance of coordinating
all such medications
K. Understanding the difference between emergent, urgent and
routine health conditions
4.3 COORDINATION WITH ESSENTIAL COMMUNITY PROVIDERS
4.3.1 GENERAL
The contractor shall identify and establish working relationships for
coordinating care and services with external organizations that
interact with its enrollees, including State agencies, schools, social
service organizations, consumer organizations, and civic/community
groups, such as an Hispanic coalition.
4.3.2 HEAD START PROGRAMS
A. The contractor shall demonstrate to DMAHS that it has
established working relationships with Head Start programs
(See Section B.4.5 of the Appendices for a list of Head Start
Programs). Such relationships will include an exchange of
information on the following:
1. Policies and procedures for referrals for routine,
urgent and emergent care.
2. Policies and procedures for scheduling appointments
for routine and urgent care.
IV-35
3. Policies and procedures for the exchange of
information of Head Start participants who are
contractor enrollees.
4. Policies and procedures for follow-up and assuring
the provision of health care services.
5. Policies and procedures for appealing denials of
service and/or reductions in the level of service.
6. Policies and procedures for Head Start staff in
supporting enforcement of contractor's health care
delivery system policies and procedures for accessing
all health care needs.
7. Policies and procedures addressing the need through
prior authorization to utilize the contractor's
established provider network and what will be done
for out-of-network referrals in cases where the
contractor does not have an appropriate participating
provider in accordance with Article 4.8.7.
8. Policies and procedures for providing comprehensive
medical examinations in accordance with EPSDT
standards and addressing the need for an examination
based on a Head Start referral if the enrollee has
had an age-appropriate EPSDT examination (for
infants) or an EPSDT examination (for children two
(2) to five (5) years old) within six (6) months of
the referral date.
9. Policies and Procedures for Head Start's role in
prevention activities or programs developed by the
contractor.
B. The contractor shall evaluate referred Head Start patients to
determine the need for treatment/therapies for problems
identified by staff of those programs. The contractor/PCP
shall be responsible for providing treatment and follow-up
information for medically necessary care.
C. The contractor shall review referrals and provide appointments
in accordance with Article 5.12. Denials of service requests
or reduction in level of service, only after an evaluation is
completed, shall be in writing, following the requirements in
Article 4.6.4.
4.3.3 SCHOOL-BASED YOUTH SERVICES PROGRAMS
A. The contractor shall demonstrate to DMAHS that it has
established a working linkage with school based youth services
programs (SBYSP) that meet credentialing and scope of service
requirements for services offered by these programs which are
covered MCE services. (See Section B.4.6 of the Appendices for
a list of SBYSPs).
IV-36
1. SBYSP service provision must meet MCE contract
requirements, e.g., twenty-four (24)-hour coverage.
2. SBYSP employees must meet credentialing requirements.
B. Such working linkages shall include, at minimum, an exchange
of information on the following:
1. Policies and procedures for referrals for routine,
urgent and emergent care, and standing referrals.
2. Policies and procedures for scheduling appointments
for routine and urgent care.
3. Policies and procedures for the exchange of
information of SBYSP participants who are contractor
enrollees.
4. Policies and procedures for follow-up and assuring
the provision of health care services.
5. Policies and procedures for appealing denials of
service and/or reductions in the level of service.
6. Policies and procedures for SBYSP staff in supporting
enforcement of contractor's health care delivery
system policies and procedures for accessing all
health care needs.
7. Policies and procedures addressing the need through
prior authorization to utilize the contractor's
established provider network and what will be done
for out-of-network referrals in cases where the
contractor does not have an appropriate participating
provider in accordance with Article 4.8.7.
8. Policies and procedures for providing comprehensive
medical examinations in accordance with EPSDT
standards and addressing the need for an examination
based on a SBYSP if the enrollee has had an
age-appropriate EPSDT examination (for infants) or an
EPSDT examination (for children two (2) to five (5)
years) within six (6) months of the referral date.
9. Policies and Procedures for the SBYSP's role in
prevention activities or programs developed by the
contractor.
C. The contractor shall evaluate referred SBYSP patients to
determine the need for treatment/therapies for problems
identified by staff of those programs. The contractor/PCP
shall be responsible for providing treatment and follow-up
IV-37
information for medically necessary care for SBYSPs
participants where there is no formal
contractual/reimbursement relationship.
D. The contractor shall review referrals and provide appointments
in accordance with Article 5.12. Denials of service requests
or reduction in level of service, only after an evaluation is
completed, shall be in writing, following the requirements in
Article 4.6.4.
E. The contractor shall provide the DMAHS with a description of
its plans to meet the requirements of this contract provision
in establishing a working linkage with SBYSPs.
4.3.4 LOCAL HEALTH DEPARTMENTS
The contractor shall demonstrate to DMAHS that it has established a
working linkage with local health departments (LHDs) that meet
credentialing and scope of service requirements.
The contractor should include linkages with LHDs especially for meeting
the lead screening and toxicity treatment compliance standards required
in this contract. The contractor shall refer lead-burdened children to
LHDs for environmental investigation to determine and remediate the
source of lead.
4.3.5 WIC PROGRAM REQUIREMENTS/ISSUES
The contractor shall require its providers to refer potentially
eligible women (pregnant, breast-feeding and postpartum), infants, and
children up to age five, to established community Women, Infants and
Children (WIC) programs. The referral shall include the information
needed by WIC programs in order to provide appropriate services. The
required information to be included with the referral is found on the
sample forms in Section B.4.8 of the Appendices, the New Jersey WIC
program medical referral form, and must be completed with the current
(within sixty (60) days) height, weight, hemoglobin, or hematocrit, and
any identified medical/nutritional problems for the initial WIC
referral and for all subsequent certifications. The contractor shall
submit a quarterly WIC referral report. (See Section A.7.14 of the
Appendices (Table 12).)
4.3.6 COMMUNITY LINKAGES
The contractor shall describe any relationships being explored,
planned, and/or existing between the contractor and provider entities
including for example:
A. Public health clinics or agencies
B. DYFS contracted Child Abuse Regional Diagnostic Centers
C. Environmental health clinics
IV-38
D. Women's health clinics
E. Family Planning/Reproductive health clinics
F. Developmental disabilities clinics
4.4 COORDINATION WITH MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
The State shall retain a separate Mental Health/Substance Abuse system
for the coordination and monitoring of most mental health/substance
abuse conditions. The contractor shall xxxxxxx XX/SA services to
clients of DDD. However, as described below, the contractor shall
retain responsibility for MH/SA screening, referrals, prescription
drugs, higher-mode transportation, and for treatment of the conditions
identified in Article 4.1.2B.
A. Screening Procedures. Mental health and substance abuse
problems shall be systematically identified and addressed by
the enrollee's PCP at the earliest possible time following
initial participation of the enrollee in the contractor or
after the onset of a condition requiring mental health and/or
substance abuse treatment. PCPs and other providers shall
utilize mental health/substance abuse screening tools as set
forth in Section B.4.9 of the Appendices as well as other
mechanisms to facilitate early identification of mental health
and substance abuse needs for treatment. The contractor may
request permission to use alternative screening tools. The use
of alternative screening tools shall be pre-approved by DMAHS.
The lack of motivation of an enrollee to participate in
treatment shall not be considered a factor in determining
medical necessity and shall not be used as a rationale for
withholding or limiting treatment of an enrollee.
The contractor shall present its policies and procedures
regarding how its providers will identify enrollees with MH/SA
service needs, how they will encourage these enrollees to
begin treatment, and the screening tools to be used to
identify enrollees requiring MH/SA services. The contractor
should refer to the DSM-IV Primary Care Version in development
of its procedures.
B. Referrals. The contractor shall be responsible for referring
or coordinating referrals of enrollees as indicated to Mental
Health/Substance Abuse providers. In order to facilitate this,
the contractor may contact DMHS or its agent (e.g., if the
State contracts with a third party administrator (TPA) for a
list of MH/SA providers. Enrollees may be referred to a MH/SA
provider by the PCP, family members, other providers, State
agencies, the contractor's staff, or may self-refer.
1. The contractor shall be responsible for referrals
from MH/SA providers for medical diagnostic work-up
to formulate a diagnosis or to effect the treatment
of a MH/SA disorder and ongoing medical care for any
enrollee
IV-39
with a MH/SA diagnosis and shall coordinate the care
with the MH/SA provider. This includes the
responsibility for physical examinations (with the
exception of physical examinations performed in
direct connection with the administration of
Methadone, which will remain FFS), neurological
evaluations, laboratory testing and radiologic
examinations, and any other diagnostic procedures
that are necessary to make the diagnostic
determination between a primary MH/SA disorder and an
underlying physical disorder, as well as for medical
work-ups required for medical clearances prior to the
provision of psychiatric medication or
electroconvulsive therapy (ECT), or for transfer to a
psychiatric/SA facility. Routine laboratory
procedures ordered by treating MH/SA providers in
conjunction with MH/SA treatment, for routine blood
testing performed in conjunction with the
administration of Clozapine and the other drugs
listed in Article 4.1.4B for non-DDD enrollees, are
not the responsibility of the contractor.
2. The contractor shall develop a referral process to be
used by its providers which shall include providing a
copy of the medical consultation and diagnostic
results to the MH/SA provider. The contractor shall
develop procedures to allow for notification of an
enrollee's MH/SA provider of the findings of his/her
physical examination and laboratory/radiological
tests within twenty-four (24) hours of receipt for
urgent cases and within five business days in
non-urgent cases. This notification shall be made by
phone with follow-up in writing when feasible.
C. Pharmacy Services. Except for the drugs specified in Article
4.1.4 (Clozapine, Risperidone, Olanzapine, etc.), all pharmacy
services are covered by the contractor. This includes drugs
prescribed by the contractor or MH/SA providers. The
contractor shall only restrict or require a prior
authorization for prescriptions or pharmacy services
prescribed by MH/SA providers if one of the following
exceptions is demonstrated:
1. The drug prescribed is not related to the treatment
of substance abuse/dependency/addiction or mental
illness or to any side effects of the
psychopharmacological agents. These drugs are to be
prescribed by the contractor's PCP or specialists in
the contractor's network.
2. The prescribed drug does not conform to standard
rules of the contractor's pharmacy plan.
3. The contractor, at its option, may require a prior
authorization (PA) process if the number of
prescriptions written by the MH/SA provider for
MH/SA-related conditions exceed four (4) per month
per enrollee. For drugs that require weekly
prescriptions, these prescriptions shall be counted
as one per month and not as four separate
prescriptions. The
IV-40
contractor's PA process for the purposes of this
section shall require review and prior approval by
DMAHS.
D. Prescription Abuse. If the contractor suspects prescription
abuse by a MH/SA provider, the contractor shall contact DMAHS
for investigation and decision of potentially excluding the
provider from the NJ Medicaid program. The contractor shall
provide the Department with any and all documentation.
E. Inpatient Hospital Services for Enrollees who are not clients
of DDD with both a Physical Health as well as a Mental
Health/Substance Abuse Diagnosis. The contractor's financial
and medical management responsibilities are as follows:
1. If the inpatient hospital admission of an enrollee
who is not a client of DDD is for a physical health
primary diagnosis, the contractor shall be
responsible for inpatient hospital costs and medical
management. Where psychiatric consultation is
required to assist the contractor with mental
health/substance abuse management, the State or its
agent (e.g., a TPA) shall be responsible for
authorizing the psychiatric consult/services provided
during the inpatient stay. The State shall not
require service authorization for at least one
psychiatric consultation per inpatient admission.
When a substance abuse disorder is known to be the
primary diagnosis of an enrollee and a co-occurring
psychiatric disorder is not a management concern,
then the State or its agent may authorize that the
consult/services be by an ASAM certified physician.
The contractor shall coordinate inpatient MH/SA
consultations and services with the enrollee's MH/SA
provider as well as discharge planning and follow-up.
2. If the inpatient hospital admission of an enrollee
who is not a client of DDD is for a mental
health/substance abuse primary diagnosis, the
inpatient stay will be paid by the State through the
FFS program. The contractor shall provide and pay for
participating providers who may be called in as
consultants to manage any physical problems.
F. Transportation. The contractor shall be responsible for all
transportation through ambulance, Mobile Intensive Care Units
(MICUs), and invalid coach modalities, even if the enrollee is
being transported to a Medicaid or NJ FamilyCare service that
is not included in the contractor's benefit package including
to MH/SA services.
4.5 ENROLLEES WITH SPECIAL NEEDS
4.5.1 INTRODUCTION
For purposes of this contract, adults with special needs includes
complex/chronic medical conditions requiring specialized health care
services, including persons with physical, mental, substance abuse,
and/or developmental disabilities, including such
IV-41
persons who are homeless. Children with special health care needs are
those who have or are at increased risk for a chronic physical,
developmental, behavioral, or emotional condition and who also require
health and related services of a type or amount beyond that required by
children generally.
In addition to the standards set forth in this Article, contractor
shall make all reasonable efforts and accommodations to ensure that
services provided to enrollees with special needs are equal in quality
and accessibility to those provided to all other enrollees.
4.5.2 GENERAL REQUIREMENTS
A. Identification and Service Delivery. The contractor shall have
in place all of the following to identify and serve enrollees
with special needs:
1. Methods for identifying persons at risk of, or having
special needs who should be referred for a
comprehensive needs assessment. (See Articles 4.5.4B
and 4.6.5D for information on Complex Needs
Assessments). Such methods should include the
application of screening procedures/instruments for
new enrollees as well as the conditions and
indicators listed in Article 4.6.5D.1 and 2. These
include review of hospital and pharmacy utilization
and policies and procedures for providers or, where
applicable, authorized persons, to make referrals of
assessment candidates and for enrollees to self-refer
for a Complex Needs Assessment.
2. Methods and guidelines for determining the specific
needs of referred individuals who have been
identified through a Complex Needs Assessment as
having complex needs and developing care plans that
address their service requirements with respect to
specialist physician care, durable medical equipment,
medical supplies, home health services, social
services, transportation, etc. Article 4.5.4D
contains additional information on Individual Health
Care Plans.
3. Care management systems to ensure all required
services, as identified through a Complex Needs
Assessment, are furnished on a timely basis, and that
communication occurs between participating and
nonparticipating providers (to the extent the latter
are used). Articles 4.5.4 and 4.6.5 contain
additional information on care management.
4. Policies and procedures to allow for the continuation
of existing relationships with non-participating
providers, when appropriate providers are not
available within network or it is otherwise
considered by the contractor to be in the best
medical interest of the enrollee with special needs.
Articles 4.5.2D and 4.8.7G contain more specific
standards for use of non-participating providers.
IV-42
5. Methods to assure that access to all
contractor-covered services, including
transportation, is available for enrollees with
special needs whose disabilities substantially impede
activities of daily living. The contractor shall
reasonably accommodate enrollees with disabilities
and shall ensure that physical and communication
barriers do not prohibit enrollees with disabilities
from obtaining services from the contractor.
6. Services for enrollees with special needs must be
provided in a manner responsive to the nature of a
person's disability/specific health care need and
include adequate time for the provision of the
service.
B. The contractor shall ensure that any new enrollee identified
(either by the information on the Plan Selection form at the
time of enrollment or by contractor providers after
enrollment) as having complex/chronic conditions receives
immediate transition planning. The planning shall be completed
within a timeframe appropriate to the enrollee's condition,
but in no case later than ten (10) business days from the
effective date of enrollment when the Plan Selection form has
an indication of special health care needs or within thirty
(30) days after special conditions are identified by a
provider. This transition planning shall not constitute the
IHCP described in Sections 4.5.4 and 4.6.5. Transition
planning shall provide for a brief, interim plan to ensure
uninterrupted services until a more detailed plan of care is
developed. The transition planning process includes, but is
not limited to:
1. Review of existing care plans.
2. Preparation of a transition plan that ensures
continuous care during the transfer into the
contractor's network.
3. If durable medical equipment had been ordered prior
to enrollment but not received by the time of
enrollment, the contractor must coordinate and
follow-through to ensure that the enrollee receives
necessary equipment.
C. Outreach and Enrollment Staff. The contractor shall have
outreach and enrollment staff who are trained to work with
enrollees with special needs, are knowledgeable about their
care needs and concerns, and are able to converse in the
different languages common among the enrolled population,
including TDD/TT and American Sign Language if necessary.
D. Specialty Care. The contractor shall have a procedure by which
a new enrollee upon enrollment, or an enrollee upon diagnosis,
who requires very complex, highly specialized health care
services over a prolonged period of time, or with (i) a
life-threatening condition or disease or (ii) a degenerative
and/or disabling condition or disease, either of which
requires specialized medical care over a prolonged period of
time, may receive a referral to a specialist or a specialty
care center with expertise in treating the life-threatening
disease or specialized
IV-43
condition, who shall be responsible for and capable of
providing and coordinating the enrollee's primary and
specialty care.
If the contractor or primary care provider in consultation
with the contractor's medical director and a specialist, if
any, determines that the enrollee's care would most
appropriately be coordinated by such specialist/specialty care
center, the contractor shall refer the enrollee. Such referral
shall be pursuant to a care plan approved by the contractor,
in consultation with the primary care provider if appropriate,
the specialist, care manager, and the enrollee (or, where
applicable, authorized person). The contractor-participating
specialist/specialty care center acting as both primary and
specialty care provider shall be permitted to treat the
enrollee without a referral from the enrollee's primary care
provider and may authorize such referrals, procedures, tests
and other medical services as the enrollee's primary care
provider would otherwise be permitted to provide or authorize,
subject to the terms of the care plan. If the
specialist/specialty care center will not be providing primary
care, then the contractor's rules for referrals apply.
Consideration for policies and procedures should be given for
a standing referral when on-going, long-term specialty care is
required.
If the contractor refers an enrollee to a non contractor-
participating provider, services provided pursuant to the
approved care plan shall be provided at no additional cost to
the enrollee. In no event shall the contractor be required to
permit an enrollee to elect to have a non contractor-
participating specialist/specialty care center.
For purposes of this Article a specialty care center shall
mean the Centers of Excellence identified in Section B.4.10 of
the Appendices. These centers have special expertise in
treating life-threatening diseases/conditions and degenerative
/disabling diseases/conditions.
E. Dental. While the contractor must assure that enrollees with
special needs have access to all medically necessary care, the
State considers dental services to be an area meriting
particular attention. The contractor, therefore, shall accept
for network participation dental providers with expertise in
the dental management of enrollees with developmental
disabilities. All current providers of dental services to
enrollees with developmental disabilities shall be considered
for participation in the contractor's dental provider network.
Credentialing and recredentialing standards must be
maintained. The contractor shall make provisions for providers
of dental services to enrollees with developmental
disabilities to allow for limiting their dental practices at
their choice to only those patients with developmental
disabilities.
The contractor shall develop specific policies and procedures
for the provision of dental services to enrollees with
developmental disabilities. At a minimum, the policies and
procedures shall address:
IV-44
1. Special needs/issues of enrollees with developmental
disabilities, including the importance of providing
consultations and assistance to patient caregivers.
2. Provisions in the contractor's dental reimbursement
system for initial and follow-up dental visits which
may require up to 60 minutes on average to allow for
a comprehensive dental examination and other services
to include, but not limited to: a visual examination
of the enrollee; appropriate radiographs; dental
prophylaxis, including extra scaling and topical
applications, such as fluoride treatments;
non-surgical periodontal treatment, including root
planing and scaling; the application of dental
sealants on molars and premolars; thorough inquiries
regarding patient medical histories; and most
importantly, consultations with patient caregivers to
establish a thorough understanding of proper dental
management during visits.
3. Standards for dental visits that recognize the
additional time that may be required in treatment of
patients with developmental disabilities. Standards
should allow for up to four (4) visits annually
without prior authorization.
4. Provisions for home visits when medically necessary
and where available.
5. Policies and procedures to ensure that providers
specializing in the treatment of enrollees with
developmental disabilities have adequate support
staff to meet the needs of such patients.
6. Provisions for use and replacement of fixed as well
as removable prosthetic devices as medically
necessary and appropriate.
7. Provisions in the contractor's dental reimbursement
system to reimburse dentists for the costs of
preoperative and postoperative evaluations associated
with dental surgery performed on patients with
developmental disabilities. Preauthorization shall
not be required for dental procedures performed
during surgery on these patients for dentally
appropriate restorative care provided under general
anesthesia. Informed consent, signed by the enrollee
or authorized person, must be obtained prior to the
surgical procedure. Provisions should be made to
evaluate such procedures as part of a post payment
review process.
8. Provisions in the contractor's dental reimbursement
system for dentists to receive reimbursement for the
cost of providing oral hygiene instructions to
caregivers to maintain a patient's overall oral
health between dental visits. Such provisions shall
include designing and implementing a "dental
management" plan, coordinated by the care manager,
for overseeing a patient's oral health.
IV-45
9. The care manager of an enrollee with a developmental
disability shall coordinate authorizations for
dentally required hospitalizations by consulting with
the plan's dental and medical consultants in an
efficient and time-sensitive manner.
F. After Hours. The contractor shall have policies and procedures
to respond to crisis situations after hours for enrollees with
special needs. Training sessions/materials and triage
protocols for all staff/providers who respond to after-hours
calls shall address enrollees with special needs. For example,
protocols should recognize that a non-urgent condition for an
otherwise healthy individual, such as a moderately elevated
temperature, may indicate an urgent care need in the case of a
child with a congenital heart anomaly.
G. Behavior Problems. The contractor shall take appropriate steps
to ensure that its care managers, network providers and Member
Services staff are able to serve persons with behavior
problems associated with developmental disabilities, including
to the extent these problems affect their level of compliance.
The contractor shall educate providers and staff about the
nature of such problems and how to address them. The
contractor shall identify providers who have expertise in
serving persons with behavior problems.
H. ADA Compliance. The contractor shall have written policies and
procedures that ensure compliance with requirements of the
Americans with Disabilities Act of 1990, and a written plan to
monitor compliance to determine the ADA requirements are being
met. The plan shall be sufficient to determine the specific
actions that will be taken to remove existing barriers and/or
to accommodate the needs of enrollees who are qualified
individuals with a disability. The plan shall include the
assurance of appropriate physical access to obtain included
benefits for all enrollees who are qualified individuals with
a disability including, but not limited to, the following:
1. Street level access or accessible ramp into
facilities;
2. Access to lavatory; and
3. Access to examination rooms.
The contractor shall also address in its policies and
procedures regarding ADA compliance the following issues:
1. Provider refusal to treat qualified individuals with
disabilities, including but not limited to
individuals with HIV/AIDS.
2. Contractor's role in ensuring providers receive
available resource information on how to accommodate
qualified individuals with a
IV-46
disability, particularly mobility impaired enrollees,
in examination rooms and for examinations.
3. How the contractor will accommodate visual and
hearing impaired individuals and assist its providers
in communicating with these individuals.
4. How the contractor will accommodate individuals with
communication-affecting disorders and assist its
providers in communicating with these individuals.
5. Holding community events as part of its provider and
consumer education responsibilities in places of
public accommodation, i.e., facilities readily
accessible to and useable by qualified individuals
with disabilities.
6. How the contractor will ensure it will link qualified
individuals with disabilities with the
providers/specialists with the knowledge and
expertise in treating the illness, condition, and
special needs of the enrollees.
4.5.3 PROVIDER NETWORK REQUIREMENTS
A. General. The contractor's provider network shall include
primary care and specialist providers who are trained and
experienced in treating individuals with special needs. The
contractor shall ensure that such providers will be equally
accessible to all enrollees covered under this contract.
1. The contractor shall operate a program to provide
services for enrollees with special needs that
emphasizes: (a) that providers are educated regarding
the needs of enrollees with special needs; (b) that
providers will reasonably accommodate enrollees with
special needs; (c) that providers will assist
enrollees in maximizing involvement in the care they
receive and in making decisions about such care; and
(d) that providers maximize for enrollees with
special needs independence and functioning through
health promotions and preventive care, decreased
hospitalization and emergency room care, and the
ability to be cared for at home.
2. The contractor shall describe how its provider
network will respond to the cultural and linguistic
needs of enrollees with special needs.
3. The network shall include primary care providers and
dentists whose clinical practice has specialized to
some degree in treating one or more groups of
children and adults with complex/chronic or disabling
conditions. To the extent possible, children and
adults with complex physical conditions should be in
the care of board certified pediatricians and family
practitioners or internists, respectively, or
subspecialists, as appropriate.
IV-47
4. The network shall include adult and pediatric
subspecialists for cardiology, hematology/oncology,
gastroenterology, emergency medicine, endocrinology,
infectious disease, orthopedics, neurology,
neurosurgery, ophthalmology, physiatry, pulmonology,
surgery, and urology, as well as providers who have
knowledge and experience in behavioral-developmental
pediatrics, adolescent health, geriatrics, and
chronic illness management.
5. The network shall include an appropriate and
accessible number of institutional facilities,
professional allied personnel, home care and
community based services to perform the
contractor-covered services included in this
contract.
B. SCHSNA. The contractor shall include in its provider network
Special Child Health Services Network Agencies (SCHSNA) for
children with special health care needs. These agencies are
designated and approved by the Department of Health and Senior
Services and include Pediatric Ambulatory Tertiary Centers
(pediatric tertiary centers may also be used when a pediatric
subspecialty is not sufficiently accessible in a county to
meet the needs of the child), Regional Cleft Lip/Palate
Centers, Pediatric AIDS/HIV Network, Comprehensive Regional
Sickle Cell/Hemoglobinopathies Treatment Centers, PKU
Treatment Centers, Genetic Testing and Counseling Centers, and
Hemophilia Treatment Centers, and others as designated from
time to time by the Department of Health and Senior Services.
A list of such providers is found in Section B.4.10 of the
Appendices.
C. Credentialing. The contractor shall collect and maintain, as
part of its credentialing process or through special survey
process, information from licensed practitioners including
pediatricians and pediatric subspecialists about the nature
and extent of their experience in serving children with
special health care needs including developmental
disabilities.
4.5.4 CARE MANAGEMENT AND COORDINATION OF CARE FOR PERSONS WITH SPECIAL NEEDS
A. The contractor shall provide coordination of care to actively
link the enrollee to providers, medical services, residential,
social and other support services as needed. For persons with
special needs, care management shall be provided, but, for
those with higher needs, as determined through the Complex
Needs Assessment (the CNA is described in Article 4.6.5), the
contractor shall provide care management at a higher level of
intensity. (See Section B.4.12 of the Appendices for a
flowchart of the three levels of care management.) Specific
requirements for this highest level of care management are
described below.
B. Complex Needs Assessment. For enrollees with special needs,
the contractor shall perform a Complex Needs Assessment no
later than thirty (30) days (or
IV-48
earlier, if urgent) from initial enrollment if special needs
are indicated on the Plan Selection Form or from the point of
identification of special needs. See 4.6.5 for a description
of the CNA.
C. Experience and Caseload. Care managers for enrollees who
require a higher level of care management will have the same
role and responsibilities as the care manager for the lower
intensity care management and additionally will address the
complex intensive needs of the enrollee identified as being at
"high risk" of adverse medical outcomes absent active
intervention by the contractor. For example, a
visually-impaired, insulin-dependent diabetic who requires
frequent glucose monitoring, nutritional guidance, vision
checks, and assistance in coordination with visits with
multiple providers, therapeutic regimen, etc. The contractor
shall provide intensive acute care services to treat
individuals with multiple complex conditions. The number of
medical and social services required by an enrollee in this
level of care management will generally be greater, thus the
number of linkages to be created, maintained, and monitored,
including the promotion of communication among providers and
the consumer and of continuity of care, will be greater. The
contractor shall provide these enrollees greater assistance
with scheduling appointments/visits. The intensity and
frequency of interaction with the enrollee and other members
of the treatment team will also be greater. The care manager
shall contact the enrollee bi-weekly or as needed.
1. At a minimum, the care manager for this level of care
management shall include, but is not limited to,
individuals with an undergraduate or graduate degree
in nursing or a graduate degree in social work and
with at least two (2) years experience serving
enrollees with special needs.
2. The contractor shall ensure that the care manager's
caseload is adjusted, as needed, to accommodate the
work and level of effort needed to meet the needs of
the entire case mix of assigned enrollees including
those determined to be high risk.
3. The contractor should include care managers with
experience working with pediatric as well as adult
enrollees with special needs.
D. IHCPs. The contractor through its care manager shall ensure
that an Individual Health Care Plan (IHCP) is developed and
implemented as soon as possible, according to the
circumstances of the enrollee. The contractor shall ensure the
full participation and consent of the enrollee or, where
applicable, authorized person and participation of the
enrollee's PCP and other case managers identified through the
Complex Needs Assessment (e.g. DDD case manager) in the
development of the plan.
E. The contractor shall provide written notification to the
enrollee, or authorized person, of the level of care
management approved and the name of the care
IV-49
manager as soon as the IHCP is completed. The contractor shall
have a mechanism to allow for changing levels of care
management as needs change.
F. Offering of Service. The contractor shall offer and document
the enrollee's response for this higher level care management
to enrollees (or, where applicable, authorized persons) who,
upon completion of a Complex Needs Assessment, are determined
to have complex needs which merit development of an IHCP and
comprehensive service coordination by a care manager.
Enrollees shall have the right to decline coordination of care
services; however, such refusal does not preclude the
contractor from case managing the enrollee's care.
4.5.5 CHILDREN WITH SPECIAL HEALTH CARE NEEDS
A. The contractor shall provide services to children with special
health care needs, who may have or are suspected of having
serious or chronic physical, developmental, behavioral, or
emotional conditions (short-term, intermittent, persistent, or
terminal), who manifest some degree of delay or disability in
one or more of the following areas: communication, cognition,
mobility, self-direction, and self-care; and with specified
clinically significant disturbance of thought, behavior,
emotions, or relationships that can be described as a syndrome
or pattern, generally resulting from neurochemical
dysfunction, negative environmental influences, or some
combination of both. Services needed by these children may
include but are not limited to psychiatric care and substance
abuse counseling for DDD clients (appropriate referrals for
all other pediatric enrollees); medications; crisis
intervention; inpatient hospital services; and intensive care
management to assure adherence to treatment requirements.
B. The contractor shall be responsible for establishing:
1. Methods for well child care, health promotion, and
disease prevention, specialty care for those who
require such care, diagnostic and intervention
strategies, home therapies, and ongoing ancillary
services, as well as the long-term management of
ongoing medical complications.
2. Care management systems for assuring that children
with serious, chronic, and rare disorders receive
appropriate diagnostic work-ups on a timely basis.
3. Access to specialty centers in and out of New Jersey
for diagnosis and treatment of rare disorders. A
listing of specialty centers is included in Section
B.4.10 of the Appendices.
4. Policies and procedures to allow for continuation of
existing relationships with out-of-network providers,
when considered to be in the best medical interest of
the enrollee.
IV-50
C. Linkages. The contractor shall have methods for coordinating
care and creating linkages with external organizations,
including but not limited to school districts, child
protective service agencies, early intervention agencies,
behavioral health, and developmental disabilities service
organizations. At a minimum, linkages shall address:
1. Contractor's process for generating or receiving
referrals, and sharing information;
2. Contractor's process for obtaining consent from
enrollees or, where applicable, authorized persons to
share individual beneficiary medical information; and
3. Ongoing coordination efforts (regularly scheduled
meetings, newsletters, joint community based
project).
D. IEPs. The contractor shall cooperate with school districts to
provide medically necessary contractor-covered services when
included as a recommendation in an enrollee's Individualized
Education Program (IEP) developed by the school district's
child study team, e.g. recommended medications or DME. The
contractor shall work with local school districts to develop
and implement procedures for linking and coordinating services
for children who need to receive medical services under an
Individualized Education Plan, in order to prevent duplication
of services, and to provide for cost effective services. Those
services which are included in the IEP as required services
are paid for by the school district, e.g. physical therapy.
Services covered under the Special Education Medicaid
Initiative (SEMI) program, or not included in Article 4.1 of
this contract, or not available under EPSDT are not the
contractor's responsibility. The provision of services shall
be based on medical necessity as defined in this contract.
E. Early Intervention. The contractor shall cooperate with and
coordinate its services with local Early Intervention Programs
to provide medically necessary (as defined in this contract)
contractor-covered services included in the Individualized
Family Support Plan (IFSP). These programs are comprehensive,
community based programs of integrated developmental services
which use a family centered approach to facilitate the
developmental progress of children between the ages of birth
and three (3) years of age whose developmental patterns are
atypical, or are at serious risk to become atypical through
the influence of certain biological or environmental risk
factors. At a minimum, the contractor must have policies and
procedures for identifying children who are candidates for
early intervention, making referrals through Special Child
Health Services County Case Management Units (See Appendix
B.4.11) in accordance with the Department of Health and Senior
Services procedures for referrals, and sharing information
with early intervention providers.
IV-51
4.5.6 CLIENTS OF THE DIVISION OF DEVELOPMENTAL DISABILITIES
A. The contractor shall provide all physical health services
required by this contract as well as the MH/SA services
included in the Medicaid State Plan to enrollees who are
clients of DDD. The contractor shall include in its provider
network a specialized network of providers who will deliver
both physical as well as MH/SA services (in accordance with
Medicaid program standards) to clients of DDD, and ensure
continuity of care within that network.
B. The contractor's specialized network shall provide disease
management services for clients of DDD, which shall include
participation in:
1. Care Management, including Complex Needs Assessment,
development and implementation of IHCP, referral,
coordination of care, continuity of care, monitoring,
and follow-up and documentation.
2. Coordination of care across multi-disciplinary
treatment teams to assist PCPs in identifying the
providers within the network who will meet the
specific needs and health care requirements of
clients of DDD with both physical health and MH/SA
needs and provide continuity of care with an
identified provider who has an established
relationship with the patient.
3. Apply quality improvement techniques/protocols to
effect improved quality of life outcomes.
4. Design and implement clinical pathways and practice
guidelines that will produce overall quality outcomes
for specific diseases/conditions identified in
clients of DDD.
5. Medical treatment.
C. The specialized provider network shall consist of credentialed
providers for physical health and MH/SA services, who have
experience and expertise in treating clients of DDD who have
both physical health and MH/SA needs, and who can provide
internal management of the complex care needs of these
enrollees. The contractor shall ensure that the specialized
provider network will be able to deliver identified physical
health and MH/SA outcomes.
D. Clients of DDD may, at their option, receive their physical
health and/or MH/SA services from any qualified provider in
the contractor's network. They are not required to receive
their services through the contractor's specialized network.
E. Individuals who are both DYFS clients and clients of DDD who
voluntarily enroll shall receive MH/SA services through the
contractor's network.
IV-52
4.5.7 PERSONS WITH HIV/AIDS
A. Pregnant Women. The contractor shall implement a program to
educate, test and treat pregnant women with HIV/AIDS to reduce
perinatal transmission of HIV from mother to infant. All
pregnant women shall receive HIV education and counseling and
HIV testing with their consent as part of their regular
prenatal care. A refusal of testing shall be documented in the
patient's medical record. Additionally, counseling and
education regarding perinatal transmission of HIV and
available treatment options (the use of Zidovudine [AZT] or
most current treatment accepted by the medical community for
treating this disease) for the mother and newborn infant
should be made available during pregnancy and/or to the infant
within the first months of life. The contractor shall submit a
quarterly report on HIV referrals and treatment. (See Section
A.7.15 of the Appendices (Table 13).)
B. Prevention. The contractor shall address the HIV/AIDS
prevention needs of uninfected enrollees, as well as the
special needs of HIV+ enrollees. The contractor shall
establish:
1. Methods for promoting HIV prevention to all enrollees
in the contractor's plan. HIV prevention information
shall be consistent with the enrollee's age, sex, and
risk factors as well as culturally and linguistically
appropriate.
2. Methods for accommodating self-referral and early
treatment.
3. A process to facilitate access to specialists and/or
include HIV/AIDS specialists as PCPs.
C. Traditional Providers. The contractor shall include
traditional HIV/AIDS providers in its networks, including
HIV/AIDS Specialty Centers (Centers of Excellence), and shall
establish linkages with AIDS clinical educational programs to
keep current on up-to-date treatment guidelines and standards.
D. Current Protocols. The contractor shall establish policies and
procedures for its providers to assure the use of the most
current diagnosis and treatment protocols and standards
established by the DHSS and the medical community.
E. Care Management. The contractor shall develop and implement an
HIV/AIDS care management program with adequate capacity to
provide services to all enrollees who would benefit from
HIV/AIDS care management services. Contractors shall establish
linkage with Xxxx Xxxxx CARE Act grantees for these services
either through a contract, MOA, or other cooperative working
agreement approved by the Department.
IV-53
F. ADDP. The contractor shall have policies and procedures for
supplying DHSS application forms and referring qualified NJ
FamilyCare enrollees to the AIDS Drug Distribution Program
(ADDP). Qualified individuals, described in Article 8.5.16,
receive protease inhibitors and certain anti- retrovirals
solely through the ADDP. The contractor shall ensure timely
referral for registration with the program to assure these
individuals receive appropriate and timely treatment.
4.6 QUALITY MANAGEMENT SYSTEM
A. The contractor shall provide for medical care and health
services that comply with federal and State Medicaid and NJ
FamilyCare standards and regulations and shall satisfy all
applicable requirements of the federal and State statutes and
regulations pertaining to medical care and services.
1. The contractor shall fulfill all its obligations
under this contract so that all health care services
required by its enrollees under this contract will
meet quality standards within the acceptable medical
practice of care for that individual, consistent with
the medical community standards of care, and such
services will comply with equal amount, duration, and
scope requirements in this contract, as described in
Article 4.1.
B. The contractor shall use its best efforts to ensure that
persons and entities providing care and services for the
contractor in the capacity of physician, dentist, CNP/CNS,
physician's assistant, CNM, or other medical professional meet
applicable licensing, certification, or qualification
requirements under New Jersey law or applicable state laws in
the state where service is provided, and that the functions
and responsibilities of such persons and entities in providing
medical care and services under this contract do not exceed
those permissible under New Jersey law. This shall also
include knowledge, training and experience in providing care
to individuals with special needs.
4.6.1 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PLAN
A. General. The contractor shall implement and maintain a Quality
Assessment and Performance Improvement program (QAPI) that is
capable of producing prospective, concurrent, and
retrospective analyses. Delegation of any QAPI activities
shall not relieve the contractor of its obligations to perform
all QAPI functions.
B. Goals. The contractor's QAPI shall be based on HCFA Guidelines
and shall:
1. Provide for health care that is medically necessary
with an emphasis on the promotion of health in an
effective and efficient manner;
2. Assess the appropriateness and timeliness of the care
provided;
IV-54
3. Evaluate and improve, as necessary, access to care
and quality of care with a focus on improving
enrollee outcomes; and
4. Focus on the clinical quality of medical care
rendered to enrollees.
C. Required Standards. The contractor's QAPI shall include all
standards described in New Jersey modified QARI/QISMC (See
Section B.4.14 of the Appendices). The following standards
shall be included in addition to the QARI/QISMC requirements:
1. QM Committee. The contractor shall have adequate
general liability insurance for members of the QM
committee and subcommittees, if any. The committee
shall include representation by providers who serve
enrollees with special needs.
2. Medical Director. The contractor shall have on staff
a Medical Director who is currently licensed in New
Jersey as a Doctor of Medicine or Doctor of
Osteopathic Medicine. The Medical Director shall be
responsible for:
a. The development, implementation and medical
interpretation of medical policies and
procedures to guide and support the
provision of medical care to enrollees;
b. Oversight of provider recruitment
activities;
c. Reviewing all providers' applications and
making recommendations to those with
contracting authority regarding
credentialing and reappointing all providers
prior to the providers' contracting (or
renewal of contract) with the contractor's
plan;
d. Continuing surveillance of the performance
of providers in their provision of health
care to enrollees;
e. Administration of all medical activities of
the contractor;
f. Continuous assessment and improvement of the
quality of care provided to enrollees;
g. Serving as Chairperson of Quality Management
Committee; [Note: the medical director may
designate another physician to serve as
chairperson with prior approval from DMAHS.]
h. Oversight of provider education, in-service
training and orientation;
IV-55
i. Assuring that adequate staff and resources
are available for the provision of proper
medical care to enrollees; and
j. The review and approval of studies and
responses to DMAHS concerning QM matters.
3. Enrollee Rights and Responsibilities. Shall include
the right to the Medicaid Fair Hearing Process for
Medicaid enrollees.
4. Medical Record standards shall address both Medical
and Dental records. Records shall also contain
notation of any cultural/linguistic needs of the
enrollee.
5. Provider Credentialing. Before any provider may
become part of the contractor's network, that
provider shall be credentialed by the contractor. The
contractor must comply with Standard IX of NJ
modified QARI/QISMC (Section B.4.14 of the
Appendices). Additionally, the contractor's
credentialing procedures shall include verification
that providers and subcontractors have not been
suspended, debarred, disqualified, terminated or
otherwise excluded from Medicaid, Medicare, or any
other federal or state health care program. The
contractor shall obtain federal and State lists of
suspended/debarred providers from the appropriate
agencies.
6. Institutional and Agency Provider Credentialing. The
contractor shall have written policies and procedures
for the initial quality assessment of institutional
and agency providers with which it intends to
contract. At a minimum, such procedures shall include
confirmation that a provider has been reviewed and
approved by a recognized accrediting body and is in
good standing with State and federal regulatory
bodies. If a provider has not been approved by a
recognized accrediting body, the contractor shall
develop and implement standards of participation. For
home health agency and hospice agency providers, the
contractor shall verify that the providers are
licensed and meet Medicare certification
participation requirements.
7. Delegation/subcontracting of QAPI activities shall
not relieve the contractor of its obligation to
perform all QAPI functions. The contractor shall
submit a written request and a plan for active
oversight of the QAPI activities to DMAHS for review
and approval prior to subcontracting/delegating any
QAPI responsibilities.
4.6.2 QAPI ACTIVITIES
The contractor shall carry out the activities described in its QAPI.
The contractor shall develop and submit to DMAHS annually an annual
work plan of expected
IV-56
accomplishments which includes a schedule of clinical standards to be
developed, medical care evaluations to be completed, and other key
quality assurance activities to be completed. The contractor shall also
prepare and submit to DMAHS an annual report on quality assurance
activities which demonstrate the contractor's accomplishments,
compliance and/or deficiencies in meeting its previous year's work plan
and should include studies undertaken, subsequent actions, and
aggregate data on utilization and clinical quality of medical care
rendered.
The contractor's quality assurance activities shall include,
at a minimum:
A. Guidelines. The contractor shall develop guidelines for the
management of selected diagnoses and basic health maintenance,
and shall distribute all standards, protocols, and guidelines
to all providers.
B. Treatment Protocols. The contractor may use treatment
protocols, ho xxxxx, such protocols shall allow for
adjustments based on the enrollee's medical condition and
contributing family and social factors.
C. Monitoring. The contractor shall have procedures for
monitoring the quality and adequacy of medical care including:
1) assessing use of the distributed guidelines and 2)
assessing possible under-treatment/under-utilization of
services.
D. Focused Evaluations. The contractor shall have procedures for
focused medical care evaluations to be employed when
indicators suggest that quality may need to be studied. The
contractor shall also have procedures for conducting
problem-oriented clinical studies of individual care.
E. Follow-up. The contractor shall have procedures for prompt
follow-up of reported problems and complaints involving
quality of care issues.
F. Utilization Data. The contractor shall conduct a quarterly
analysis of utilization data, including inpatient utilization,
and shall follow-up on cases of potential under- and
over-utilization. Over- and under-utilization shall be
determined based on comparison to established medical
community standards. See Section A.7.7 of the Appendices
(Table 5) for a description of utilization data to be
submitted to the Department.
G. Data Collection. The contractor shall have procedures for
gathering and trending data including outcome data.
H. Mortality Rates. The contractor shall review inpatient
hospital mortality rates of its enrollees.
I. Corrective Action. The contractor shall have procedures for
informing providers of identified deficiencies, conducting
ongoing monitoring of corrective actions, and taking
appropriate follow-up actions, such as instituting progressive
sanctions
IV-57
and appeal processes. The contractor shall conduct
reassessments to determine if corrective action yields
intended results.
J. Discharge Planning. The contractor shall have procedures to
ensure adequate discharge planning, and to include
coordination with services enrollees with special needs.
K. Ethical Issues. The contractor shall comply and monitor its
providers for compliance with state and federal laws and
regulations concerning ethical issues, including but not
limited to:
- Advance Directives
- Family Planning services for minors
- Other issues as identified
Contractor shall submit report annually or within thirty (30)
days to DMAHS with changes or updates to the policies.
L. Emergency Care. The contractor shall have methods to track
emergency care utilization and to take follow-up action,
including individual counseling, to improve appropriate use of
urgent and emergency care settings.
M. New Medical Technology. The contractor shall have policies and
procedures for criteria which are based on scientific evidence
for the evaluation of the appropriate use of new medical
technologies or new applications of established technologies
including medical procedures, drugs, devices, assistive
technology devices, and DME.
N. Informed Consent. The contractor is required and shall require
all participating providers to comply with the informed
consent forms and procedures for hysterectomy and
sterilization as specified in 42 C.F.R. Part 441, Sub-part B,
and shall include the annual audit for such compliance in its
quality assurance reviews of participating providers. Copies
of the forms are included in Section B.4.15 of the Appendices.
O. Continuity of Care. The contractor's Quality Management Plan
shall include a continuity of care system including a
mechanism for tracking issues over time with an emphasis on
improving health outcomes, as well as preventive services and
maintenance of function for enrollees with special needs.
P. HEDIS. The contractor shall submit annually, on a date
specified by the State, HEDIS 3.0 data or more updated
version, stratified by eligibility group: 1) aged, blind, and
disabled; 2) AFDC/TANF; and 3) NJ FamilyCare and aggregate
population data as well as, if available, the contractor's
commercial and Medicare enrollment HEDIS data for its
aggregate, enrolled commercial and Medicare population in the
State or region (if these data are collected and reported to
IV-58
DHSS, a copy of the report should be submitted also to
DMAHS) the following clinical indicator measures:
Report Period
Reporting Set Measures by Contract Year
---------------------- ----------------
childhood immunization status annually
adolescent immunization status annually
well-child care annually
prenatal care in the first trimester annually
low birth weight babies annually
check ups after delivery annually
prenatal care utilization annually
Q. Quality Improvement Projects (QIPs). The contractor shall
participate in QIPs defined annually by the State with input
from the contractor. The State will, with input from the
contractor and possibly other MCEs, define measurable
improvement goals and QIP-specific measures which shall serve
as the focus for each QIP. The contractor shall be responsible
for designing and implementing strategies for achieving each
QIP's objectives. At the beginning of each contract year the
contractor shall present a plan for designing and implementing
such strategies, which shall receive approval from the State
prior to implementation. The contractor shall then submit
semiannual progress reports summarizing performance relative
to each of the objectives of each contract year.
For year one the QIPs shall be the two areas identified below.
The external review organization (ERO) under contract with DHS
shall prepare a final report for year one that will contain
data, using State-approved sampling and measurement
methodologies, for each of the two measures below. Future
contract year QIPs shall be defined by the DHS and
incorporated into the contract by amendment.
For each measure the DHS will identify a baseline and a
compliance standard. The baselines in the following chart are
the year one QIPs. They are based on 1995 and 1996 focused
studies conducted by the ERO or MCE self-reported data (for
immunizations). Baseline data, target standards, and
compliance standards shall be established or updated by the
State.
If DHS determines that the contractor is not in compliance
with the requirements of the annual QIP objectives, either
based on the contractor's progress report or the ERO's report,
the contractor shall prepare and submit a corrective action
plan for DHS approval.
1. Well-Child Care (EPSDT)
IV-59
The QIP for Well-Child Care shall focus upon achieving
compliance with the EPSDT periodicity schedule (See Article
4.2.6) in the following four priority areas:
----------------------------------------------------------------------------------
Minimum
Clinical Area Performance Compliance Discretionary
Standard Standard Sanction
----------------------------------------------------------------------------------
Age-appropriate
Comprehensive exams
0 - 24 months 80% 60% 60 - 70%
2 - 4 yr olds 80% 60% 60 - 70%
4 - 6 yr olds (at least 1 visit) 80% 65% 60 - 70%
12 - 20 yr olds (at least 1 visit) 80% 60% 60 - 70%
----------------------------------------------------------------------------------
Immunizations
2 year olds (combined rate) 80% 60% 60 - 70%
----------------------------------------------------------------------------------
Annual Dental Visit -
3 - 12 yr olds 80% 60% 60 - 70%
13 - 21 yr olds 80% 60% 60 - 70%
----------------------------------------------------------------------------------
Lead screens (6 months
through 4 yr olds) 80% 60% 60 - 70%
----------------------------------------------------------------------------------
2. Prenatal Care and Pregnancy Outcome
The QIP for Prenatal Care and Pregnancy Outcome shall
focus upon achieving improvements in compliance with
prenatal care protocols and in obtaining positive
pregnancy outcomes
----------------------------------------------------------------------------
Compliance
Clinical Area Target Standard Standard
----------------------------------------------------------------------------
Initial visit in first trimester or
within 6 wks of enrollment 85% 75%
----------------------------------------------------------------------------
Adequate frequency of prenatal care 85% 75%
----------------------------------------------------------------------------
Low birth weight babies
1500 grams or less - 1%
2500 grams or less - 6%
----------------------------------------------------------------------------
Post partum exam within 60 days
after delivery 75% 60%
----------------------------------------------------------------------------
R. Care for Persons with Disabilities and the Elderly (Defined as
SSI-Aged and New Jersey Care - Aged enrollees and SSI and New
Jersey Care enrollees with disabilities)
IV-60
1. General. The contractor's Quality Committee shall
promote improved or clinical outcomes and enhanced
quality of life for elderly enrollees and enrollees
with disabilities. The Quality Committee shall:
a. Oversee quality of life indicators, such as:
i. Degree of personal autonomy;
ii. Provision of services and supports
that assist people in exercising
medical and social choices;
iii. Self-direction of care to the
greatest extent appropriate; and
iv. Maximum use of natural support
networks.
b. Review persistent or significant complaints
from elderly enrollees and enrollees with
disabilities or their authorized person,
identified through contractors' complaint
procedures and through external oversight;
c. Review quality assurance policies, standards
and written procedures to ensure they
adequately address the needs of elderly
enrollees and enrollees with disabilities;
d. Review utilization of services, including
any relationship to adverse or unexpected
outcomes specific to elderly enrollees and
enrollees with disabilities;
e. Develop written procedures and protocols for
at least the following:
i. Assessing the quality of complex
health care/care management;
ii. Ensuring contractor compliance
with the Americans with
Disabilities Act; and
iii. Instituting effective health
management protocols for elderly
enrollees and enrollees with
disabilities.
f. Develop and test methods to identify and
collect quality measurements including
measures of treatment efficacy of particular
relevance to elderly enrollees and enrollees
with disabilities.
g. The contractor shall submit an annual report
of the quality activities of this Article.
IV-61
2. Initiatives for Aged. The contractor shall implement
specific initiatives for the aged population through
the development of programs and protocols approved by
DMAHS including:
a. The contractor shall develop a program to
ensure provision of the pneumococcal vaccine
and influenza immunizations, as recommended
by the Centers for Disease Control (CDC).
The adult preventive immunization program
shall include the following components:
i. Development, distribution, and
measurement of PCP compliance with
practice guidelines;
ii. Educational outreach for enrollees
and practitioners;
iii. Access for ambulatory and homebound
enrollees; and
iv. Mechanism to report to DMAHS, via
encounter data, all immunizations
given.
b. The contractor shall develop a program to
ensure the provision of preventive cancer
screening services including, at a minimum,
mammography and prostate cancer screening.
The program shall include the following
components:
i. Measurement of provider compliance
with performance standards;
ii. Education outreach for both
enrollees and practitioners
regarding preventive cancer
screening services;
iii. Mammography services for women ages
sixty-five (65) to seventy-five
(75) offered at least annually;
iv. Screen for prostate cancer
scheduled for enrollees aged
sixty-five (65) to seventy-five
(75) at least every two (2) years;
and
v. Documentation on medical records of
all tests given, positive findings
and actions taken to provide
appropriate follow-up care.
c. The contractor shall develop specific
programs for the care of enrollees
identified with congestive heart failure,
chronic obstructive lung disease (COPD),
diabetes, hypertension, and depression. The
program shall include the following:
i. Written quality of care plan to
monitor clinical management,
including diagnostic,
pharmacological, and functional
standards and to evaluate outcomes
of care;
ii. Measurement and distribution to
providers of reports on outcomes of
care;
IV-62
iii. Educational programming for
enrollees and significant
caregivers which emphasizes
self-care and maximum independence;
iv. Educational materials for clinical
providers in the best practices of
managing the disease;
v. Evaluation of effectiveness of each
program by measuring outcomes of
care; and
d. The contractor shall develop a program to
manage the care for enrollees identified
with cognitive impairments. The program
shall include the following:
i. Written quality of care plans to
monitor clinical management,
including functional standards, and
to evaluate outcomes of care;
ii. Measurement and distribution to
providers of reports on outcomes of
care;
iii. Educational programming for
significant caregivers which
emphasizes community based care and
support systems for caregivers; and
iv. Educational materials for clinical
providers in the best practices of
managing cognitive impairments.
e. Initiatives to Prevent Long Term
Institutionalization: Contractor shall
develop a program to prevent unnecessary or
inappropriate nursing facility admissions
for the ABD, dually eligible population.
This program shall include, but is not
limited to, the following:
i. Identification of medical and
social conditions that indicate
risk of being institutionalized;
ii. Monitoring and risk assessment
mechanisms that assist PCPs and
others to identify enrollees
at-risk of institutionalization;
iii. Protocols to ensure the timely
provision of appropriate preventive
care services to at-risk enrollees.
Such protocols should emphasize
continuity of care and coordination
of services; and
iv. Provision of home/community
services covered by the contractor
as needed.
f. Abuse and Neglect Identification Initiative:
Contractor shall develop a program on
prevention, awareness, and treatment of
abuse and neglect of enrollees, to include
the following:
IV-63
i. Diagnostic tools for identifying
enrollees who are experiencing or
who are at risk of abuse and
neglect;
ii. Protocols and interventions to
treat abuse and neglect of
enrollees, including ongoing
evaluation of the effectiveness of
these protocols and interventions;
and
iii. Coordination of these efforts
through the PCP.
3. QIP for Persons with Disabilities and the Elderly.
The contractor shall cooperate with the DMAHS and the
ERO in providing the data and in participating in the
QIP studies for persons with disabilities and the
elderly. The study and final report will be conducted
and prepared by the ERO.
a. Preventive Medicine
i. Influenza vaccinations rates:
percentage of enrollees who have
received an influenza vaccination
in the past year;
ii. Pneumonia vaccination rate:
percentage of enrollees who have
received the pneumonia vaccination
at any time.
iii. Biennial eye examination:
percentage of enrollees receiving
vision screening in the past two
(2) years;
iv. Biennial hearing examination:
percentage of enrollees receiving
hearing screening in the past two
(2) years;
v. Screening for smoking: percentage
of enrollees who reported smoking
tobacco, and percentage of those
encouraged to stop smoking during
the past year;
vi. Screening for drug abuse:
percentage of enrollees reporting
alcohol utilization in the
substance abuse risk areas, and
percentage of those referred for
counseling; and
vii. Screening for colon cancer:
percentage of enrollees who
received this service in the past
two (2) years.
b. Congestive Heart Failure (CHF):
i. The number of enrollees diagnosed
with CHF:
ii. The number hospitalized for CHF and
average lengths of stay;
iii. Percentage of enrollees for whom
Angiotensin Converting Enzyme (ACE)
Inhibitors were prescribed;
iv. Percentage for whom cardiac
arrhythmias were diagnosed;
v. CHF readmission rate (the number of
enrollees admitted more than once
for CHF during the past year);
vi. CHF readmission rate ratio (the
ratio of enrollees admitted more
than once for CHF compared to
enrollees admitted only once);
vii. Percentage who died during the past
year in hospitals; and
IV-64
viii. Percentage who died during the past
year in non-hospital settings.
c. Hypertension:
i. The number of enrollees identified
as hypertensive using HEDIS
measures
ii. Percentage who received a blood
test for cholesterol or LDL.
S. For the elderly and enrollees with disabilities, the
contractor shall monitor and report outcomes annually to DMAHS
of the following quality indicators of potential adverse
outcomes and provide for appropriate education, outreach and
care management, and quality improvement activities as
indicated:
1. Aspiration pneumonia
2. Injuries, fractures, and contusions
3. Decubiti
4. Seizure management
T. MH/SA Services for Clients of DDD. In addition to including
clients of DDD and MH/SA services for clients of DDD in other
required reports, the contractor shall monitor and report on
the following measures: 1) timely outpatient follow-up to
intensive treatment, defined as the percentage of enrollees
discharged from acute treatment who receive ambulatory
services within 7 days; and 2) adequacy of outpatient
follow-up, defined as the percentage of enrollees discharged
from an inpatient hospital who attend a minimum of one
ambulatory service appointment per month for four months.
U. The contractor shall provide to DMAHS for review and approval
a written description of its compensation methodology for
marketing representatives, including details of commissions,
financial incentives, and other income.
V. Provider Performance Measures. The contractor shall conduct a
multidimensional assessment of a provider's performance, and
utilize such measures in the evaluation and management of
those providers. Data shall be supplied to providers for their
management activities. The contractor shall indicate in its
QAPI/Utilization Management Plan how it will address this
provision subject to DHS approval. At a minimum, the
evaluation management approach shall address the following:
1. Resource utilization of services, specialty and
ancillary services;
2. Clinical performance measures on outcomes of care;
3. Maintenance and preventive services;
IV-65
4. Enrollee experience and perceptions of service
delivery; and
5. Access.
For MH/SA services provided to enrollees who are clients of
DDD the contractor shall report MH/SA utilization data to its
providers.
W. Member Satisfaction. The State will assess member satisfaction
of contractor services by conducting surveys employing the
Consumer Assessments of Health Plans Study (CAHPS) survey, or
another survey instrument specified by the State. The survey
shall be stratified to capture statistically significant
results for all categories of New Jersey Care 2000+ enrollees
including AFDC/TANF, DYFS, SSI and New Jersey Care Aged, Blind
and Disabled, NJ FamilyCare, pregnant and parenting women, and
racial and linguistic minorities. Sample size, sample
selection, and implementation methodology shall be determined
by the State, with contractor input, to assure comparability
of results across State contractors.
The State will select an independent survey administrator to
perform the survey on behalf of all of the State's New Jersey
Care 2000+ contractors.
The contractor shall fully cooperate with the State and the
independent survey administrator such that final, analyzed
survey results shall be available from the survey
administrator to the State, in a format approved by the State,
by a date specified by the State of each contract year. Within
sixty (60) days of receipt of the final, analyzed survey
results sent to the contractor, it shall identify leading
sources of enrollee dissatisfaction, specify additional
measurement or intervention efforts developed to address
enrollee dissatisfaction, and a timeline, subject to State
approval, indicating when such activities will be completed. A
status report on the additional measurement or intervention
efforts shall be submitted to the State by a date specified by
DMAHS. The contractor shall respond to and submit a corrective
action to address and correct problems and deficiencies found
through the survey.
If the contractor conducts a member satisfaction survey of its
own, it shall send to DMAHS the results of the survey.
X. Focus Groups. The State will annually conduct four focus
groups with enrolled populations identified by the State and
communicated in writing to the contractor. Objectives for the
focus groups will be collaboratively developed by the State
and the contractor. For the first contract year, two focus
groups each will be conducted with enrollees who have
communication-affecting disorders and with enrollees who are
elderly.
Focus group results will be reported by the State. The
contractor shall identify opportunities for improvement
identified through the focus groups, specify
IV-66
additional measurement or intervention efforts developed to
address the opportunities for improvement, and a timeline,
subject to State approval, indicating when such activities
will be completed. A status report on the additional
measurement or intervention efforts shall be submitted
annually to the State by a date specified by DMAHS.
Y. ERO. Other "areas of concern" shall be monitored through the
external review process. The External Review Organization
(ERO) shall, in its monitoring activities, validate the
contractor's protocols, sampling, and review methodologies.
Z. Community/Health Education Advisory Committee. The contractor
shall establish and maintain a community advisory committee,
consisting of persons being served by the contractor,
including enrollees or authorized persons, individuals and
providers with knowledge of and experience with serving
elderly people or people with disabilities; and
representatives from community agencies that do not provide
contractor-covered services but are important to the health
and well-being of members. The committee shall meet at least
quarterly and its input and recommendations shall be employed
to inform and direct contractor quality management activities
and policy and operations changes. The contractor shall submit
a narrative annual report indicating the constituencies on
this committee, as well as the committee's activities
throughout the year.
AA. Provider Advisory Committee. The contractor shall establish
and maintain a provider advisory committee, consisting of
providers contracting with the contractor to serve enrollees.
At least two providers on the committee shall maintain
practices that predominantly serve Medicaid beneficiaries and
other indigent populations, in addition to at least one other
practicing provider on the committee who has experience and
expertise in serving enrollees with special needs. The
committee shall meet at least quarterly and its input and
recommendations shall be employed to inform and direct
contractor quality management activities and policy and
operations changes. The contractor shall submit a narrative
annual report indicating the constituencies on this committee,
as well as the committee's activities throughout the year.
4.6.3 REFERRAL SYSTEMS
A. The contractor shall have a system whereby enrollees needing
specialty medical and dental care will be referred timely and
appropriately. The system shall address authorization for
specific services with specific limits or authorization of
treatment and management of a case when medically indicated
(e.g., treatment of a terminally ill cancer patient requiring
significant specialist care). The contractor shall maintain
and submit a flow chart accurately describing the contractor's
referral system, including the title of the person(s)
responsible for approving referrals. The following items shall
be contained within the referral system:
IV-67
1. Procedures for recording and tracking each authorized
referral.
2. Documentation and assurance of completion of
referrals.
3. Policies and procedures for identifying and
rescheduling broken referral appointments with the
providers and/or contractor as appropriate (e.g.
EPSDT services).
4. Policies and procedures for accepting, resolving and
responding to verbal and written enrollee requests
for referrals made to the PCP and/or contractor as
appropriate. Such requests shall be logged and
documented. Requests that cannot be decided upon
immediately shall be responded to in writing no later
than five (5) business days from the date of receipt
of the request (with a call made to the enrollee on
final disposition) and postmarked the next day.
5. Policies and procedures for proper notification of
the enrollee and where applicable, authorized person,
the enrollee's provider, and the enrollee's care
manager, including notice of right to appeal and/or
right to a request a second opinion when services are
denied.
6. A referral form which can be given to the enrollee
or, where applicable, an authorized person to take to
a specialist.
7. Referral form mailed, faxed, or sent by electronic
means directly to the referral provider.
8. Telephoned authorization for urgent situations or
when deemed appropriate by the enrollee's PCP or the
contractor.
9. Where applicable, the contractor must also notify the
contractor care manager or authorized person.
B. The contractor shall provide a mechanism to assure the
facilitation of referrals when traveling by an enrollee
(especially when very ill) from one location to another to
pick-up and deliver forms can cause undue hardship for the
enrollee. Referrals from practitioners or prior authorizations
by the contractor shall be sent/processed within two (2)
working days of the request, one (1) day for urgent cases. The
contractor shall have procedures to allow enrollees to receive
a standing referral to a specialist in cases where an enrollee
needs ongoing specialty care.
C. The contractor shall not impose an arbitrary number of
attempted dental treatment visits by a PCD as a condition
prior to the PCD initiating any specialty referral requests.
IV-68
D. The contractor shall authorize any reasonable referral request
from a PCP/PCD without imposing any financial penalties to the
same PCP/PCD.
E. All final decisions regarding denials of referrals, PAs,
treatment and treatment plans for non-emergency services shall
be made by a physician and/or peer physician specialist or by
a dentist/dental specialist in the case of dental services.
Prior authorization decisions for non-emergency services shall
be made within ten (10) business days or sooner as required by
the needs of the enrollee.
4.6.4 UTILIZATION MANAGEMENT
A. Utilization Review Plan. The contractor shall develop a
written Utilization Review Plan that includes all standards
described in the NJ modified QARI/QISMC (See Section B.4.14 of
the Appendices). The written plan shall also include policies
and procedures that address the following:
1. The contractor shall not deny benefits to require
enrollees and providers to go through the appeal
process in an effort to forestall and reduce needed
benefits. The contractor shall provide all medically
necessary services covered by the NJ Division of
Medical Assistance and Health Services program in
this contract. If a dispute arises concerning the
provision of a service or the level of service, the
service, if initiated, shall be continued until the
issue is resolved.
2. Utilization Management Committee. The committee shall
have written parameters for operating and will meet
on a regular schedule, defined to be at least
quarterly. Committee members shall be clearly
identified and representative of the contractor's
providers, accountable to the medical director and
governing body, and shall maintain appropriate
documentation of the committee's activities,
findings, recommendations, and actions.
3. Data Collection and Reporting. The plan shall provide
for systematic utilization data collection and
analysis, including profiling of provider utilization
patterns and patient results. The contractor must use
aggregate data to establish utilization patterns,
allow for trend analysis, and develop statistical
profiles of both individual providers and all network
providers. Such data shall be regularly reported to
the contractor management and contractor providers.
The plan shall also provide for interpretation of the
data to providers.
4. Corrective Action. The plan shall include procedures
for corrective action and follow-up activities when
problems in utilization are identified.
IV-69
5. Roles and Responsibilities. The plan shall clearly
define the roles, functions, and responsibilities of
the utilization management committee and medical
director.
6. Prohibitions on Compensation. The contractor or the
contractor's delegated utilization review agent shall
not permit or provide compensation or anything of
value to its employees, agents or contractors based
on:
a. Either a percentage of the amount by which a
claim is reduced for payment or the number
of claims or the cost of services for which
the person has denied authorization or
payment; or
b. Any other method that encourages the
rendering of an adverse determination.
7. Retrospective Review. If a health care service has
been pre-authorized or approved, the specific
standards, criteria or procedures used in the
determination shall not be modified pursuant to
retrospective review.
8. Collection of Information. Only such information as
is necessary to make a determination shall be
collected. During prospective or concurrent review,
copies of medical records shall only be required when
necessary to verify that the health care services
subject to review are medically necessary. In such
cases, only the relevant sections of the records
shall be required. Complete or partial medical
records may be requested for retrospective reviews.
In no event shall such information be reviewed by
persons other than health care professionals,
registered health information technicians, registered
health information administrators, or administrative
personnel who have received appropriate training and
who will safeguard patient confidentiality.
9. Prohibited Actions. Neither the contractor's UM
committee nor its utilization review agent shall take
any action with respect to an enrollee or a health
care provider that is intended to penalize or
discourage the enrollee or the enrollee's health care
provider from undertaking an appeal, dispute
resolution or judicial review of an adverse
determination.
B. Prior Authorization. The contractor shall have policies and
procedures for prior-authorization. Prior authorization shall
be conducted by a currently licensed, registered or certified
health care professional, including a registered nurse or a
physician who is appropriately trained in the principles,
procedures and standards of utilization review. The following
timeframes and requirements shall apply to all prior
authorization determinations:
IV-70
1. Routine determinations. Prior authorization
determinations for non-urgent services shall be made
and a notice of determination provided by telephone
and in writing to the provider within ten (10)
business days (or sooner as required by the needs of
the enrollee) of receipt of necessary information
sufficient to make an informed decision.
2. Urgent determinations. Prior authorization
determinations for urgent services shall be made
within twenty-four (24) hours of receipt of the
necessary information.
3. Determination for Services that have been delivered.
Determinations involving health care services which
have been delivered shall be made within thirty (30)
days of receipt of the necessary information.
4. Adverse Determinations. A physician and/or a
physician peer reviewer shall make the final
determination in all adverse determinations.
5. Continued/Extended Services. A utilization review
agent shall make a determination involving continued
or extended health care services, or additional
services for an enrollee undergoing a course of
continued treatment prescribed by a health care
provider and provide notice of such determination to
the enrollee or the enrollee's designee, which may be
satisfied by notices to the enrollee's health care
provider, by telephone and in writing within one (1)
business day of receipt of the necessary information.
Notification of continued or extended services shall
include the number of extended services approved, the
new total of approved services, the date of onset of
services and the next review date. For services that
require multiple visits, a series of tests, etc. to
complete the service, the authorized time period
shall be adequate to cover the anticipated span of
time that best fits the service needs and
circumstances of each individual enrollee.
6. Reconsiderations. The contractor shall have policies
and procedures for reconsideration in the event that
an adverse determination is made without an attempt
to discuss such determination with the referring
provider. Determinations in such cases shall be made
within the timeframes established for initial
considerations.
7. The contractor shall provide written notification to
enrollees and/or, where applicable, an authorized
person at the time of denial, deferral or
modification of a request for prior approval to
provide a medical/dental service(s), when the
following conditions exist:
a. The request is made by a medical/dental or
other health care provider who has a formal
arrangement with the contractor to provide
services to the enrollee.
IV-71
b. The request is made by the provider through
the formal prior authorization procedures
operated by the contractor.
c. The service for which prior authorization is
requested is a Medicaid covered service for
which the contractor has established a prior
authorization requirement.
d. The prior authorization decision is being
made at the ultimate level of responsibility
within the contractor's organization for
approving, denying, deferring or modifying
the service requested but prior to the point
at which the enrollee must initiate the
contractor's grievance procedure.
8. Notice of Action. Written notification shall be given
on a standardized form approved by the Department and
shall inform the provider, enrollee or authorized
person of the following:
a. The effective date of the denial, reduction
of service, or other medical coverage
determination;
b. The enrollee's rights to, and method for
obtaining, a State hearing (Fair Hearing
and/or IURO) to contest the denial, deferral
or modification action;
c. The enrollee's right to represent
himself/herself at the State hearing or to
be represented by legal counsel, friend or
other spokesperson;
d. The action taken by the contractor on the
request for prior authorization and the
reason for such action including clinical
rationale and the underlying contractual
basis or Medicaid authority;
e. The name and address of the contractor;
f. Notice of internal (contractor) appeal
rights and instructions on how to initiate
such appeal;
g. Notice of the availability, upon request, of
the clinical review criteria relied upon to
make the determination;
h. The notice to the enrollee shall inform the
enrollee that he or she may file an appeal
concerning the contractor's action using the
contractor's appeal procedure prior to or
concurrent with the initiation of the State
hearing process;
IV-72
i. The contractor shall notify enrollees,
and/or authorized persons within the time
frames set forth in this contract;
9. In no instance shall the contractor apply prior
authorization requirements and utilization controls
that effectively withhold or limit medically
necessary services, or establish prior authorization
requirements and utilization controls that would
result in a reduced scope of benefits for any
enrollee.
C. Appeal Process for UM Determinations. The contractor shall
have policies and procedures for the appeal of utilization
management determinations and similar determinations. In the
case of an enrollee who was receiving a covered service (from
the contractor, another contractor, or the Medicaid
Fee-for-Service program) prior to the determination, the
contractor shall continue to provide the same level of service
while the determination is in appeal. However, the contractor
may require the enrollee to receive the service from within
the contractor's provider network, if equivalent care can be
provided within network.
1. The contractor shall provide that an enrollee, and
any provider acting on behalf of the enrollee with
the enrollee's consent (enrollee's consent shall not
be required in the case of a deceased patient, or
when an enrollee has relocated and cannot be found),
may appeal any UM decision resulting in a denial,
termination, or other limitation in the coverage of
and access to health care services in accordance with
this contract and as defined in C.2 under the
procedures described in this Article. Such enrollees
and providers shall be provided with a written
explanation of the appeal process upon the conclusion
of each stage in the appeal process.
2. Appealable decision means, at a minimum, any of the
following:
a. An adverse determination under a utilization
review program;
b. Denial of access to specialty and other
care;
c. Denial of continuation of care;
d. Denial of a choice of provider;
e. Denial of coverage of routine patient costs
in connection with an approved clinical
trial;
f. Denial of access to needed drugs;
g. The imposition of arbitrary limitation on
medically necessary services; or
h. Denial of payment for a benefit.
3. Hearings. If the contractor provides a hearing to the
enrollee on the appeal, the enrollee shall have the
right to representation. The contractor shall permit
the enrollee to be accompanied by a representative of
the enrollee's choice to any proceedings and
grievances. Such hearing must
IV-73
take place in community locations convenient and
accessible to the enrollee.
4. The appeal process shall consist of an informal
internal review by the contractor (stage 1 appeal), a
formal internal review by the contractor (stage 2
appeal), and a formal external review (stage 3
appeal) by an independent utilization review
organization under the DHSS and/or the Medicaid Fair
Hearing process shall be in accordance with N.J.A.C
10:49 et seq. Stages 1-3 appeals shall be in
accordance with N.J.A.C. 8:38-8.
5. Utilization Management Grievances. Appropriate
clinical personnel shall be involved in the
investigation and resolution of all UM grievances.
The processing of all such grievances shall be
incorporated in the contractor's quality management
activities and shall be reviewed periodically (at
least quarterly) by the Medical Director/Dental
Director.
6. Nothing in this Article shall be construed as
removing any legal rights of enrollees under State or
federal law, including the right to file judicial
actions to enforce rights or request a Medicaid Fair
Hearing for Medicaid enrollees in accordance with
their rights under State and federal laws and
regulations. All written notices to Medicaid/NJ
FamilyCare Plan A enrollees shall include a statement
of their right to access the Medicaid Fair Hearing
process at any time.
D. Drug Utilization Review Program (DUR): The contractor shall
establish and maintain a drug utilization review (DUR) program
that satisfies the minimum requirements for prospective and
retrospective DUR as described in 1927(g) of the Social
Security Act, amended by the Omnibus Budget Reconciliation Act
(OBRA) of 1990. The contractor shall include review of Mental
Health/Substance Abuse drugs in its DUR program. The State or
its agent shall provide its expertise in developing review
protocols and shall assist the contractor in analyzing MH/SA
drug utilization. Results of the review shall be provided to
the State or its agent and, where applicable, to the
contractor's network providers. The State or its agent will
take appropriate corrective action to report its actions and
outcomes to the contractor.
1. DUR standards shall encourage proper drug utilization
by ensuring maximum compliance, minimizing potential
fraud and abuse, and taking into consideration both
the quality and cost of the pharmacy benefit.
2. The contractor shall implement a claims adjudication
system, preferably on-line, which shall include a
prospective review of drug utilization, and include
age-specific edits.
3. The prospective and retrospective DUR standards
established by the contractor shall be consistent
with those same standards established by the
IV-74
Medicaid Drug Utilization Review Board. DMAHS shall
approve the effective date for implementation of any
DUR standards by the contractor as well as any
subsequent changes within thirty (30) days of such
change.
4.6.5 CARE MANAGEMENT
A. Care Management Standards. The contractor shall develop and
implement care management as defined in Article 1 with
adequate capacity to provide services to all enrollees who
would benefit from care management services. In addition, the
contractor shall develop a higher level of care management for
enrollees with special needs, as described in Article 4.5.4.
Specific care management activities shall include at least the
following:
1. An effective mechanism to initiate and discontinue
care management services in both inpatient and
outpatient settings, in addition to catastrophic
incidents.
2. An effective mechanism to coordinate services
required by enrollees, including community support
services. When appropriate, such activities shall be
coordinated with those of the Division of Family
Development (DFD), Division of Youth and Family
Services (DYFS), Division of Mental Health Services
(DMHS), Division of Developmental Disabilities,
Special Child Health Services County Case Management
Units, Division of Addiction Services, and community
agencies.
3. Care plans specifically developed for each care
managed enrollee which ensure continuity and
coordination of care among the various clinical and
non-clinical disciplines and services.
4. A process to evaluate and improve individual care
management services as well as the effectiveness of
care management as a whole.
5. Protocols for the following care management
activities:
a. Pregnancy services including HealthStart
program requirements;
b. All EPSDT services and coordination for children with elevated
blood lead levels;
c. Mental health/substance abuse services
coordination;
d. HIV/AIDS services coordination; and
e. Dental services for enrollees with
developmental disabilities.
B. Early Identification. The contractor shall develop policies
and procedures for early identification of enrollees who
require care management. The contractor shall include in its
policies and procedures a review of the following possible
indicators of complex care needs:
IV-75
1. Poor health or functional status, as reported by the
enrollee or authorized person;
2. Existence of a care plan;
3. Existence of a case manager;
4. Request for an assessment from the enrollee or
authorized person;
5. Request for an assessment from a State agency or
private agency contracting with DDD involved with the
enrollee;
6. A chronic condition;
7. A recent hospitalization or admission to a nursing
facility;
8. Recent critical social events, such as the death or
relocation of a family member or a move to a new
home;
9. Existence of multiple medical or social service
systems or providers in the life of the enrollee;
10. Use of prescription drugs, particularly multiple
drugs; and
11. Use of interpreter or any special services.
C. Complex Needs Assessment. The contractor shall have protocols
and tools for performing and reviewing/updating Complex Needs
Assessments.
1. The Complex Needs Assessment must cover at least the
following risk factors:
a. Medical status and history, including
primary and secondary diagnosis and current
and past medications prescribed
b. Functional status
c. Physical well-being
d. Mental health status
e. History of tobacco, alcohol and drug use or
abuse
f. Identification of existing and potential
formal and informal supports
g. Determination of willingness and capacity of
family members or, where applicable,
authorized persons and others to provide
informal support
h. Condition and proximity to services of
current housing, and access to appropriate
transportation
i. Identification of current or potential long
term service needs
j. Need for medical supplies and DME
2. When any of the following conditions are met, the
contractor shall ensure that a Complex Needs
Assessment is conducted, or an existing assessment is
reviewed, within a time frame that meets the needs of
the enrollee but within no more than thirty (30)
days:
a. Special needs are identified at the time of
enrollment or any time thereafter;
b. An enrollee or authorized person requests an
assessment;
IV-76
c. The enrollee's PCP requests an assessment;
d. A State agency involved with an enrollee
requests an assessment; or
e. An enrollee's status otherwise indicates.
D. Plan of Care. The contractor, through its care manager, shall
ensure that a plan of care is developed and implementation has
begun within thirty (30) business days of the date of a needs
assessment, or sooner, according to the circumstances of the
enrollee. The contractor shall ensure the full participation
and consent of the enrollee or, where applicable, authorized
person and participation of the enrollee's PCP and other case
managers identified through the Complex Needs Assessment
(e.g., DDD case manager) in the development of the plan. The
plan shall specify treatment goals, identify medical service
needs, relevant social and support services, appropriate
linkages and timeframe as well as provide an ongoing accurate
record of the individual's clinical history. The care manager
shall be responsible for implementing the linkages identified
in the plan and monitoring the provision of services
identified in the plan. This includes making referrals,
coordinating care, promoting communication, ensuring
continuity of care, and conducting follow-up. The care manager
shall also be responsible for ensuring that the plan is
updated as needed, but at least annually. This includes early
identification of changes in the enrollee's needs.
E. Referrals. The contractor shall have policies and procedures
to process and respond within ten (10) business days to care
management referrals from network providers, state agencies,
private agencies under contract with DDD, self-referrals, or,
where applicable, referrals from an authorized person.
F. Continuity of Care
1. The contractor shall establish and operate a system
to assure that a comprehensive treatment plan for
every enrollee will progress to completion in a
timely manner without unreasonable interruption.
2. The contractor shall construct and maintain policies
and procedures to ensure continuity of care by each
provider in its network.
3. An enrollee shall not suffer unreasonable
interruption of his/her active treatment plan. Any
interruptions beyond the control of the provider will
not be deemed a violation of this requirement.
4. If an enrollee has already had a medical or dental
treatment procedure initiated prior to his/her
enrollment in the contractor's plan, the initiating
treating provider must complete that procedure (not
the entire treatment plan). See 4.1.1.E for details.
IV-77
G. Documentation. The contractor shall document all contacts and
linkages to medical and other services in the enrollee's case
files.
H. Informing Providers. The contractor shall inform its PCPs and
specialists of the availability of care management services,
and must develop protocols describing how providers will
coordinate services with the care managers.
I. Care Managers. The contractor shall establish a distinct care
management function within the contractor's plan. This
function shall be overseen by a Care Management Supervisor, as
described in Article 7.3. Care managers shall be dedicated to
providing care management and may be employees or contracted
agents of the contractor. The care manager, in conjunction
with and with approval from, the enrollee's PCP, shall make
referrals to needed services. The care management system shall
recognize three levels set forth in Section B.4.12 of the
Appendices. Level 3 is described in Article 4.5.4.
1. The care manager for the first level of care
management shall have as a minimum a license as a
registered nurse or a Bachelor's degree in social
work, health or behavioral science.
2. For level two of care management, in addition to the
requirements in 4.6.5I.1. above, the care managers
shall also have at least one (1) year of experience
serving enrollees with special needs.
3. The contractor shall have procedures to monitor the
adequacy of staffing and must adjust staffing ratios
and caseloads as appropriate based on its staffing
assessment.
J. Care management shall also be made available to enrollees who
exhibit inappropriate, disruptive or threatening behaviors in
a medical practitioner's office when such behaviors may relate
to or result from the existence of the enrollee's special
needs.
K. Hours of Service. The contractor shall make care management
services available during normal office hours, Monday through
Friday.
4.7 MONITORING AND EVALUATION
4.7.1 GENERAL PROVISIONS
A. For purposes of monitoring and evaluating the contractor's
performance and compliance with contract provisions, to assure
overall quality management (QM), and to meet State and federal
statutes and regulations governing monitoring, DMAHS or its
agents shall have the right to monitor and evaluate on an
on-going basis, through inspection or other means, the
contractor's provision of health care services and operations
including, but not limited to, the quality, appropriateness,
IV-78
and timeliness of services provided under this contract and
the contractor's compliance with its internal QM program.
DMAHS shall establish the scope of review, review sites,
relevant time frames for obtaining information, and the
criteria for review, unless otherwise provided or permitted by
applicable laws, rules, or regulations.
B. The contractor shall cooperate with and provide reasonable
assistance to DMAHS in monitoring and evaluation of the
services provided under this contract.
C. The contractor hereby agrees to medical audits in accordance
with the protocols for care specified in this contract, in
accordance with medical community standards for care, and of
the quality of care provided all enrollees, as may be required
by appropriate regulatory agencies.
D. The contractor shall cooperate with DMAHS in carrying out the
provisions of applicable statutes, regulations, and guidelines
affecting the administration of this contract.
E. The contractor shall distribute to all subcontractors
providing services to enrollees, informational materials
approved by DMAHS that outlines the nature, scope, and
requirements of this contract.
F. The contractor, with the prior written approval of DMAHS,
shall print and distribute reporting forms and instructions,
as necessary whenever such forms are required by this
contract.
G. The contractor shall make available to DMAHS copies of all
standards, protocols, manuals and other documents used to
arrive at decisions on the provision of care to its DMAHS
enrollees.
H. The contractor shall use appropriate clinicians to evaluate
the clinical data, and must use multi-disciplinary teams to
analyze and address systems issues.
I. Contractor shall develop an incentive system for providers to
assure submission of encounter data. At a minimum, the system
shall include:
1. Mandatory provider profiling that includes complete
and timely submissions of encounter data. Contractor
shall set specific requirements for profile elements
based on data from encounter submissions.
2. Contractor shall set up data submission requirements
based on encounter data elements for which compliance
performance will be both rewarded and/or sanctioned.
J. The contractor shall include in its quality management system
reviews/audits which focus on the special dental needs of
enrollees with developmental
IV-79
disabilities. Using encounter data reflecting the utilization
of dental services and other data sources, the contractor
shall measure clinical outcomes; have these outcomes evaluated
by clinical experts; identify quality management tools to be
applied; and recommend changes in clinical practices intended
to improve the quality of dental care to enrollees with
developmental disabilities.
4.7.2 EVALUATION AND REPORTING - CONTRACTOR RESPONSIBILITIES
A. The contractor shall collect data and report to the State its
findings on the following:
1. Encounter Data: The contractor shall prepare and
submit encounter data to DMAHS. Instructions and
formats for this report are specified in Section
B.3.3 of the Appendices of this contract.
2. Grievance Reports: The contractor shall provide to
DMAHS quarterly reports of all grievances in
accordance with Articles 5.15 and the contractor's
approved grievance process included in this contract.
See Section A.7.5 of the Appendices (Table 3).
3. Appointment Availability Studies: The contractor
shall conduct a review of appointment availability
and submit a report to DMAHS semi-annually. The
report must list the average time that enrollees wait
for appointments to be scheduled in each of the
following categories: baseline physical, routine,
specialty, and urgent care appointments. DMAHS must
approve the methodology for this review in advance in
writing. The contractor shall assess the impact of
appointment waiting times on the health status of
enrollees with special needs.
4. Twenty-four (24) Hour Access Report: The contractor
shall submit to DMAHS an annual report describing its
twenty-four (24) hour access procedures for
enrollees. The report must include the names and
addresses of any answering services that the
contractor uses to provide twenty-four (24) hour
access.
5. The contractor shall submit to DMAHS, on a quarterly
basis, records of early discharge information which
pertain to hospital stays for newborns and mothers.
6. The contractor shall monitor, evaluate, and submit an
annual report to DMAHS on the incidence of HIV/AIDS
patients, the impact of the contractor's program to
promote HIV prevention (Article 4.5.7), counseling,
treatment and quality of life outcomes, mortality
rates.
7. Additional Reports: The contractor shall prepare and
submit such other reports as DMAHS may request.
Unless otherwise required by law or
IV-80
regulation, DMAHS shall determine the timeframe for
submission based on the nature of the report and give
the contractor the opportunity to discuss and comment
on the proposed requirements before the contractor is
required to submit such additional reports.
8. The contractor shall submit to the Division, on a
quarterly basis, documentation of its ongoing
internal quality assurance activities. Such
documentation shall include at a minimum:
a. Agenda of quality assurance meetings of its
medical professionals; and
b. Attendance sheets with attendee signatures.
B. Clinical areas requiring improvement shall be identified and
documented with a corrective action plan developed and
monitored by the State.
1. Implementation of remedial/corrective action. The
QAPI shall include written procedures for taking
appropriate remedial action whenever, as determined
under the QAPI, inappropriate or substandard services
are furnished, or services that should have been
furnished were not. Quality assurance actions which
result in the termination of a medical provider shall
be immediately forwarded by the contractor to DMAHS.
Written remedial/corrective action procedures shall
include:
a. Specification of the types of problems
requiring remedial/corrective action;
b. Specification of the person(s) or body
responsible for making the final
terminations regarding quality problems;
c. Specific actions to be taken;
d. Provision of feedback to appropriate health
professionals, providers and staff;
e. The schedule and accountability for
implementing corrective actions;
f. The approach to modifying the corrective
action if improvements do not occur; and
g. Procedures for notifying a primary care
physician/provider group that a particular
physician/provider is no longer eligible to
provide services to enrollees.
2. Assessment of effectiveness of corrective actions.
The contractor shall monitor and evaluate corrective
actions taken to assure that appropriate changes have
been made. In addition, the contractor shall track
changes in practice patterns.
IV-81
3. The contractor shall assure follow-up on identified
issues to ensure that actions for improvement have
been effective and provide documentation of same.
4. The findings, conclusions, recommendations, actions
taken, and results of the actions taken as a result
of QM activity, shall be documented and reported to
appropriate individuals within the organization and
through the established QM channels. The contractor
shall document coordination of QM activities and
other management activities.
C. The contractor shall conduct an annual satisfaction survey of
a statistically valid sample of its participating providers
who provide services to DMAHS enrollees. The contractor shall
submit a copy of the survey instrument and methodology to
DMAHS. The survey should include as a minimum questions that
address provider opinions of the impact of the referral, prior
authorization and provider appeals processes on his/her
practice/services, reimbursement methodologies, care
management assistance from the contractor. The contractor
shall communicate the findings of the survey to DMAHS in
writing within one hundred twenty (120) days after conducting
the survey. The written report shall also include
identification of any corrective measures that need to be
taken by the contractor as a result of the findings, a time
frame in which such corrective action will be taken by the
contractor and recommended changes as needed for subsequent
use.
4.7.3 MONITORING AND EVALUATION - DEPARTMENT ACTIVITIES
The contractor shall permit the Department and the United States Department of
Health and Human Services or its agents to have the right to inspect, audit or
otherwise evaluate the quality, appropriateness and timeliness of services
performed under this contract, including through a medical audit. Medical audit
by Department staff shall include, at a minimum, the review of:
A. Health care delivery system for patient care;
B. Utilization data;
C. Medical evaluation of care provided and patient outcomes for
specific enrollees as well as for a statistical representative
sample of enrollee records;
D. Health care data elements submitted electronically to DMAHS;
E. Annual, on-site review of the contractor's operations with
necessary follow-up reviews and corrective actions;
IV-82
F. The grievances and complaints (recorded in a separately
designated complaint log for DMAHS enrollees) relating to
medical care including their disposition;
G. Minutes of all quality assurance committee meetings conducted
by the contractor's medical staff. Such reviews will be
conducted on-site at the contractor's facilities or
administrative offices.
4.7.4 INDEPENDENT EXTERNAL REVIEW ORGANIZATION REVIEWS
A. The contractor shall cooperate with the external review
organization (ERO) audits and provide the information
requested and in the time frames specified (generally within
sixty (60) days or as indicated in the notice), including
medical and dental records, QAPI reports and documents, and
financial information. Contractors shall submit a plan of
action to correct, evaluate, respond to, resolve, and follow-
up on any identified problems reported by such activities.
B. The scope of the ERO reviews shall be as follows:
1. Annual, onsite review of contractor's operations with
necessary follow-up reviews and corrective actions.
2. The contractor's quality management plan and
activities.
3. Individual medical record reviews.
4. Randomly selected studies.
5. Focus studies utilizing where possible HEDIS
measurements and comparison to Healthy People 2010
Objectives and/or Healthy New Jersey 2010 standards
and/or EPSDT or HealthStart standards as appropriate.
6. Validation review of the contractor's QM/HEDIS
studies required in this contract.
7. Validation and evaluation of encounter data.
8. Health care data analysis.
9. Monitoring to ensure enrollees are issued written
determinations, including appeal rights and
notification of their right to a Medicaid Fair
Hearing as well as a review by the DHSS IURO.
10. Ad hoc studies and reviews.
11. ERO reviews for dental services include but are not
limited to:
a. New Jersey licensed Dental Consultants of
the ERO will review a random sample of
patient charts and conduct provider
interviews. A random number of patients will
receive screening examinations.
b. Auditors will review appointment logs,
referral logs, health education material,
and conduct staff interviews.
c. Audit documents will be completed by
appropriate consultant/auditor.
IV-83
4.8 PROVIDER NETWORK
4.8.1 GENERAL PROVISIONS
A. The contractor shall establish and maintain at all times a
complete provider network consisting of traditional providers
for primary and specialty care, including primary care
physicians, other approved non-physician primary care
providers, physician specialists, non-physician practitioners,
hospitals (including teaching hospitals), Federally Qualified
Health Centers and other essential community
providers/safety-net providers, and ancillary providers. The
provider network shall be reviewed and approved by DMAHS and
the sufficiency of the number of participating providers shall
be determined by DMAHS in accordance with the standards found
in Article 4.8.8 "Provider Network Requirements."
B. The contractor shall ensure that its provider network
includes, at a minimum:
1. Sufficient number, available and physically
accessible, of physician and non-physician providers
of health care to cover all services in the amount,
duration, and scope included in the benefits package
under this contract. The number of enrollees assigned
to a PCP shall be decreased by the contractor if
necessary to maintain the appointment availability
standards. The contractor's network, at a minimum,
shall be sufficient to serve at least 33 percent of
all individuals eligible for managed care in each
urban county it serves. The contractor's network, at
a minimum, shall be sufficient to serve at least 50
percent of all individuals eligible for managed care
in the remaining non-urban counties it serves, i.e.,
Cape May, Hunterdon, Salem, Sussex, and Xxxxxx.
2. A number and distribution of Primary Care Physicians
shall be such as to accord to all enrollees a ratio
of at least one (1) full time equivalent Primary Care
Physician who will serve no more than 1,500 enrollees
and one FTE primary care dentist for 1,500 enrollees.
Exemption to the 1:1,500 ratio limit may be granted
by DMAHS if criteria specified further below are met.
3. Providers who can accommodate the different languages
of the enrollees including bilingual capability for
any language which is the primary language of five
(5) percent or more of the enrolled DMAHS population.
4. Providers, including dentists, pediatricians,
physiatrists, gynecologists, family practitioners,
internists, neurologists, nurse practitioners or
other individual specialists, who are experienced in
treating enrollees with special needs. This includes
dentists who provide service to persons with
developmental disabilities and who may have to take
additional time in providing a specific service. Each
contractor shall demonstrate the availability and
accessibility of institutional facilities and
professional
IV-84
allied personnel, home care and community based
services to perform the agreed upon services.
5. Medical primary care network shall include
internists, pediatricians, family and general
practice physicians. The contractor shall have the
option to include obstetricians/gynecologists as PCPs
as well as other physician specialists as primary
care providers for enrollees with special needs who
will supervise and coordinate their care via a team
approach providing that the contract with the
physician specialist is, at a minimum, the same as
for all other PCPs and that enrollees are enrolled
with the physician specialist in the same manner and
with the same physician/enrollee ratio requirements
as for all other primary care physicians. The
contractor shall include certified nurse midwives in
its provider network where they are available and
willing to participate in accordance with 1905
(a)(17) of the Social Security Act. CNPs/CNSs
included as PCPs or specialists in the network may
provide a scope of services that comply with their
licensure requirements.
6. A CNP/CNS to enrollee ratio may not exceed one CNP or
one CNS to 1000 enrollees per contractor or 1500
enrollees cumulative across plans.
7. Compliance with the standards delineated in Article
4.8.
C. All providers and subcontractors shall, at a minimum, meet
Medicaid provider requirements and standards as well as all
other federal and State requirements. For example, a home
health agency subcontractor shall meet Medicare certification
participation requirements and be licensed by the Department
of Health and Senior Services; hospice providers shall meet
Medicare certification participation requirements; providers
for mammography services shall meet the Food and Drug
Administration (FDA) requirements.
D. The contractor shall include in its network at least one (1)
hospital located in the inner city urban area and at least 1
non-urban-based hospital in every county. For those counties
with only one (1) hospital, the contractor shall include that
hospital in its network subject to good faith negotiations.
E. The contractor shall offer a choice of two specialists in each
county where available. If only one or no providers of a
particular specialty is available, the contractor shall
provide documentation of the lack of availability and propose
alternative specialty providers in neighboring counties.
F. The contractor shall include in its network mental
health/substance abuse providers for Medicaid covered MH/SA
services with expertise to serve enrollees who are clients of
the Division of Developmental Disabilities.
IV-85
G. Changes in large provider groups, IPAs or subnetworks such as
pharmacy benefits manager, vision network, or dental network
shall be submitted to DMAHS for review and prior approval at
least ninety (90) days before the anticipated change. The
submission shall include contracts, provider network files,
enrollee/provider notices and any other pertinent information.
H. Requirement to contract with FQHC. The contractor shall
contract for primary care services with at least one Federally
Qualified Health Center (FQHC) located in each enrollment area
based on the availability and capacity of the FQHCs in that
area. FQHC providers shall meet the contractor's credentialing
and program requirements.
4.8.2 PRIMARY CARE PROVIDER REQUIREMENTS
A. The contractor shall offer each enrollee a choice of two (2)
or more primary care physicians furnished by the contractor.
Where applicable, this offer can be made to an authorized
person. An enrollee with special needs shall be given the
choice of a primary care provider which must include a
pediatrician, general/family practitioner, and internist, and
may include physician specialists and nurse practitioners. The
PCP shall supervise the care of the enrollee with special
needs who requires a team approach. Subject to any limitations
in the benefits package, each primary care provider shall be
responsible for overall clinical direction, serve as a central
point of integration and coordination of covered services
listed in Article 4.1, provide a minimum of twenty (20) hours
per week of personal availability as a primary care provider;
provide health counseling and advice; conduct baseline and
periodic health examinations; diagnose and treat covered
conditions not requiring the referral to and services of a
specialist; arrange for inpatient care, for consultation with
specialists, and for laboratory and radiological services when
medically necessary; coordinate referrals for dental care,
especially in accordance with EPSDT requirements; coordinate
the findings of laboratories and consultants; and interpret
such findings to the enrollee and the enrollee's family (or,
where applicable, an authorized person), all with emphasis on
the continuity and integration of medical care; and, as
needed, shall participate in care management and specialty
care management team processes. The primary care provider
shall also be responsible, subject to any limitations in the
benefits package, for determining the urgency of a
consultation with a specialist and, if urgent, shall arrange
for the consultation appointment.
Justification to include a specialist as a PCP or
justification for a physician practicing in an academic
setting for less than twenty (20) hours per week must be
provided to DMAHS. Include in the justification for the
specialist as a PCP the number of enrollees to be served as a
PCP and as a specialist, full details of the services and
scope of services to be provided, and coverage arrangements
documenting twenty-four (24) hours/seven (7) days a week
coverage.
IV-86
B. The PCP shall be responsible for supervising, coordinating,
managing the enrollee's health care, providing initial and
primary care to each enrollee, for initiating referrals for
specialty care, maintaining continuity of each enrollee's
health care and maintaining the enrollee's comprehensive
medical record which includes documentation of all services
provided to the enrollee by the PCP, as well as any specialty
or referral services. The contractor shall establish policies
and procedures to ensure that PCPs are adequately notified of
specialty and referral services. PCPs who provide professional
inpatient services to the contractor's enrollees shall have
admitting and treatment privileges in a minimum of one general
acute care hospital that is under subcontract with the
contractor and is located within the contractor's service
area. The PCP shall be an individual, not a facility, group or
association of persons, although he/she may practice in a
facility, group or clinic setting.
1. The PCP shall provide twenty-four (24) hour, seven
(7) day a week access; and
2. Make referrals for specialty care and other medically
necessary services, both in-network and out-of-
network.
3. Enrollees with special needs requiring very complex,
highly specialized health care services over a
prolonged period of time, and by virtue of their
nature and complexity would be difficult for a
traditional PCP to manage or with a life-threatening
condition or disease, or with a degenerative and/or
disabling condition or disease may be offered the
option of selecting an appropriate physician
specialist (where available) in lieu of a traditional
PCP. Such physicians having the clinical skills,
capacity, accessibility, and availability shall be
specially credentialed and contractually obligated to
assume the responsibility for overall health care
coordination and assuring that the special needs
person receives all necessary specialty care related
to their special need, as well as providing for or
arranging all routine preventive care and health
maintenance services, which may not customarily be
provided by or the responsibility of such specialist
physicians.
4. Where a specialist acting as a PCP is not available
for chronically ill persons or enrollees with complex
health care needs, those enrollees shall have the
option to select a traditional PCP upon enrollment,
with the understanding that the contractor may permit
a more liberal, direct specialty access (See section
4.5.2) to a specific specialist for the explicit
purpose of meeting those specific specialty service
needs. The PCP shall in this case retain all
responsibility for provision of primary care services
and for overall coordination of care, including
specialty care.
5. If the enrollee's existing PCP is a participating
provider in the contractor's network, and if the
enrollee wishes to retain the PCP, contractor shall
IV-87
ensure that the PCP is assigned, even if the PCP's
panel is otherwise closed at the time of the
enrollee's enrollment.
C. In addition to offering, at a minimum, a choice of two or more
primary care physicians, the contractor shall also offer an
enrollee or, where applicable, an authorized person the option
of choosing a certified nurse midwife, certified nurse
practitioner or clinical nurse specialist whose services must
be provided within the scope of his/her license. The
contractor shall submit to DMAHS for review a detailed
description of the CNP/CNS's responsibilities and health care
delivery system within the contractor's plan.
4.8.3 PROVIDER NETWORK FILE REQUIREMENTS
The contractor shall provide a provider network file, to be reported by
hard copy and diskette in a format and software application system
determined by DMAHS that will include the names and addresses of every
provider in the contractor's network. The format for computer diskette
submission is found in Section A.4.1 of the Appendices.
A. The contractor shall provide the DMAHS a full network,
monthly, on computer diskette in accordance with the
specifications provided in Section A.4.1 of the Appendices.
The network file shall include an indicator for new additions
and deletions and shall include:
1. Any and all changes in participating primary care
providers, including, for example, additions,
deletions, or closed panels, must be reported monthly
to DMAHS;
2. Any and all changes in participating physician
specialists, health care providers, CNPs/CNSs,
ancillary providers, and other subcontractors must be
reported to DMAHS on a monthly basis; and
B. The contractor shall provide the HBC with a full network on a
monthly basis in accordance with the specifications found in
Section A.4.1 of the Appendices. The diskettes shall be sent
to OMHC, DMAHS for distribution.
4.8.4 PROVIDER DIRECTORY REQUIREMENTS
The contractor shall prepare a provider directory which shall be
presented in the following manner. Fifty (50) copies of the provider
directory, and any updates, shall be provided to the HBC, and one copy
shall be provided to DMAHS.
A. Primary care providers who will serve enrollees listed by
- County, by city, by specialty
- Provider name and degree; specialty board
eligibility/certification status; office address(es)
(actual street address); telephone number; fax number
if
IV-88
available; office hours at each location; indicate if
a provider serves enrollees with disabilities and how
to receive additional information such as type of
disability; hospital affiliations; transportation
availability; special appointment instructions if
any; languages spoken; disability access; and any
other pertinent information that would assist the
enrollee in choosing a PCP.
B. Contracted specialists and ancillary services providers who
will serve enrollees
- Listed by county, by city, by physician specialty, by
non-physician specialty, and by adult specialist and
by pediatric specialist for those specialties
indicated in Section 4.8.8.C.
C. Subcontractors
- Provide, at a minimum, a list of all other health
care providers by county, by service specialty, and
by name. The contractor shall demonstrate its ability
to provide all of the services included under this
contract.
4.8.5 CREDENTIALING/RECREDENTIALING REQUIREMENTS/ISSUES
The contractor shall develop and enforce credentialing and
recredentialing criteria for all provider types which should follow the
HCFA's credentialing criteria, as delineated in the NJ modified
QARI/QISMC standards found in Article 4.6.1 and Section B.4.14 of the
Appendices.
4.8.6 LABORATORY SERVICE PROVIDERS
A. The contractor shall ensure that all laboratory testing sites
providing services under this contract, including those
provided by primary care physicians, specialists, other health
care practitioners, hospital labs, and independent
laboratories have either a Clinical Laboratory Improvement
Amendment (CLIA) certificate of waiver or a certificate of
registration along with a CLIA identification number. Those
laboratory service providers with a certificate of waiver
shall provide only those tests permitted under the terms of
their waiver. Laboratories with certificates of registration
may perform a full range of laboratory tests.
1. The contractor shall provide to DMAHS, on request,
copies of certificates that its own laboratory or any
other laboratory it conducts business with, has a
CLIA certificate for the services it is performing as
fulfillment of requirements in 42 C.F.R. Section
493.1809.
2. If the contractor has its own laboratory, the
contractor shall submit at the time of initial
contracting a written list of all diagnostic tests
performed in
IV-89
its own laboratory if applicable and those tests
which are referred to other laboratories annually and
within fifteen (15) working days of any changes.
3. The contractor shall inform DMAHS if it contracts
with a new laboratory subcontractor 30 days prior to
the effective date of the subcontractor's contract
and shall notify DMAHS of a termination of a
laboratory subcontractor 90 days prior to the
effective date of the subcontractor's termination.
The contractor shall provide a copy of a new
subcontractor's certificate of waiver or certificate
of registration within ten (10) days of operation.
B. The contractor shall contract with clinical diagnostic
laboratories that have implemented a compliance plan to help
avoid activities that might be regarded as fraudulent. The
compliance plan shall, at a minimum, include the following:
1. Written standards of conduct for employees;
2. Development and distribution of written policies that
promote the laboratory's commitment to compliance and
that address specific areas of potential fraud, such
as billing, marketing, and claims processing;
3. The designation of a chief compliance officer or
other appropriate high-level corporate structure or
official who is charged with the responsibility of
operating the compliance program;
4. The development and offering of education and
training programs to all employees;
5. The use of audits and/or other evaluation techniques
to monitor compliance and ensure a reduction in
identified problem areas;
6. The development of a code of improper/illegal
activities and the use of disciplinary action against
employees who have violated internal compliance
policies or applicable laws or who have engaged in
wrongdoing;
7. The investigation and remediation of identified
systemic and personnel problems;
8. The promotion of and adherence to compliance as an
element in evaluating supervisors and managers;
9. The development of policies addressing the non-
employment or retention of sanctioned individuals;
IV-90
10. The maintenance of a hotline to receive complaints
and the adoption of procedures to protect the
anonymity of complainants; and
11. The adoption of requirements applicable to record
creation and retention.
C. The contractor shall maintain a sufficient network of
drawing/specimen collection stations (may include independent
lab stations, hospital outpatient departments, provider
offices, etc.) to ensure ready access for all enrollees.
4.8.7 SPECIALTY PROVIDERS AND CENTERS (ALSO ADDRESSED IN 4.5)
A. The contractor shall include in its network pediatric medical
subspecialists, pediatric surgical specialists, and
consultants. Access to these services shall be provided when
referred by a pediatrician.
B. The contractor shall include in its provider network Centers
of Excellence (designated by the DHSS; See Appendix B.4.10)
for children with special health care needs. Inclusion of such
agencies or their equivalent may be by direct contracting,
consultant, or on a referral basis. Payment mechanism and
rates shall be negotiated directly with the center.
C. The contractor shall include primary care providers
experienced in caring for enrollees with special needs.
D. The contractor shall include providers who have knowledge and
experience in identifying child abuse and neglect and should
include Child Abuse Regional Diagnostic Centers or their
equivalent through either direct contracting, consultant or on
a referral basis. A list of Child Abuse Regional Diagnostic
Centers is in Section B.4.16 of the Appendices.
E. The contractor shall have a procedure by which an enrollee who
needs ongoing care from a specialist may receive a standing
referral to such specialist. If the contractor, or the primary
care provider in consultation with the medical director of the
contractor and specialist, if any, determines that such a
standing referral is appropriate, the organization shall make
such a referral to a specialist. The contractor shall not be
required to permit an enrollee to elect to have a
nonparticipating specialist if network provider of equivalent
expertise is available. Such referral shall be pursuant to a
treatment plan approved by the contractor in consultation with
the primary care provider, the specialist, the care manager,
and the enrollee or, where applicable, authorized person. Such
treatment plan may limit the number of visits or the period
during which such visits are authorized and may require the
specialist to provide the primary care provider with regular
updates on the specialty care provided, as well as all
necessary medical information.
IV-91
F. The contractor shall have a procedure by which an enrollee as
described in Articles 4.5.2D may receive a referral to a
specialist or specialty care center with expertise in treating
such conditions in lieu of a traditional PCP.
G. If the contractor determines that it does not have a health
care provider with appropriate training and experience in its
panel or network to meet the particular health care needs of
an enrollee, the contractor shall make a referral to an
appropriate out-of-network provider, pursuant to a treatment
plan approved by the contractor in consultation with the
primary care provider, the non-contractor participating
provider and the enrollee or where applicable, authorized
person, at no additional cost to the enrollee. The contractor
shall provide for a review by a specialist of the same or
similar specialty as the type of physician or provider to whom
a referral is requested before the contractor may deny a
referral.
4.8.8 PROVIDER NETWORK REQUIREMENTS
Provider networks and all provider types within the network shall be
reviewed on a county basis, i.e., must be located within the county
except where indicated. The contractor shall monitor the capacity of
each of its providers and decrease ratio limits as needed to maintain
appointment availability standards.
A. Primary Care Provider Ratios
PCP ratios shall be reviewed and calculated by provider
specialty on a county basis and on an index city basis, i.e.,
the major city of each county where the majority of the
Medicaid and NJ FamilyCare beneficiaries reside.
Physician
A primary care physician shall be a General Practitioner,
Family Practitioner, Pediatrician, or Internist.
Obstetricians/Gynecologists and other physician specialists
may also participate as primary care providers providing they
participate on the same contractual basis as all other PCPs
and contractor enrollees are enrolled with the specialists in
the same manner and with the same PCP/enrollee ratio
requirements applied.
1. 1 FTE PCP per 1500 enrollees per contractor; 1 FTE
per 2000 enrollees, cumulative across all
contractors.
2. 1 FTE PCP per 1000 DD enrollees per contractor; 1 FTE
per 1500 DD enrollees cumulative across all
contractors.
IV-92
Dentist
The contractor shall include and make available sufficient
number of primary care dentists from the time of initial
enrollment in the contractor's plan. Pediatric dentists shall
be included in the network and may be both primary care and
specialty care providing primary care ratio limits are
maintained.
1. 1 FTE primary care dentist per 1500 enrollees per
contractor; 1 FTE per 2000 enrollees, cumulative
across all contractors.
Certified Nurse Midwife (CNM)
If the contractor includes CNMs in its provider network as
PCPs, it shall utilize the following ratios for CNMs as PCPs.
1. 1 FTE CNM per 1000 enrollees per contractor; 1 FTE
CNM per 1500 enrollees across all contractors.
2. A minimum of two (2) providers shall be initially
available for selection at the enrollee's option.
Additional providers shall be included as capacity
limits are needed.
Certified Nurse Practitioner/Clinical Nurse Specialist
(CNP/CNS)
If the contractor includes CNPs/CNSs in the provider network
as PCPs, it shall utilize the following ratios.
1. 1 FTE CNP or 1 CNS per 1000 enrollees per contractor;
1 FTE CNP or 1 FTE CNS per 1500 enrollees cumulative
across all contractors.
2. A minimum of two (2) providers where available shall
be initially available for selection at the
enrollee's option. Additional providers shall be
included as capacity limits are reached.
B. Primary Care Providers [Non-Institutional File]
The contractor shall contract with the following primary care
providers. All provider types within the network shall be
located within the enrollment area, i.e., county, except where
indicated.
1. The contractor shall include contracted providers
for:
a. General/Family Practice Physicians
b. Internal Medicine Physicians
c. Pediatricians
d. Dentists - adult and pediatric
IV-93
2. Certified Nurse Midwives and Nurse Practitioners
[Non-Institutional File]
The contractor shall include in the network and
provide access to CNMs/CNPs/CNSs at the enrollee's
option. If there are no contracted CNMs/CNPs/CNSs in
the contractor's network in an enrollment area, then
the contractor shall reimburse for these services out
of network.
a. Certified Nurse Midwife
b. Clinical Nurse Specialist
c. Certified Nurse Practitioner
3. Optional Primary Care Provider Designations
The contractor may include as primary care providers:
a. OB/GYNs who will provide such services in
accordance with the requirements and
responsibilities of a primary care provider.
b. Other physician specialists who have agreed
to provide primary care to enrollees with
special needs and will provide such services
in accordance with the requirements and
responsibilities of a primary care provider.
c. Physician Assistants in accordance with
their licensure and scope of practice
provisions.
C. Physician Specialists [Non-Institutional File]
The contractor shall contract with physician specialists,
listed below, and should include two (2) providers per
specialty to permit enrollee choice. All specialty types
within the enrollment area network are reviewed on a county
basis, i.e., must be located within the county. Where certain
specialists are not available within the county, the
contractor shall provide written documentation (not just a
statement that there are no specialists available) of the lack
of a specialist located in the county and a detailed
description of how, by whom, and where the specialty care will
be provided. The contractor shall utilize an official
resource, such as the Board of Medical Examiners, for
determining presence or absence of specialists with offices
located in the county. Specialists shall have admitting
privileges in at least one participating hospital in the
county in which the specialist will be seeing enrollees.
IV-94
The contractor shall submit prior to execution of this
contract and semi-annually thereafter, a capacity assessment
(form found in Section A.4.2 of the Appendices) demonstrating
adequate capacity. Access standards shall be maintained at all
times.
The contractor shall provide a detailed description of
accessibility and capacity for each physician who will serve
as both a PCP and a specialist; and/or who will serve with
more than one specialty. The description shall include at a
minimum a certification that the physician is actively
practicing in each specialty, has been credentialed in each
specialty, and a description of the provider's availability in
each specialty (i.e. percent of time and number of hours per
week in each specialty). The credentialing criteria used to
determine a provider's appropriateness for a specialty shall
indicate whether the provider is board eligible, board
certified, or has completed an accredited fellowship in the
specialty.
The contractor shall include contracted providers for:
1. Allergy/Immunology
2. Anesthesiology
3. Cardiology - adult and pediatric
4. Cardiovascular surgery
5. Colorectal surgery
6. Dermatology
7. Emergency Medicine
8. Endocrinology - adult and pediatric
9. Gastroenterology - adult and pediatric
10. General Surgery - adult and pediatric
11. Geriatric Medicine
12. Hematology - adult and pediatric
13. Infectious Disease - adult and pediatric
14. Neonatology
15. Nephrology - adult and pediatric
16. Neurology - adult and pediatric
17. Neurological surgery
18. Obstetrics/gynecology
19. Oncology - adult and pediatric
20. Ophthalmology
21. Orthopedic Surgery
22. Otology, Rhinology, Laryngology (ENT)
23. Physical Medicine (for inpatient rehabilitation
services)
24. Plastic Surgery
25. Psychiatry (for clients of DDD)
26. Pulmonary Disease - adult and pediatric
27. Radiation Oncology
28. Radiology
IV-95
29. Rheumatology - adult and pediatric
30. Thoracic surgery
31. Urology
D. Non-Physician Providers [Non-Institutional File]
The contractor shall include contracted providers for:
1. Chiropractor
2. Dentists (including primary care, prosthodontia and
specialists for endodontia, orthodontia, periodontia,
and oral/maxillary surgery)
3. Optometrist
4. Podiatrist
5. Audiologist
6. Psychologist (for clients of DDD)
E. Ancillary Providers [Institutional File]
The contractor shall include contracted providers for:
1. Durable Medical Equipment
2. Federally Qualified Health Centers
3. Hearing Aid Providers
4. Home Health Agency - must be approved on a county-
specific basis
5. Hospice Agency
6. Hospitals - inpatient and outpatient services; at
least two per county with one urban where the
majority of Medicaid beneficiaries reside
7. Laboratory with one (1) drawing station per every
five mile radius within a county
8. Medical Supplier
9. Optical appliance providers
10. Organ Transplant Providers/Centers
11. Pharmacy
12. Private Duty Nursing Agency (service area which
includes a 50 mile radius from its home
administrative base office must be approved on a
county-specific basis)
13. Prosthetist, Orthotist, and Pedorthist
14. Radiology centers including diagnostic and
therapeutic
15. Transportation providers (ambulance, MICUs, invalid
coach)
F. The contractor shall also establish relationships with
physician specialists and subspecialists [Non-Institutional
File] for:
1. Pain Management
2. Medical Toxicology
3. Adolescent Medicine
IV-96
4. Maternal and Fetal Medicine
5. Medical Genetics
6. Developmental and Behavioral Pediatrics
G. Specialty Centers (Centers of Excellence) shall be included in
the network [Institutional File]
1. Providers and health care facilities for the care and
treatment of HIV/AIDS (list of available centers
found in Section B.4.13 of the Appendices).
2. Special Child Health Services Network Agencies for:
a. Pediatric Ambulatory Tertiary Centers
b. Regional Cleft Lip/Palate Centers
c. Pediatric HIV Treatment Centers
d. Comprehensive Regional Sickle
Cell/Hemoglobinpathies Treatment Centers
e. PKU Treatment Centers
f. Other as designated from time to time by the
Department of Health and Senior Services.
3. Other:
a. Genetic Testing and Counseling Centers
b. Hemophilia Treatment Centers
H. Other Specialty Centers/Providers [Institutional File]
Contractor should establish relationships with the following
providers/centers on a consultant or referral basis.
1. Xxxxx Bifida Centers/providers
2. Adult Scoliosis
3. Autism and Attention Deficits
4. Spinal Cord Injury
5. Lead Poisoning Treatment Centers
6. Child Abuse Regional Diagnostic Centers
7. County Case Management Units
IV-97
I. Provider Network Access Standards and Ratios
Specialty A - Miles per 2 B - Miles per 1 Min. No. Capacity Limit
Urban Non-Urban Urban Non-urban Required per County Per Provider
-------------------------------------------------------------------------------------------------------------------------
PCP Children GP 6 15 2 10 2 1: 1,500
-------------------------------------------------------------------------------------------------------------------------
FP 6 15 2 10 2 1: 1,500
-------------------------------------------------------------------------------------------------------------------------
Peds 6 15 2 10 2 1: 1,500
-------------------------------------------------------------------------------------------------------------------------
Adults GP 6 15 2 10 2 1: 1,500
-------------------------------------------------------------------------------------------------------------------------
FP 6 15 2 10 2 1: 1,500
-------------------------------------------------------------------------------------------------------------------------
IM 6 15 2 10 2 1: 1,500
-------------------------------------------------------------------------------------------------------------------------
CNP/CNS 6 15 2 10 2 1: 800
-------------------------------------------------------------------------------------------------------------------------
CNM 12 25 6 15 2 1: 1,500
-------------------------------------------------------------------------------------------------------------------------
Dentist, Primary Care 6 15 2 10 2 1: 1,500
-------------------------------------------------------------------------------------------------------------------------
Allergy 15 25 10 15 2 1: 75,000
-------------------------------------------------------------------------------------------------------------------------
Anesthesiology 15 25 10 15 2 1: 17,250
-------------------------------------------------------------------------------------------------------------------------
Cardiology 15 25 10 15 2 1: 100,000
-------------------------------------------------------------------------------------------------------------------------
Cardiovascular surgery 15 25 10 15 2 1: 166,000
-------------------------------------------------------------------------------------------------------------------------
Chiropractor 15 25 10 15 2 1: 10,000
-------------------------------------------------------------------------------------------------------------------------
Colorectal surgery 15 25 10 15 2 1: 30,000
-------------------------------------------------------------------------------------------------------------------------
Dermatology 15 25 10 15 2 1: 75,000
-------------------------------------------------------------------------------------------------------------------------
Emergency Medicine 15 25 10 15 2 1: 19,000
-------------------------------------------------------------------------------------------------------------------------
Endocrinology 15 25 10 15 2 1: 143,000
-------------------------------------------------------------------------------------------------------------------------
Endodontia 15 25 10 15 1 1: 30,000
-------------------------------------------------------------------------------------------------------------------------
Gastroenterology 15 25 10 15 2 1: 100,000
-------------------------------------------------------------------------------------------------------------------------
General Surgery 15 25 10 15 2 1: 30,000
-------------------------------------------------------------------------------------------------------------------------
Geriatric Medicine 6 15 2 10 2 1: 1,500
-------------------------------------------------------------------------------------------------------------------------
Hematology 15 25 10 15 2 1: 100,000
-------------------------------------------------------------------------------------------------------------------------
Infectious Disease 15 25 10 15 2 1: 125,000
-------------------------------------------------------------------------------------------------------------------------
Neonatology 15 25 10 15 2 1: 100,000
-------------------------------------------------------------------------------------------------------------------------
Nephrology 15 25 10 15 2 1: 125,000
-------------------------------------------------------------------------------------------------------------------------
Neurology 15 25 10 15 2 1: 100,000
-------------------------------------------------------------------------------------------------------------------------
Neurological Surgery 15 25 10 15 2 1: 166,000
-------------------------------------------------------------------------------------------------------------------------
Obstetrics/Gynecology 15 25 10 15 2 1: 7,100
-------------------------------------------------------------------------------------------------------------------------
Oncology 15 25 10 15 2 1: 100,000
-------------------------------------------------------------------------------------------------------------------------
Ophthalmology 15 25 10 15 2 1: 60,000
-------------------------------------------------------------------------------------------------------------------------
Optometrist 15 25 10 15 2 1: 8,000
-------------------------------------------------------------------------------------------------------------------------
Oral Surgery 15 25 10 15 2 1: 20,000
-------------------------------------------------------------------------------------------------------------------------
Orthodontia 15 25 10 15 1 1: 20,000
-------------------------------------------------------------------------------------------------------------------------
Orthopedic Surgery 15 25 10 15 2 1: 28,000
-------------------------------------------------------------------------------------------------------------------------
Otolaryngology (ENT) 15 25 10 15 2 1: 53,000
-------------------------------------------------------------------------------------------------------------------------
Periodontia 15 25 10 15 1 1: 30,000
-------------------------------------------------------------------------------------------------------------------------
Physical Medicine 15 25 10 15 2 1: 75,000
-------------------------------------------------------------------------------------------------------------------------
Plastic Surgery 15 25 10 15 2 1: 250,000
-------------------------------------------------------------------------------------------------------------------------
Podiatrist 15 25 10 15 2 1: 20,000
-------------------------------------------------------------------------------------------------------------------------
Prosthodontia 15 25 10 15 1 (where available) 1: 30,000
-------------------------------------------------------------------------------------------------------------------------
Psychiatrist 15 25 10 15 2 1: 30,000
-------------------------------------------------------------------------------------------------------------------------
Psychologist 15 25 10 15 2 1: 30,000
-------------------------------------------------------------------------------------------------------------------------
Pulmonary Disease 15 25 10 15 2 1: 100,000
-------------------------------------------------------------------------------------------------------------------------
Radiation Oncology 15 25 10 15 2 1: 100,000
-------------------------------------------------------------------------------------------------------------------------
Radiology 15 25 10 15 2 1: 25,000
-------------------------------------------------------------------------------------------------------------------------
Rheumatology 15 25 10 15 2 1: 150,000
-------------------------------------------------------------------------------------------------------------------------
Ther. - Audiology 12 25 6 15 2 1: 100,000
-------------------------------------------------------------------------------------------------------------------------
Thoracic Surgery 15 25 10 15 2 1: 150,000
-------------------------------------------------------------------------------------------------------------------------
Urology 15 25 10 15 2 1: 60,000
-------------------------------------------------------------------------------------------------------------------------
Fed Qual Health Ctr 1 1/county if available
-------------------------------------------------------------------------------------------------------------------------
Hospital 20 35 10 15 2 2 per county
-------------------------------------------------------------------------------------------------------------------------
Pharmacies 10 15 5 12 1: 1,000
-------------------------------------------------------------------------------------------------------------------------
Laboratory N/A N/A 5 12
-------------------------------------------------------------------------------------------------------------------------
DME/Med Supplies 12 25 6 15 1 1: 50,000
-------------------------------------------------------------------------------------------------------------------------
Hearing Aid 12 25 6 15 1 1: 50,000
-------------------------------------------------------------------------------------------------------------------------
Optical Appliance 12 25 6 15 2 1: 50,000
-------------------------------------------------------------------------------------------------------------------------
IV-98
J. Geographic Access
The following lists guidelines for urban geographic access for
the DMAHS population. (Standards for non-urban areas are
included in the table in H. above.) The State shall review
(and approve) exceptions on a case-by-case basis to determine
appropriateness for each situation.
For each contractor and for each municipality in each county
in which the contractor is operational, the access shall be
reviewed in accordance with the number and percentage of:
1. Beneficiary children who reside within 6 miles of 2
PCPs whose specialty is Family Practice, General
Practice or Pediatrics or 2 CNPs/CNSs; within 2 miles
of 1 PCP whose specialty is Family Practice, General
Practice or Pediatrics or 1 CNP or 1 CNS
2. Beneficiary adults who reside within 6 miles of 2
PCPs whose specialty is Family Practice, General
Practice or Internal Medicine or 2 CNPs or 2 CNSs;
within 2 miles of 1 PCP whose specialty is Family
Practice, General Practice or Internal Medicine or 1
CNP or 1 CNS
3. Beneficiaries who reside within 6 miles of 2
providers of general dentistry services; within 2
miles of 1 provider of general dentistry services
4. Beneficiaries who reside within 10 miles of 2
pharmacies; within 5 miles of 1 pharmacy
5. Beneficiaries who reside within 15 miles of at least
2 specialists in each of the following specialties:
all physician and dental specialists, Podiatry,
Optometry, Chiropractic; within 10 miles of at least
1 provider in each type of specialty noted above
6. Beneficiaries who reside within 15 miles of 2 acute
care hospitals; within 10 miles of one acute care
hospital
7. Beneficiaries who reside within 12 miles of 2 of each
of the following provider types: durable medical
equipment, medical supplier, hearing aid supplier,
optical appliance supplier, certified nurse midwife;
within 6 miles of one of each type of provider
8. Beneficiaries who reside within 5 miles of a
laboratory/drawing station.
9. Beneficiaries with desired access and average
distance to 1, 2 or more providers
IV-99
10. Beneficiaries without desired access and average
distance to 1, 2 or more providers
Access Standards
1. 90% of the enrollees must be within 6 miles of 2 PCPs
in an urban setting
2. 85% of the enrollees must be within 15 miles of 2
PCPs in a non-urban setting
3. Covering physicians must be within 15 miles in urban
areas and 25 miles in non-urban areas.
Travel Time Standards
The contractor shall adhere to the 30 minute standard, i.e.,
enrollees will not live more than 30 minutes away from their
PCPs, PCDs or CNPs/CNSs. The following guidelines shall be
used in determining travel time.
1. Normal conditions/primary roads - 20 miles
2. Rural or mountainous areas/secondary routes - 20
miles
3. Flat areas or areas connected by interstate highways
- 25 miles
4. Metropolitan areas such as Newark, Camden, Trenton,
Paterson, Jersey City - 30 minutes travel time by
public transportation or no more than 6 miles from
PCP
5. Other medical service providers must also be
geographically accessible to the enrollees.
6. Exception: SSI or New Jersey Care-ABD enrollees and
clients of DDD may choose to see network providers
outside of their county of residence.
K. Conditions for Granting Exceptions to the 1:1500 Ratio Limit
for Primary Care Physicians
1. A physician must demonstrate increased office hours
and must maintain (and be present for) a minimum of
20 hours per week in each office.
2. In private practice settings where a physician
employs or directly works with nurse practitioners
who can provide patient care within the scope of
their practices, the capacity may be increased to 1
PCP FTE to 2500 enrollees. The PCP must be
immediately available for consultation, supervision
or to take over treatment as needed. Under no
circumstances
IV-100
will a PCP relinquish or be relieved of direct
responsibility for all aspects of care of the
patients enrolled with the PCP.
3. In private practice settings where a primary care
physician employs or is assisted by other licensed
physicians, the capacity may be increased to 1 PCP
FTE to 2500 enrollees.
4. In clinic practice settings where a PCP provides
direct personal supervision of medical residents with
a New Jersey license to practice medicine in good
standing with State Board of Medical Examiners, the
capacity may be increased with the following ratios:
1 PCP to 1500 enrollees; 1 licensed medical resident
per 1000 enrollees. The PCP must be immediately
available for consultation, supervision or to take
over treatment as needed. Under no circumstances will
a PCP relinquish or be relieved of direct
responsibility for all aspects of care of the
patients enrolled with the PCP.
5. Each provider (physician or nurse practitioner) must
provide a minimum of 15 minutes of patient care per
patient encounter and be able to provide four visits
per year per enrollee.
6. The contractor shall submit for prior approval by
DMAHS a detailed description of the PCP's delivery
system to accommodate an increased patient load, work
flow, professional relationships, work schedules,
coverage arrangements, 24 hour access system.
7. The contractor shall provide information on total
patient load across all plans, private patients,
Medicaid fee-for-service patients, other.
8. The contractor shall adhere to the access standards
required in the contractor's contract with the
Department.
9. There will be no substantiated complaints or
demonstrated evidence of access barriers due to an
increased patient load.
10. The Department will make the final decision on the
appropriateness of increasing the ratio limits and
what the limit will be.
L. Conditions for Granting Exceptions to the 1:1500 Ratio Limit
for Primary Care Dentists.
1. A PCD must provide a minimum of 20 hours per week per
office.
2. In clinic practice settings where a PCD provides
direct personal supervision of dental residents who
have a temporary permit from the State Board of
Dentistry in good standing and also dental students,
the
IV-101
capacity may be increased with the following ratios:
1 PCD to 1500 enrollees per contractor; 1 dental
resident per 1000 enrollees per contractor; 1 FTE
dental student per 200 enrollees per contractor. The
PCD shall be immediately available for consultation,
supervision or to take over treatment as needed.
Under no circumstances shall a PCD relinquish or be
relieved of direct responsibility for all aspects of
care of the patients enrolled with the PCD.
3. In private practice settings where a PCD employs or
is assisted by other licensed dentists, the capacity
may be increased to 1 PCD FTE to 2500 enrollees.
4. In private practice settings where a PCD employs
dental hygienists or is assisted by dental
assistants, the capacity may be increased to 1 PCD to
2500 enrollees. The PCD shall be immediately
available for consultation, supervision or to take
over treatment as needed. Under no circumstances
shall a PCD relinquish or be relieved of direct
responsibility for all aspects of care of the
patients enrolled with the PCD.
5. Each PCD shall provide a minimum of 15 minutes of
patient care per patient encounter.
6. The contractor shall submit for prior approval by the
DMAHS a detailed description of the PCD's delivery
system to accommodate an increased patient load, work
flow, professional relationships, work schedules,
coverage arrangements, 24 hour access system.
7. The contractor shall provide information on total
patient load across all plans, private patients,
Medicaid fee-for-service patients, other.
8. The contractor shall adhere to the access standards
required in the contractor's contract with the
Department.
9. There must be no substantiated complaints or
demonstrated evidence of access barriers due to an
increased patient load.
10. The Department will make the final decision on the
appropriateness of increasing the ratio limits and
what the limit will be.
4.8.9 DENTAL PROVIDER NETWORK REQUIREMENTS
A. The contractor shall establish and maintain a dental provider
network, including primary and specialty care dentists, which
is adequate to provide the full scope of benefits. The
contractor shall include general dentists and pediatric
dentists as primary care dentists (PCDs). A system whereby the
PCD initiates and
IV-102
coordinates any consultations or referrals for specialty care
deemed necessary for the treatment and care of the enrollee is
preferred.
B. The dental provider network shall include sufficient providers
able to meet the dental treatment requirements of patients
with developmental disabilities. (See Article 4.5.2E for
details.)
C. The contractor shall ensure the participation of traditional
and safety-net providers within an enrollment area.
Traditional providers include private practitioners/entities
who provide treatment to the general population or have
participated in the regular Medicaid program. Safety-net
providers include dental education institutions,
hospital-based dental programs, and dental clinics sponsored
by governmental agencies as well as dental clinics sponsored
by private organizations in urban/under-served areas.
4.8.10 GOOD FAITH NEGOTIATIONS
The State shall, in its sole discretion, waive the contractor's
specific network requirements in circumstances where the contractor has
engaged, or attempted to engage in good faith negotiations with
applicable providers. If the contractor asks to be waived from a
specific networking requirement on this basis, it shall document to the
State's satisfaction that good faith negotiations were offered and/or
occurred. Nothing in this Article will relieve the contractor of its
responsibility to furnish the service in question if its is medically
necessary, using qualified providers.
4.8.11 PROVIDER NETWORK ANALYSIS
The contractor shall submit prior to execution of this contract and
annually thereafter a provider network accessibility analysis, using
geographic information system software, in accordance with the
specifications found in Section A.4.3 of the Appendices.
4.9 PROVIDER CONTRACTS AND SUBCONTRACTS
4.9.1 GENERAL PROVISIONS
A. Each generic type of provider contract form shall be submitted
to the DMAHS for review and prior approval to ensure required
elements are included and shall have regulatory approval prior
to the effective date of the contract. Any proposed changes to
an approved contract form shall be reviewed and prior approved
by the DMAHS and shall have regulatory approval from DHSS and
DOBI prior to the effective date. The contractor shall comply
with all DMAHS procedures for contract review and approval
submission. Letters of Intent are not acceptable. Memoranda of
Agreement (MOAs) shall be permitted only if the MOA
automatically converts to a contract within six (6) months of
the effective date and incorporates by reference all
applicable contract provisions contained herein, including but
not limited to Appendix B.7.2, which shall be attached to all
MOAs.
IV-103
B. Each proposed subcontracting arrangement or substantial
contractual relationship including all contract documents and
any subcontractor contracts including all provider contract
forms shall be submitted to the DMAHS for review and prior
approval to ensure required elements are included and shall
have regulatory approval prior to the effective date. Any
proposed change(s) to an approved subcontracting arrangement
including any proposed changes to approved contract forms
shall be reviewed and prior approved by the DMAHS and shall
have regulatory approval from DHSS and DOBI prior to the
effective date. The contractor shall comply with all DMAHS
procedures for contract review and approval submissions.
C. The contractor shall at all times have satisfactory written
contracts and subcontracts with a sufficient number of
providers in and adjacent to the enrollment area to ensure
enrollee access to all medically necessary services listed in
Article 4.1. All provider contracts and subcontracts shall
meet established requirements, form and contents approved by
DMAHS.
D. The contractor, in performing its duties and obligations
hereunder, shall have the right either to employ its own
employees and agents or, for the provision of health care
services, to utilize the services of persons, firms, and other
entities by means of sub-contractual relationships.
E. No provider contract or subcontract shall terminate or in any
way limit the legal responsibility of the contractor to the
Department to assure that all activities under this contract
are carried out. The contractor is not relieved of its
contractual responsibilities to the Department by delegating
responsibility to a subcontractor.
F. All provider contracts and subcontracts shall be in writing
and shall fulfill the requirements of 42 C.F.R. Part 434 that
are appropriate to the service or activity delegated under the
subcontract.
1. Provider contracts and subcontracts shall contain
provisions allowing DMAHS and HHS to evaluate through
inspection or other means, the quality,
appropriateness and timeliness of services performed
under a subcontract to provide medical services (42
C.F.R. Section 434.6(a)(5)).
2. Provider contracts and subcontracts shall contain
provisions pertaining to the maintenance of an
appropriate record system for services to enrollees.
(42 C.F.R. Section 434.6(a)(7))
3. Each provider contract and subcontract shall contain
sufficient provisions to safeguard all rights of
enrollees and to ensure that the subcontract complies
with all applicable State and federal laws, including
confidentiality. See Section B.7.2 of the Appendices.
IV-104
4. Provider contracts and subcontracts shall include the
specific provisions and verbatim language found in
Appendix B.7.2. The verbatim language requirements
shall be used when entering into new provider
contracts, new subcontracts, and when renewing,
renegotiating or recontracting with providers and
subcontractors with existing contracts.
G. The contractor shall submit lists of names, addresses,
ownership/control information of participating providers and
subcontractors, and individuals or entities, which shall be
incorporated in this contract. Such information shall be
updated every quarter.
1. The contractor shall obtain prior DMAHS review and
written approval of any proposed plan for merger,
reorganization or change in ownership of the
contractor and approval by the appropriate State
regulatory agencies.
2. The contractor shall comply with Article 4.9.1G.1 to
ensure uninterrupted and undiminished services to
enrollees, to evaluate the ability of the modified
entity to support the provider network, and to ensure
that any such change has no adverse effects on
DMAHS's managed care program and shall comply with
the Departments of Banking and Insurance, and Health
and Senior Services statutes and regulations.
H. The contractor shall demonstrate its ability to provide all of
the services included under this contract through the approved
network composition and accessibility.
I. The contractor shall not oblige providers to violate their
state licensure regulations.
J. The contractor shall provide its providers and subcontractors
with a schedule of fees and relevant policies and procedures
at least 30 days prior to implementation.
K. The contractor shall arrange for the distribution of
informational materials to all its providers and
subcontractors providing services to enrollees, outlining the
nature, scope, and requirements of this contract.
4.9.2 CONTRACT SUBMISSION
The contractor shall submit to DMAHS one complete, fully executed
contract for each type of provider, i.e., primary care physician,
physician specialist, non-physician practitioner, hospital and other
health care providers/services covered under the benefits package,
subcontract and the form contract of any subcontractor's provider
contracts. The use of a signature stamp is not permitted and shall not
be considered a fully executed contract. Contracts shall be submitted
with all attachments, appendices, rate schedules, etc. A copy of the
appropriate completed contract checklist for DHS, DHSS, and DOBI shall
be attached to each contract form. Regulatory approval and approval by
the
IV-105
Department is required for each provider contract form and subcontract
prior to use. Submission of all other contracts shall follow the format
and procedures described below:
A. Copies of the complete fully executed contract with every
FQHC. Certification of the continued in force contracts
previously submitted will be permitted.
B. Hospital contracts shall list each specific service to be
covered including but not limited to:
1. Inpatient services;
2. Anesthesia and whether professional services of
anesthesiologists and nurse anesthetists are
included;
3. Emergency room services
a. Triage fee - whether facility and
professional fees are included;
b. Medical screening fee - whether facility and
professional fees are included;
c. Specific treatment rates for:
(1) Emergent services
(2) Urgent services
(3) Non-urgent services
(4) Other
d. Other - must specify
4. Neonatology - facility and professional fees
5. Radiology
a. Diagnostic
b. Therapeutic
c. Facility fee
d. Professional services
6. Laboratory - facility and professional services
7. Outpatient/clinic services must be specific and
address
a. Physical and occupational therapy and
therapists
b. Speech therapy and therapists
c. Audiology therapy and therapists
8. AIDS Centers
9. Any other specialized service or center of excellence
10. Hospice services if the hospital has an approved
hospice agency that is Medicare certified.
11. Home Health agency services if hospital has an
approved home health agency license from the
Department of Health and Senior Services that meets
licensing and Medicare certification participation
requirements.
12. Any other service.
C. FQHC contracts:
1. Shall list each specific service to be covered.
2. Shall include reimbursement schedule and methodology.
3. Shall include the credentialing requirements for
individual practitioners.
IV-106
4. Shall include assurance that continuation of the FQHC
contract is contingent on maintaining quality
services and maintaining the Primary Care Evaluation
Review (PCER) review by the federal government at a
good quality level. FQHCs must make available to the
contractor the PCER results annually which shall be
considered in the contractor's QM reviews for
assessing quality of care.
D. For those providers for whom a complete contract is not
required, the contractor shall submit a list of their names,
addresses, Social Security Numbers, and Medicaid provider
numbers (if available). The contractor shall attach to this
list a completed, signed "Certification of Contractor Provider
Network" form (See Section A.4.4 of the Appendices). This form
must be completed and signed by the contractor's attorney or
high-ranking officer with decision-making authority.
4.9.3 PROVIDER CONTRACT AND SUBCONTRACT TERMINATION
A. The contractor shall comply with all the provisions of the New
Jersey HMO regulations at N.J.A.C. 8:38 et seq. regarding
provider termination, including but not limited to 30 day
prior written notice to enrollees and continuity of care
requirements.
B. The contractor shall notify DMAHS at least 30 days prior to
the effective date of suspension, termination, or voluntary
withdrawal of a provider or subcontractor from participation
in this program. If the termination was "for cause," the
contractor's notice to DMAHS shall include the reasons for the
termination.
1. Provider resource consumption patterns shall not
constitute "cause" unless the contractor can
demonstrate it has in place a risk adjustment system
that takes into account enrollee health-related
differences when comparing across providers.
2. The contractor shall assure immediate coverage by a
provider of the same specialty, expertise, or service
provision and shall submit a new contract with a
replacement provider to DMAHS within 30 days of being
finalized.
C. If a primary care provider ceases participation in the
contractor's organization, the contractor shall provide
written notice at least thirty (30) days from the date that
the contractor becomes aware of such change in status to each
enrollee who has chosen the provider as their primary care
provider. If an enrollee is in an ongoing course of treatment
with any other participating provider who becomes unavailable
to continue to provide services to such enrollee and
contractor is aware of such ongoing course of treatment, the
contractor shall provide written notice within fifteen days
from the date that the contractor becomes aware of such
unavailability to such enrollee. Each notice shall also
describe the procedures for continuing care and choice of
other providers who can continue to care for the enrollee.
IV-107
D. All provider contracts shall contain a provision that states
that the contractor shall not terminate the contract with a
provider because the provider expresses disagreement with a
contractor's decision to deny or limit benefits to a covered
person or because the provider assists the covered person to
seek reconsideration of the contractor's decision; or because
a provider discusses with a current, former, or prospective
patient any aspect of the patient's medical condition, any
proposed treatments or treatment alternatives, whether covered
by the contractor or not, policy provisions of a plan, or a
provider's personal recommendation regarding selection of a
health plan based on the provider's personal knowledge of the
health needs of such patients. Nothing in this Article shall
be construed to prohibit the contractor from:
1. Including in its provider contracts a provision that
precludes a provider from making, publishing,
disseminating, or circulating directly or indirectly
or aiding, abetting, or encouraging the making,
publishing, disseminating, or circulating of any oral
or written statement or any pamphlet, circular,
article, or literature that is false or maliciously
critical of the contractor and calculated to injure
the contractor; or
2. Terminating a contract with a provider because such
provider materially misrepresents the provisions,
terms, or requirements of the contractor.
4.9.4 PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL COMMUNICATIONS
A. Any contract between the contractor in relation to health
coverage and a health care provider (or group of health care
providers) shall not prohibit or restrict the provider from
engaging in medical communications with the provider's
patient, either explicit or implied, nor shall any provider
manual, newsletters, directives, letters, verbal instructions,
or any other form of communication prohibit medical
communication between the provider and the provider's patient.
Providers shall be free to communicate freely with their
patients about the health status of their patients, medical
care or treatment options regardless of whether benefits for
that care or treatment are provided under the contract, if the
professional is acting within the lawful scope of practice.
The health care providers shall be free to practice their
respective professions in providing the most appropriate
treatment required by their patients and shall provide
informed consent within the guidelines of the law including
possible positive and negative outcomes of the various
treatment modalities.
B. Nothing in this Article shall be construed:
1. To prohibit the enforcement, as part of a contract or
agreement to which a health care provider is a party,
of any mutually agreed upon terms and conditions,
including terms and conditions requiring a health
care provider
IV-108
to participate in, and cooperate with, all programs,
policies, and procedures developed or operated by the
contractor to assure, review, or improve the quality
and effective utilization of health care services (if
such utilization is according to guidelines or
protocols that are based on clinical or scientific
evidence and the professional judgment of the
provider) but only if the guidelines or protocols
under such utilization do not prohibit or restrict
medical communications between providers and their
patients; or
2. To permit a health care provider to misrepresent the
scope of benefits covered under this contract or to
otherwise require the contractor to reimburse
providers for benefits not covered.
C. The contractor shall not have to provide, reimburse, or
provide coverage of a counseling service or referral service
if the contractor objects to the provision of a particular
service on moral or religious grounds and if the contractor
makes available information in its policies regarding that
service to prospective enrollees before or during enrollment.
Notices shall be provided to enrollees within 90 days after
the date that the contractor adopts a change in policy
regarding such a counseling or referral service.
4.9.5 ANTIDISCRIMINATION
The contractor shall not discriminate with respect to participation,
reimbursement, or indemnification against any provider who is acting
within the scope of the provider's license or certification under
applicable State law, solely on the basis of such licensure or
certification. The contractor may, however, include providers only to
the extent necessary to meet the needs of the organization's enrollees
or establish any measure designed to maintain quality and control costs
consistent with the responsibilities of the contractor.
4.10 EXPERT WITNESS REQUIREMENTS AND COURT OBLIGATIONS
The contractor shall comply with the following provisions concerning
expert witness testimony and court-ordered services:
A. The contractor shall bear the sole responsibility to provide
expert witness services within the State of New Jersey for any
hearings, proceedings, or other meetings and events relative
to services provided by the contractor.
B. These expert witness services shall be provided in all actions
initiated by the Department, providers, enrollees, or any
other party(ies) and which involve the Department and the
contractor.
C. The contractor shall designate and identify staff person(s)
immediately available to perform the expert witness function,
subject to prior approval by the
IV-109
Department. The Department shall exercise, at its sole
discretion, a request for additional or substitute employees
other than the designated expert witness.
D. The contractor shall notify the Department prior to the
delivery of all expert witness services, and/or response(s) to
subpoenas. The notification shall be no later than twenty-four
(24) hours after the contractor is aware of the need to appear
or of the subpoena.
E. The contractor shall provide written analysis and expert
witness services in Fair Hearings and in court regarding any
actions the contractor has taken. In the case of a
contractor's denial, modification, or deferral of a prior
authorization request, the contractor shall present its
position for the denial, modification, or deferral of
procedures during Fair Hearing proceedings.
F. The Department will notify the contractor in a timely manner
of the nature of the subject matter to be covered and the
testimony to be presented and the date, time and location of
the hearing, proceeding, or other meeting or event at which
specific expert witness services are to be provided.
G. The contractor shall coordinate and provide court ordered
medical services (except sexual abuse evaluations). It is the
responsibility of the contractor to inform the courts about
the availability of its providers. If the court orders a
noncontractor source to provide the treatment or evaluation,
the contractor shall be liable for the cost up to the Medicaid
rate if the contractor could not have provided the service
through its own provider network or arrangements.
4.11 ADDITIONS, DELETIONS, AND/OR CHANGES
The contractor shall submit any significant and material changes
regarding policies, procedures, changes to health care delivery system
and substantial changes to contractor operations, providers, provider
networks, subcontractors, and reports to DMAHS for final approval at
least 90 days prior to being published, distributed, and/or
implemented.
IV - 110
ARTICLE FIVE: ENROLLEE SERVICES
5.1 GEOGRAPHIC REGIONS
A. Service Area. The geographic region(s) for which the
contractor has been awarded a contract to establish and
maintain operations for the provision of services to Medicaid
and NJ FamilyCare beneficiaries are indicated below. The
contractor shall have complete provider networks for each of
the counties included in the region(s) approved for this
contract. Coverage for partial regions shall only be permitted
through a prior approval process by DMAHS. The contractor
shall submit a phase-in plan to DMAHS. See Article 2 for
details.
_________Region 1: Bergen, Hudson, Hunterdon, Xxxxxx,
Passaic, Somerset, Sussex, and Xxxxxx
_________Region 2: Essex, Union, Middlesex, and Xxxxxx
_________Region 3: Atlantic, Burlington, Camden, Cape May,
Cumberland, Gloucester, Monmouth,
Ocean, and Salem
B. Enrollment Area. For the purposes of this contract, the
contractor's enrollment area(s) and maximum enrollment limits
(cumulative during the term of the contract) shall be as
follows:
Maximum
Enrollment
County: Limit:
______ Atlantic
______ Bergen
______ Burlington
______ Camden
______ Cape May
______ Cumberland
______ Essex
______ Gloucester
______ Xxxxxx
______ Hunterdon
______ Xxxxxx
______ Middlesex
______ Monmouth
______ Xxxxxx
______ Ocean
______ Passaic
______ Salem
______ Somerset
______ Sussex
______ Union
______ Xxxxxx
V-1
5.2 AID CATEGORIES ELIGIBLE FOR CONTRACTOR ENROLLMENT
A. Except as specified in Article 5.3, all persons who are not
institutionalized, belong to one of the following eligibility
categories, and reside in any of the enrollment areas, as
identified in Article 5.1, are in mandatory aid categories and
shall be eligible for enrollment in the contractor's plan in
the manner prescribed by this contract.
1. Aid to Families with Dependent Children
(AFDC)/Temporary Assistance for Needy Families
(TANF);
2. AFDC/TANF-Related, New Jersey Care...Special Medicaid
Program for Pregnant Women and Children;
3. SSI-Aged, Blind, Disabled, and Essential Spouses;
4. New Jersey Care...Special Medicaid programs for Aged,
Blind, and Disabled;
5. Division of Developmental Disabilities Clients
including the Division of Developmental Disabilities
Community Care Waiver;
6. Medicaid only or SSI-related Aged, Blind, and
Disabled;
7. Uninsured parents/caretakers and children who are
covered under NJ FamilyCare;
8. Uninsured adults and couples without dependent
children under the age of 23 who are covered under NJ
FamilyCare.
B. The contractor shall enroll the entire Medicaid case, i.e.,
all individuals included under the ten digit Medicaid
identification number.
C. DYFS. Individuals who are eligible through the Division of
Youth and Family Services may enroll voluntarily. All
individuals eligible through DYFS shall be considered a unique
Medicaid case and shall be issued an individual 12 digit
Medicaid identification number, and may be enrolled in his/her
own contractor.
D. The contractor shall be responsible for keeping its network of
providers informed of the enrollment status of each enrollee.
E. Dual eligibles (Medicaid-Medicare) may voluntarily enroll.
5.3 EXCLUSIONS AND EXEMPTIONS
Persons who belong to one of the eligible populations (defined in 5.2B)
shall not be subject to mandatory enrollment if they meet one or more
criteria defined in this Article. Persons who fall into an "excluded"
category (Article 5.3.1A) shall not be eligible to enroll in the
contractor's plan. Persons falling into the categories under Article
5.3.1B are eligible to enroll on a voluntary basis. Persons falling
into a category under Article 5.3.2 may be eligible for enrollment
exemption, subject to the Department's review.
V-2
5.3.1 ENROLLMENT EXCLUSIONS
A. The following persons shall be excluded from enrollment in the
managed care program:
1. Individuals in the following Home and Community-based
Waiver programs: Model Waiver I, Model Waiver II,
Model Waiver III, Enhanced Community Options Waiver,
Aids Community Care Alternative Program (ACCAP),
Community Care Program for Elderly and Disabled
(CCPED), assisted living programs, ABC Waiver for
Children, Traumatic Brain Injury (TBI), and DYFS Code
65 children.
2. Individuals in a Medicaid demonstration program.
3. Individuals who are institutionalized in an inpatient
psychiatric institution, long term care nursing
facility or in a residential facility including
Intermediate Care Facilities for the Mentally
Retarded. However, individuals who are eligible
through DYFS and are placed in a DYFS residential
center/facility or individuals in a mental health or
substance abuse residential treatment facility are
not excluded from enrolling in the contractor's plan.
4. Individuals in the Medically Needy, Presumptive
Eligibility for pregnant women, Presumptive
Eligibility for NJ FamilyCare, Home Care Expansion
Program, or PACE program.
5. Infants of inmates of a public institution living in
a prison nursery.
6. Individuals already enrolled in or covered by a
Medicare or private HMO that does not have a contract
with the Department to provide Medicaid services.
7. Individuals in out-of-state placements.
8. Full time students attending school and residing out
of the country will be excluded from New Jersey Care
2000+ participation while in school.
9. The following types of dual beneficiaries: Qualified
Medicare Beneficiaries (QMBs) not otherwise eligible
for Medicaid; Special Low- Income Medicare
Beneficiaries (SLMBs); Qualified Disabled and Working
Individuals (QDWIs); and Qualifying Individuals 1 and
2.
B. The following individuals shall be excluded from the Automatic
Assignment process described in Article 5.4C but may
voluntarily enroll:
V-3
1. Individuals whose Medicaid eligibility will terminate
within three (3) months or less after the projected
date of effective enrollment.
2. Individuals in mandatory eligibility categories who
live in a county where mandatory enrollment is not
yet required based on a phase-in schedule determined
by DMAHS.
3. Individuals enrolled in or covered by either a
Medicare or commercial HMO will not be enrolled in
New Jersey Care 2000+ contractor unless the New
Jersey Care 2000+ contractor and the
Medicare/commercial HMO are the same.
4. Individuals in the Pharmacy Lock-in or Provider
Warning or Hospice programs.
5. Individuals in eligibility categories other than
AFDC/TANF, AFDC/TANF-related New Jersey Care,
SSI-Aged, Blind and Disabled populations, the
Division of Developmental Disabilities Community Care
Waiver population, New Jersey Care - Aged, Blind and
Disabled, or NJ FamilyCare Plan A.
6. Children awaiting adoption through a private agency.
7. Individuals identified as having more than one active
eligible Medicaid number.
8. DYFS Population.
C. The following individuals shall be excluded from the Automatic
Assignment process:
1. Individuals included under the same Medicaid Case
Number where one or more household member(s) are
exempt.
2. Individuals participating in NJ FamilyCare Plans B,
C, and D [Managed Care is the only program option
available for these individuals].
5.3.2 ENROLLMENT EXEMPTIONS
The contractor, its subcontractors, providers or agents shall not
coerce individuals to disenroll because of their health care
needs which may meet an exemption reason, especially when the
enrollees want to remain enrolled. Exemptions do not apply to
NJ FamilyCare Plan B, Plan C, or Plan D individuals or to
individuals who have been enrolled in any contractor for
greater than one hundred and eighty (180) days. All exemption
requests are reviewed by DMAHS on a case by case
V-4
basis. Individuals may be exempted by DMAHS from enrollment in
a contractor for the following reasons:
A. First-time Medicaid/NJ FamilyCare Plan A beneficiaries who are
pregnant women, beyond the first trimester, who have an
established relationship with an obstetrician who is not a
participating provider in any contractor. These individuals
will be tracked and enrolled after sixty (60) days postpartum.
B. Individuals with a terminal illness and who have an
established relationship with a physician who is not a
participating provider in any contractor's plan.
C. Individuals with a chronic, debilitating illness or disability
who have received treatment from a physician and/or team of
providers with expertise in treating that illness with whom
the individuals have an established relationship (greater than
12 months) and who are not participating in any contractor;
and there is no other reasonable alternative as determined by
DMAHS at its sole discretion. Such requests shall be reviewed
by DMAHS on a case by case basis. The individuals or
authorized persons must provide written documentation
identifying all of the providers who provide regular, ongoing
care and who will certify their continued involvement in the
care of these individuals; also provide documentation
detailing how and who will provide medical management for the
individual.
1. Temporary exemption may be granted by DMAHS to allow
the contractor time to contract with a specific
specialist needed by an enrollee with whom there is a
long-standing established relationship (greater than
twelve (12) months) and there is no equivalent
specialist available in the network. The contractor
shall establish appropriate contractual/referral
relationships with any or all specialists needed to
accommodate the needs of enrollees with special
needs.
D. Individuals who do not speak English or Spanish and who meet
the following criteria: i) have an illness requiring on-going
treatment; ii) have an established relationship with a
physician who speaks their primary language; and iii) there is
no available primary care physician in any participating
contractor who speaks the beneficiary's language. These cases
shall be reviewed by DMAHS on a case-bycase basis with no
automatic exemption from initial enrollment.
E. Individuals who do not have a choice of at least two (2) PCPs
within thirty (30) miles of their residence.
5.4 ENROLLMENT OF MANAGED CARE ELIGIBLES
A. Enrollment. The health benefits coordinator (HBC), an agent of
DMAHS, shall enroll Medicaid and NJ FamilyCare applicants. The
HBC will explain the contractors' programs, answer any
questions, and assist eligible individuals or, where
applicable, an authorized person in selecting a contractor.
The contractor
V-5
may also enroll and directly market to individuals eligible
for Aged, Blind, and Disabled (ABD) benefits. The contractor
shall not enroll any other Medicaid-eligible beneficiary
except as described in Article 5.16.A.2. Except as provided in
5.16, the contractor shall not directly market to or assist
managed care eligibles in completing enrollment forms. The
duties of the HBC will include, but are not limited to,
education, enrollment, disenrollment, transfers, assistance
through the contractor's grievance process and other problem
resolutions with the contractor, and communications. The
duties of the contractor, when enrolling ABD beneficiaries
will include education and enrollment, as well as other
activities required within this contract. The contractor shall
cooperate with the HBC in developing information about its
plan for dissemination to Medicaid/NJ FamilyCare
beneficiaries.
B. Individuals eligible under NJ FamilyCare Plan A and NJ
FamilyCare Plan B, Plan C, and Plan D may request an
application via a toll-free number operated under contract for
the State, through an outreach source, or from the contractor.
The applications, including ABD applications taken by the
contractor, may be mailed back to a State vendor. Individuals
eligible under Plan A also have the option of completing the
application either via a mail-in process or on site at the
county welfare agency. Individuals eligible under Plan B, Plan
C, and Plan D have the option of requesting assistance from
the State vendor, the contractor or one of the registered
servicing centers in the community. Assistance will also be
made available at State field offices (e.g. the Medicaid
District Offices) and county offices (e.g. Offices on Aging
for grandparent caretakers).
C. Automatic Assignment. Medicaid eligible persons who reside in
enrollment areas that have been designated for mandatory
enrollment, who qualify for AFDC/TANF, New Jersey
Care...Special Medicaid programs eligibility categories, NJ
FamilyCare Plan A, and SSI populations, who do not meet the
exemption criteria, and who do not voluntarily choose
enrollment in the contractor's plan, shall be assigned
automatically by DMAHS to a contractor.
5.5 ENROLLMENT AND COVERAGE REQUIREMENTS
A. General. The contractor shall comply with DMAHS enrollment
procedures. The contractor shall accept for enrollment any
individual who selects or is assigned to the contractor's
plan, whether or not they are subject to mandatory enrollment,
without regard to race, ethnicity, gender, sexual or
affectional preference or orientation, age, religion, creed,
color, national origin, ancestry, disability, health status or
need for health services.
B. Coverage commencement. Coverage of enrollees shall commence at
12:00 a.m., Eastern Time, on the first day of the calendar
month as specified by the DMAHS with the exceptions noted in
Article 5.5. The day on which coverage commences shall be the
enrollee's effective date of enrollment.
V-6
C. The contractor shall accept enrollment of Medicaid/NJ
FamilyCare eligible persons within the defined enrollment
areas in the order in which they apply or are auto-assigned to
the contractor (on a random basis with equal distribution
among all participating contractors) without restrictions,
within contract limits. Enrollment shall be open at all times
except when the contract limits have been met. A contractor
shall not deny enrollment of a person with an SSI disability
or New Jersey Care Disabled category who resides outside of
the enrollment area. However, such enrollee with a disability
shall be required to utilize the contractor's established
provider network. The contractor shall accept enrollees for
enrollment throughout the duration of this contract.
D. Enrollment timeframe. As of the effective date of enrollment,
and until the enrollee is disenrolled from the contractor's
plan, the contractor shall be responsible for the provision
and cost of all care and services covered by the benefits
package listed in Article 4.1. Enrollees who become eligible
to receive services between the 1st through the end of the
month shall be eligible for Managed Care services in that
month. When an enrollee is shown on the enrollment roster as
covered by a contractor's plan, the contractor shall be
responsible for providing services to that person from the
first day of coverage shown to the last day of the calendar
month of the effective date of disenrollment. DMAHS will pay
the contractor a capitation rate during this period of time.
E. Hospitalizations. For any eligible person who applies for
participation in the contractor's plan, but who is
hospitalized prior to the time coverage under the plan becomes
effective, such coverage shall not commence until the date
after such person is discharged from the hospital and DMAHS
shall be liable for payment for the hospitalization, including
any charges for readmission within forty-eight (48) hours of
discharge for the same diagnosis. If an enrollee's
disenrollment or termination becomes effective during a
hospitalization, the contractor shall be liable for
hospitalization until the date such person is discharged from
the hospital, including any charges for readmission within
fortyeight (48) hours of discharge for the same diagnosis. The
contractor shall notify DMAHS within 180 days of initial
hospital admission.
F. Unless otherwise required by statute or regulation, the
contractor shall not condition any Medicaid/NJ FamilyCare
eligible person's enrollment upon the performance of any act
or suggest in any way that failure to enroll may result in a
loss of Medicaid/NJ FamilyCare benefits.
G. There shall be no retroactive enrollment in Managed Care.
Services for those beneficiaries during any retroactive period
will remain fee-for-service, except for individuals eligible
under NJ FamilyCare Plans B, C, and D who are not eligible
until enrolled in an MCE. Coverage shall continue indefinitely
unless this contract expires or is terminated, or the enrollee
is no longer eligible or is deleted from the contractor's list
of eligible enrollees.
V-7
1. Exceptions and Clarifications
a. The contractor shall be responsible for
providing services to an enrollee unless
otherwise notified by DMAHS. In certain
situations, retroactive re-enrollments may
be authorized by DMAHS.
b. Deceased enrollees. If an enrollee is
deceased and appears on the recipient file
as active, the contractor shall promptly
notify DMAHS. DMAHS shall recover capitation
payments made on a prorated basis after the
date of death.
c. Newborn infants. Newborn infants shall be
the responsibility of the contractor that
covered the mother on the date of birth. The
contractor shall notify DMAHS when a newborn
has not been accreted to its enrollment
roster after eight weeks from the date of
birth. DMAHS will take action with the
appropriate CWA to have the infant accreted
to the eligibility file and subsequently the
enrollment roster following this
notification. (See Section B.5.1 of the
Appendices, for the applicable Notification
of Newborns form and amendments thereto).
The mother's MCE shall be responsible for
the hospital stay for the newborn following
delivery and for subsequent services based
on enrollment in the contractor's plan.
Capitation payments shall be prorated to
cover newborns from the date of birth.
i. SSI. Newborns born to an SSI mother
who never applies for or may not be
eligible for AFDC/TANF remain the
responsibility of the mother's MCE
from the date of birth. The
contractor shall be responsible for
notifying DMAHS when a newborn has
not been accreted to its enrollment
roster after eight weeks from the
date of birth.
ii. DYFS. Newborns who are placed under
the jurisdiction of the Division of
Youth and Family Services are the
responsibility of the MCE that
covered the mother on the date of
birth for medically necessary
newborn care. Such children shall
become FFS upon their placement in a
DYFS-approved out-of-home placement.
iii. NJ FamilyCare. Newborn infants born
to NJ FamilyCare Plans B, C, and D
mothers shall be the responsibility
of the MCE that covered the mother
on the date of birth for a minimum
of 60 days after the birth through
the period ending at the end of the
month in which the 60th day falls
unless the child is determined
eligible beyond this time
V-8
period. The contractor shall notify
DMAHS of the birth immediately in
order to assure payment for this
period.
d. Enrollee no longer in contract area. If an
enrollee moves out of the contractor's
enrollment area and would otherwise still be
eligible to be enrolled in the contractor's
plan, the contractor shall continue to
provide or arrange benefits to the enrollee
until the DMAHS can disenroll him/her. The
contractor shall ask DMAHS to disenroll the
enrollee due to the change of residence as
soon as it becomes aware of the enrollee's
relocation. This provision does not apply to
persons with disabilities, who may elect to
remain with the contractor, or to NJ
FamilyCare Plans B, C, and D enrollees, who
remain enrolled until the end of the month
in which the 60th day after the request
falls.
H. Enrollment Roster. The enrollment roster and weekly
transaction register generated by DMAHS shall serve as the
official contractor enrollment list. However, enrollment
changes can occur between the time when the monthly roster is
produced and capitation payment is made. The contractor shall
only be responsible for the provision and cost of care for an
enrollee during the months on which the enrollee's name
appears on the roster, except as indicated in Article 8.8.
DMAHS shall make available data on eligibility determinations
to the contractor to resolve discrepancies that may arise
between the roster and contractor enrollment files. If DMAHS
notifies the contractor in writing of changes in the roster,
the contractor shall rely upon that written notification in
the same manner as the roster. Corrective action shall be
limited to one (1) year from the date that the change was
effective.
I. Enrollment of Medicaid case. Enrollment shall be for the
entire Medicaid case, i.e., all individuals included under the
ten-digit Medicaid identification number (or 12-digit ID
number in the case of DYFS population). The contractor shall
not enroll a partial case except at the DMAHS' sole
discretion.
J. Weekly Enrollment Transactions. In keeping with a schedule
established by DMAHS, DMAHS will process and forward
enrollment transactions to the contractor on a weekly basis.
K. Capitation Recovery. Capitation payments for a full month
coverage shall be recovered from the contractor on a prorated
basis when an enrollee is admitted to a nursing facility,
psychiatric care facility or other institution including
incarceration and the individual is disenrolled from the
contractor's plan on the day prior to such admission.
L. Adjustments to Capitation. The monthly capitation payments
shall include all adjustments made by DMAHS for reasons such
as but not limited to retroactive validation as for newborns
or retroactive termination of eligibility as for death,
V-9
incarceration or institutionalization. These adjustments will
be documented by DMAHS by means of a remittance tape. With the
exception of newborns, DMAHS shall be responsible for
fee-for-service payments incurred by the enrollee during the
period prior to actual enrollment in the contractor's plan.
M. The contractor shall cooperate with established procedures
whereby DMAHS and the HBC shall monitor enrollment and
disenrollment practices.
N. Nothing in this Article or contract shall be construed to
limit or in any way jeopardize a Medicaid beneficiary's
eligibility for New Jersey Medicaid.
O. DMAHS shall arrange for the determination of eligibility of
each potential enrollee for covered services under this
contract and to arrange for the provision of complete
information to the contractor with respect to such
eligibility, including notification whenever an enrollee's
Medicaid/NJ FamilyCare eligibility is discontinued.
5.6 VERIFICATION OF ENROLLMENT
A. The contractor shall be responsible for keeping its network of
providers informed of the enrollment status of each enrollee.
The contractor shall be able to report and ensure enrollment
to network providers through electronic means.
B. The contractor shall maintain procedures to ensure that each
individual's enrollment in the contractor's plan may be
verified with the use of the Medicaid/NJ FamilyCare
Eligibility Identification Card issued by the State and/or
card issued by the contractor through:
1. Point of Service Device (POS)
2. Claims and Eligibility Real Time System (CERTS)
3. Automated Eligibility Verification System (AEVS)
C. Providers should not wait more than three (3) minutes to
verify enrollment.
5.7 MEMBER SERVICES UNIT
A. Defined. The contractor shall have in place a Member Services
Unit to coordinate and provide services to Medicaid/NJ
FamilyCare managed care enrollees. The services as described
in this Article include, but are not limited to enrollee
selection, changes, assignment, and/or reassignment of a PCP,
explanation of benefits, assistance with filing and resolving
inquiries, billing problems, grievances and appeals,
referrals, appointment scheduling and cultural and/or
linguistic needs. This unit shall also provide orientation to
contractor operations and assistance in accessing medical and
dental care.
V-10
B. Staff Training. The contractor shall develop a system to
ensure that new and current Member Services staff receive
basic and ongoing training and have expertise necessary to
provide accurate information to all Medicaid/NJ FamilyCare
enrollees regarding program benefits and contractor's
procedures.
C. Communication-Affecting Conditions. The contractor shall
ensure that Member Services staff have training and experience
needed to provide effective services to enrollees with special
needs, and are able to communicate effectively with enrollees
who have communication-affecting conditions, in accordance
with this Article.
D. Language Requirements. The Member Services staff shall include
individuals who speak English, Spanish and any other language
which is spoken as a primary language by a population that
exceeds five (5) percent of the contractor's Medicaid/NJ
FamilyCare enrollees or two hundred (200) enrollees in the
contractor's plan, whichever is greater.
E. Member Services Manual. The contractor shall maintain a
current Member Services Manual to serve as a resource of
information for Member Services staff. A copy shall be
provided to the Department during the readiness site visit. On
an annual basis, all changes to the Member Services Manual
shall be incorporated into the master used for making
additional distribution copies of the manual.
F. The contractor shall provide an after-hours call-in system to
triage urgent care and emergency calls from enrollees.
G. The contractor shall have written policies and procedures for
member services to refer enrollees to a health professional to
triage urgent care and emergencies during normal hours of
operation.
H. The Contractor shall submit any significant and material
changes to its member services policies and procedures to the
Department prior to being implemented.
5.8 ENROLLEE EDUCATION AND INFORMATION
5.8.1 GENERAL REQUIREMENTS
A. Written Material Submission to DMAHS. The contractor shall
submit the format and content of all written
materials/notifications and orientations described in this
contract to DMAHS for review and approval prior to enrollee
contact/distribution. All appropriate materials shall be
submitted by DMAHS to the State Medical Advisory Committee for
review.
B. The contractor shall prepare and distribute with prior
approval by DMAHS, bilingual marketing and informational
materials to Medicaid/NJ FamilyCare beneficiaries, enrollees
(or, where applicable, an authorized person), and
V-11
providers, and shall include basic information about its plan.
Information must be in language that ensures that all
beneficiaries can understand each process. Written information
shall be culturally and linguistically sensitive.
C. The contractor shall establish a mechanism and present to
DMAHS how its enrollees will be continually educated about its
policies and procedures; the role of participants in the
education process including contractor administration, member
and provider services, care managers, and network providers;
how the "educators" are made aware of their education role;
and how the contractor will assure the State this process will
be monitored to assure successful outcomes for all enrollees,
particularly enrollees with special needs and the homeless.
5.8.2 ENROLLEE NOTIFICATION/HANDBOOK
Prior to the effective date of enrollment, the contractor shall provide
each enrolled case or, where applicable, authorized person, with a
bilingual (English/Spanish) member handbook and an Identification Card.
The handbook shall be written at the fifth grade reading level or at an
appropriate reading level for enrollees with special needs. The
handbook shall also be available on request in other languages and
alternative formats, e.g., large print, Braille, audio cassette, or
diskette for enrollees with sensory impairments or in a modality that
meets the needs of enrollees with special needs. The content and format
of the handbook shall have the prior written approval of DMAHS and
shall describe all services covered by the contractor, exclusions or
limitations on coverage, the correct use of the contractor's plan, and
other relevant information, including but not limited to the following:
A. Cover letter, explaining the member handbook, expected
effective date of enrollment, and when identification card
will be received (if not sent with the handbook);
1. The enrollee's expected effective date of enrollment;
provided that, if the actual effective date of
enrollment is different from that given to the
enrollee or, where applicable, an authorized person,
at the time of enrollment, the contractor shall
notify the enrollee or, where applicable, an
authorized person of the change;
B. A clear description of benefits included in this contract with
exclusions, restrictions, and limitations. Clarification that
enrollees who are clients of the Division of Developmental
Disabilities will receive mental health/substance abuse
services through the contractor (may be addressed through a
separate insert to the basic handbook);
C. An explanation of the procedures for obtaining covered
services;
D. An explanation of the use of the contractor's toll free
telephone number (staffed for twenty-four (24) hours per
day/seven (7) days per week communication);
V-12
E. A listing of primary care practitioners (in the format
described in Article 4.8.4);
F. An identification card clearly indicating that the bearer is
an enrollee of the contractor's plan; and the name of the
primary care practitioner and telephone number on the card; a
description of the enrollee identification card to be issued
by the contractor; and an explanation as to its use in
assisting beneficiaries to obtain services;
G. An explanation that beneficiaries shall obtain all covered
non-emergency health care services through the contractor's
providers;
H. An explanation of the process for accessing emergency services
and services which require or do not require referrals;
I. A definition of the term "emergency medical condition" and an
explanation of the procedure for obtaining emergency services,
including the need to contact the PCP for urgent care
situations and prior to accessing such services in the
emergency room;
J. An explanation of the importance of contacting the PCP
immediately for an appointment and appointment procedures;
K. An explanation of where and how twenty-four (24) hour per day,
seven (7) day per week, emergency services are available,
including out-of-area coverage, and procedures for emergency
and urgent health care service;
L. A list of the Medicaid and/or NJ FamilyCare services not
covered by the contractor and an explanation of how to receive
services not covered by this contract including the fact that
such services may be obtained through the provider of their
choice according to regular Medicaid program regulations. The
contractor may also assist an enrollee or, where applicable,
an authorized person, in locating a referral provider;
M. A notification of the enrollee's right to obtain family
planning services from the contractor or from any appropriate
Medicaid participating family planning provider (42 C.F.R.
Sections 431.51(b)); as well as an explanation that
enrollees covered under NJ FamilyCare Plan D may only obtain
family planning services through the contractor's provider
network, and that family planning services outside the
contractor's provider network are not covered services.
N. A description of the process for referral to specialty and
ancillary care providers and second opinions;
V-13
O. An explanation of the reasons for which an enrollee may
request a change of PCP, the process of effectuating that
change, and the circumstances under which such a request may
be denied;
P. The reasons and process by which a provider may request an
enrollee to change to a different PCP;
Q. An explanation of an enrollee's rights to disenroll or
transfer at any time for cause; disenroll or transfer in the
first 90 days after the latter of the date the individual
enrolled or the date they receive notice of enrollment and at
least every twelve (12) months thereafter without cause and
that the lock-in period does not apply to ABD, DDD or DYFS
individuals;
R. Complaints and Grievances
1. Procedures for resolving complaints, as approved by
the DMAHS;
2. A description of the grievance procedures to be used
to resolve disputes between a contractor and an
enrollee, including: the name, title, or department,
address, and telephone number of the person(s)
responsible for assisting enrollees in grievance
resolutions; the time frames and circumstances for
expedited and standard grievances; the right to
appeal a grievance determination and the procedures
for filing such an appeal; the time frames and
circumstances for expedited and standard appeals; the
right to designate a representative; a notice that
all disputes involving clinical decisions will be
made by qualified clinical personnel; and that all
notices of determination will include information
about the basis of the decision and further appeal
rights, if any;
3. The contractor shall notify all enrollees in their
primary language of their rights to file grievances
and appeal grievance decisions by the contractor;
S. An explanation that Medicaid/NJ FamilyCare Plan A enrollees
have the right to a Medicaid Fair Hearing with DMAHS and the
appeal process through the DHSS for Medicaid and NJ FamilyCare
enrollees, including instructions on the procedures involved
in making such a request;
T. Title, addresses, phone numbers and a brief description of the
contractor for contractor management/service personnel;
U. The interpretive, linguistic, and cultural services available
through the contractor's personnel;
V. An explanation of the terms of enrollment in the contractor's
plan, continued enrollment, disenrollment procedures, time
frames for each procedure, default procedures, enrollee's
rights and responsibilities and causes for which an enrollee
V-14
shall lose entitlement to receive services under this
contract, and what should be done if this occurs;
W. A statement strongly encouraging the enrollee to obtain a
baseline physical and dental examination, and to attend
scheduled orientation sessions and other educational and
outreach activities;
X. A description of the EPSDT program, and language encouraging
enrollees to make regular use of preventive medical and dental
services;
Y. Provision of information to enrollees or, where applicable, an
authorized person, to enable them to assist in the selection
of a PCP;
Z. Provision of assistance to clients who cannot identify a PCP
on their own;
AA. An explanation of how an enrollee may receive mental health
and substance abuse services;
BB. An explanation of how to access transportation services;
CC. An explanation of service access arrangements for home bound
enrollees;
DD. A statement encouraging early prenatal care and ongoing
continuity of care throughout the pregnancy;
EE. A notice that an enrollee may obtain a referral to a health
care provider outside of the contractor's network or panel
when the contractor does not have a health care provider with
appropriate training and experience in the network or panel to
meet the particular health care needs of the enrollee and
procedure by which the enrollee can obtain such referral;
FF. A notice that an enrollee with a condition which requires
ongoing care from a specialist may request a standing referral
to such a specialist and the procedure for requesting and
obtaining such a specialist referral;
GG. A notice that an enrollee with (i) a life-threatening
condition or disease or (ii) a degenerative and/or disabling
condition or disease, either of which requires specialized
medical care over a prolonged period of time may request a
specialist or specialty care center responsible for providing
or coordinating the enrollee's medical care and the procedure
for requesting and obtaining such a specialist or access to
the center;
HH. A notice of all appropriate mailing addresses and telephone
numbers to be utilized by enrollees seeking information or
authorization;
II. A notice of pharmacy Lock-In program and procedures;
V-15
JJ. An explanation of the time delay of thirty (30) to forty-five
(45) days between the date of initial application and the
effective date of enrollment; however, during this interim
period, prospective Medicaid enrollees will continue to
receive health care benefits under the regular fee-for-service
Medicaid program or the HMO with which the person is currently
enrolled. Enrollment is subject to verification of the
applicant's eligibility for the Medicaid program and New
Jersey Care 2000+ enrollment; and the time delay of thirty
(30) to forty-five (45) days between the date of request for
disenrollment and the effective date of disenrollment;
KK. An explanation of the appropriate uses of the Medicaid/NJ
FamilyCare identification card and the contractor
identification card;
LL. A notification, whenever applicable, that some primary care
physicians may employ other health care practitioners, such as
nurse practitioners or physician assistants, who may
participate in the patient's care;
MM. The enrollee's or, where applicable, an authorized person's
signed authorization on the enrollment application allows
release of medical records;
NN. Notification that the enrollee's health status survey
(obtained only by the HBC) will be sent to the contractor by
the Health Benefits Coordinator;
OO. A notice that enrollment and disenrollment is subject to
verification and approval by DMAHS;
PP. An explanation of procedures to follow if enrollees receive
bills from providers of services, in or out of network;
QQ. An explanation of the enrollee's financial responsibility for
payment when services are provided by a health care provider
who is not part of the contractor's organization or when a
procedure, treatment or service is not a covered health care
benefit by the contractor and/or by Medicaid;
RR. A written explanation at the time of enrollment of the
enrollee's right to terminate enrollment, and any other
restrictions on the exercise of those rights, to conform to 42
U.S.C. Section 1396b(m)(2)(F)(ii). The initial enrollment
information and the contractor's member handbook shall be
adequate to convey this notice and shall have DMAHS approval
prior to distribution;
SS. An explanation that the contractor will contact or facilitate
contact with, and require its PCPs to use their best efforts
to contact, each new enrollee or, where applicable, an
authorized person, to schedule an appointment for a complete,
age/sex specified baseline physical, and for enrollees with
special needs who have been identified through a Complex Needs
Assessment as having complex needs,
V-16
the development of an Individual Health Care Plan at a time
mutually agreeable to the contractor and the enrollee, but not
later than ninety (90) days after the effective date of
enrollment for children under twenty-one (21) years of age,
and not later than one hundred eighty (180) days after initial
enrollment for adults; for adult clients of DDD, no later than
ninety (90) days after the effective date of enrollment; and
encourage enrollees to contact the contractor and/or their PCP
to schedule an appointment;
TT. An explanation of the enrollee's rights and responsibilities
which should include, at a minimum, the following, as well as
the provisions found in Standard X in NJ modified QARI/QISMC
in Section B.4.14 of the Appendices.
1. Provision for "Advance Directives," pursuant to 42
C.F.R. Part 489, Subpart I;
2. Participation in decision-making regarding their
health care;
3. Provision for the opportunity for enrollees or, where
applicable, an authorized person to offer suggestions
for changes in policies and procedures; and
4. A policy on the treatment of minors.
UU. Notification that prior authorization for emergency services,
either in-network or out-of-network, is not required;
VV. Notification that the costs of emergency screening
examinations will be covered by the contractor when the
condition appeared to be an emergency medical condition to a
prudent layperson;
WW. For beneficiaries subject to cost-sharing (i.e., those
eligible through NJ FamilyCare Plan C and D; See Section B.5.2
of the Appendices), information that specifically explains:
1. The limitation on cost-sharing;
2. The dollar limit that applies to the family based on
the reported income;
3. The need for the family to keep track of the
cost-sharing amounts paid; and
4. Instructions on what to do if the cost-sharing
requirements are exceeded.
XX. An explanation on how to access WIC services;
V-17
YY. Any other information essential to the proper use of the
contractor's plan as may be required by the Division; and
ZZ. Inform enrollees of the availability of care management
services.
AAA. Enrollee right to adequate and timely information related to
physician incentives.
BBB. An explanation that Medicaid benefits received after age 55
may be reimbursable to the State of New Jersey from the
enrollee's estate. The recovery may include premium payments
made on behalf of the beneficiary to the managed care
organization in which the beneficiary enrolls.
5.8.3 ANNUAL INFORMATION TO ENROLLEES
The contractor shall distribute an updated handbook which will include
the information specified in Article 5.8.2 to each enrollee or
enrollee's family unit and to all providers at least once every twelve
(12) months.
5.8.4 NOTIFICATION OF CHANGES IN SERVICES
The contractor shall revise and distribute the information specified in
Article 5.8 at least thirty (30) calendar days prior to any changes
that the contractor makes in services provided or in the locations at
which services may be obtained, or other changes of a program nature or
in administration, to each enrollee and all providers affected by that
change.
5.8.5 ID CARD
A. Except as set forth in Section 5.9.1C. the contractor shall
deliver to each new enrollee prior to the effective enrollment
date but no later than seven (7) days after the enrollee's
effective date of enrollment a contractor Identification Card
for those enrollees who have selected a PCP. The
Identification Card shall have at least the following
information:
1. Name of enrollee
2. Issue Date for use in automated card replacement
process
3. Primary Care Provider Name (may be affixed by
sticker)
4. Primary Care Provider Phone Number (may be affixed by
sticker)
5. What to do in case of an emergency and that no prior
authorization is required
6. Relevant copayments/Personal Contributions to Care
7. Contractor 800 number - emergency message
Any additional information shall be approved by DMAHS prior to
use on the ID card.
V-18
B. For children and individuals eligible solely through the NJ
FamilyCare Program, the identification card must clearly
indicate "NJ FamilyCare"; for children and individuals who are
participating in NJ FamilyCare Plans C and D the cost-sharing
amount shall be listed on the card. However, if the family
limit for cost-sharing has been reached, the identification
card shall indicate a zero cost-sharing amount. The State will
notify the contractor when such limits have been reached.
5.8.6 ORIENTATION AND WELCOME LETTER
A. Welcome Letter. The contractor shall mail a welcome letter to
each new enrollee or authorized person prior to the enrollee's
effective date of coverage. The welcome letter shall explain
the member handbook, the enrollee's expected effective date of
enrollment, and when the enrollee's identification card will
be received.
B. Individual or Group Orientation. The contractor shall offer
barrier free individual or group orientation, by telephone or
in person, to enrollees, family members, or, where applicable,
authorized persons who are able to be contacted regarding the
delivery system. Orientation shall normally occur within
thirty (30) days of the date of enrollment, except that the
contractor shall attempt to provide orientation within ten
(10) days to each enrollee who has been identified as having
special needs. The contractor shall provide orientation
education that includes at least the following:
1. Specific information listed within the member
handbook.
2. The circumstances under which a team of professionals
(e.g., care management) is convened, the role of the
team, and the manner in which it functions.
C. Prior to conducting the first orientation, the contractor
shall submit for the readiness on-site review a curriculum
that meets the requirements of this provision to DMAHS for
approval.
5.9 PCP SELECTION AND ASSIGNMENT
The contractor shall place a high emphasis on ensuring that enrollees
are informed and have access to enroll with traditional and safety net
providers. The contractor shall place a high priority on enrolling
enrollees with their existing PCP. If an enrollee does not select a
PCP, the enrollee shall be assigned to his/her PCP of record (based
upon prior history information) if that PCP is still a participating
provider with the contractor. All contract materials shall provide
equal information about enrollment with traditional and safety net
providers as that provided about contractor operated offices. All
materials, documents, and phone scripts shall be reviewed and approved
by the Department before use.
V-19
5.9.1 INITIAL SELECTION/ASSIGNMENT
A. General. Each enrollee in the contractor's plan shall be given
the option of choosing a specific PCP in accordance with
Articles 4.5 and 4.8 within the contractor's provider network
who will be responsible for the provision of primary care
services and the coordination of all other health care needs
through the mechanisms listed in this Article.
The HBC will provide the contractor with information, when
available, of existing PCP relationships via the Plan
Selection Form. The contractor shall, at the enrollee's
option, maintain the PCP-patient relationship.
B. PCP Selection. The contractor shall provide enrollees with
information to facilitate the choice of an appropriate PCP.
This information shall include, where known, the name of the
enrollee's provider of record, and a listing of all
participating providers in the contractor's network. (See
Article 4.8.4 for a description of the required listing.)
C. PCP Assignment. If the contractor has not received an
enrollee's PCP selection within ten (10) calendar days from
the enrollee's effective date of coverage or the selected
PCP's panel is closed, the contractor shall assign a PCP and
deliver an ID card by the fifteenth (15th) calendar day after
the effective date of enrollment. The assignment shall be made
according to the following criteria, in hierarchical order:
1. The enrollee shall be assigned to his/her current
provider, if known, as long as that provider is a
part of the contractor's provider network.
2. The enrollee shall be assigned to a PCP whose office
is within the travel time/distance standards, as
defined in Article 4.8.8. If the language and/or
cultural needs of the enrollee are known to the
contractor, the enrollee shall be assigned to a PCP
who is or has office staff who are linguistically and
culturally competent to communicate with the enrollee
or have the ability to interpret in the provision of
health care services and related activities during
the enrollee's office visits or contacts.
5.9.2 PCP CHANGES
A. Enrollee Request. Any enrollee or, where applicable,
authorized person dissatisfied with the PCP selected or
assigned shall be allowed to reselect or be assigned to
another PCP. Such reassignment shall become effective no later
than the beginning of the first month following a full month
after the request to change the enrollee's PCP. Except for
DYFS enrollees, this reselection or reassignment for any cause
may be limited, at the contractor's discretion, to two (2)
times per year. However, in the event there is reasonable
cause following policies and
V-20
procedures as determined by the contractor and approved by the
Department, the enrollee or, where applicable, authorized
person may reselect or be reassigned at any time, regardless
of the number of times the enrollee has previously changed
PCPs.
In the event an enrollee becomes non-eligible and then
re-eligible within six (6) months in the same region, said
enrollee shall, if at all possible, be assigned to the same
PCP. In such a circumstance, the contractor may count previous
PCP changes toward the annual two-change limit.
B. PCP Request. The contractor shall develop policies and
procedures, which shall be prior approved by the Department,
for allowing a PCP to request reassignment of an enrollee,
e.g., for irreconcilable differences, for when an enrollee has
taken legal action against the provider, or if an enrollee
fails to comply with health care instructions and such
non-compliance prevents the provider from safely and/or
ethically proceeding with that enrollee's health care
services. The contractor shall approve any reassignments and
require documentation of the reasons for the request for
reassignment. For example, if a PCP requests reassignment of
an enrollee for failure to comply with health care
instructions, the contractor shall take into consideration
whether the enrollee has a physical or developmental
disability that may contribute to the noncompliance, and
whether the provider has made reasonable efforts to
accommodate the enrollee's needs. In the case of DYFS-eligible
children, copies of such requests shall be sent to the
Division of Youth and Family Services, c/o Medicaid Liaison,
XX Xxx 000, Xxxxxxx, XX 00000-0000.
C. PCP Change Form. If a change form is used, by the contractor,
the contractor shall immediately provide the PCP Change Form
to an enrollee wishing a change, if such request is made in
person, or by mail if requested by telephone or in writing.
The contractor shall mail the form within three (3) business
days of receiving a telephone or written request for a form.
D. Processing of PCP Change Forms. If a change form is used by
the contractor, enrollees shall submit the PCP change form to
the contractor for processing. The contractor shall process
the form and return the enrollee identification card or
self-adhering sticker to the enrollee within ten (10) calendar
days of the postmark date on the mailing envelope or, if not
received by mail, the date received by the contractor.
E. Verbal Requests for PCP Change. The contractor may accept
verbal requests from enrollees or authorized persons to change
PCPs. However, the contractor shall document the verbal
request including at a minimum name of caller, date of call,
and selected PCP. The contractor shall process the request and
return the enrollee identification card or self-adhering
sticker to the enrollee within ten (10) calendar days of the
request for PCP change.
V-21
5.10 DISENROLLMENT FROM CONTRACTOR'S PLAN
5.10.1 GENERAL PROVISIONS
A. Non-discrimination. Disenrollment from contractor's plan shall
not be based in whole or in part on an adverse change in the
enrollee's health, on any of the factors listed in Article
7.8, or on amounts payable to the contractor related to the
enrollee's participation in the contractor's plan.
B. Coverage. The contractor shall not be responsible for the
provision and cost of care and services for an enrollee after
the effective date of disenrollment unless the enrollee is
admitted to a hospital prior to the expected effective date of
disenrollment, in which case the contractor is responsible for
the provision and cost of care and services covered under this
contract until the date on which the enrollee is discharged
from the hospital, including any charge for the enrollee
readmitted within forty-eight (48) hours of discharge for the
same diagnosis.
C. Notification of Disenrollment Rights. The contractor shall
notify through personalized, written notification the enrollee
or, where applicable, authorized person of the enrollee's
disenrollment rights at least sixty (60) days prior to the end
of his/her twelve (12)-month enrollment period. The contractor
shall notify the enrollee of the effective disenrollment date
D. Release of Medical Records. The contractor shall transfer or
facilitate the transfer of the medical record (or copies of
the medical record), upon the enrollee's or, where applicable,
an authorized person's request, to either the enrollee, to the
receiving provider, or, in the case of a child eligible
through the Division of Youth and Family Services, to a
representative of the Division of Youth and Family Services or
to an adoptive parent receiving subsidy through DYFS, at no
charge, in a timely fashion, i.e., no later than ten days
prior to the effective date of transfer. The contractor shall
release medical records of the enrollee, and/or facilitate the
release of medical records in the possession of participating
providers as may be directed by DMAHS authorized personnel and
other appropriate agencies of the State of New Jersey, or the
federal government. Release of medical records shall be
consistent with the provisions of confidentiality as expressed
in Article 7.40 of this contract and the provisions of 42
C.F.R. Section 431.300. For individuals being served through
the Division of Youth and Family Services, release of medical
records must be in accordance with the provisions under
N.J.S.A. 9:6-8.10a and 9:6-8.40 and consistent with the need
to protect the individual's confidentiality.
E. In the event the contract, or any portion thereof, is
terminated, or expires, the contractor shall assist DMAHS in
the transition of enrollees to other contractors. Such
assistance and coordination shall include, but not be limited
to, the forwarding of medical and other records and the
facilitation and scheduling of medically necessary
appointments for care and services. The cost of reproducing
V-22
and forwarding medical charts and other materials shall be
borne by the contractor. The contractor shall be responsible
for providing all reports set forth in this contract. The
contractor shall make provision for continuing all management
and administrative services until the transition of enrollees
is completed and all other requirements of this contract are
satisfied. The contractor shall be responsible for the
following:
1. Identification and transition of chronically ill,
high risk and hospitalized enrollees, and enrollees
in their last four weeks of pregnancy.
2. Transfer of requested medical records.
5.10.2 DISENROLLMENT FROM THE CONTRACTOR'S PLAN AT THE ENROLLEE'S REQUEST
A. An individual enrolled in a contractor's plan may be subject
to the enrollment Lock-In period provided for in this Article.
The enrollment Lock-In provision does not apply to SSI and New
Jersey Care ABD individuals, clients of DDD or to individuals
eligible to participate through the Division of Youth and
Family Services.
1. An enrollee subject to the enrollment Lock-In period
may initiate disenrollment or transfer for any reason
during the first ninety (90) days after the latter of
the date the individual is enrolled or the date they
receive notice of enrollment with a new contractor
and at least every twelve (12) months thereafter
without cause. NJ FamilyCare Plans B, C, or D
enrollees will be subject to a twelve (12)-month
Lock-In period.
a. The period during which an individual has
the right to disenroll from the contractor's
plan without cause applies to an
individual's initial period of enrollment
with the contractor. If that individual
chooses to re-enroll with the contractor,
his/her initial date of enrollment with the
contractor will apply.
2. An enrollee subject to the Lock-In period may
initiate disenrollment for good cause at any time.
a. Good cause reasons for disenrollment or
transfer shall include, unless otherwise
defined by DMAHS:
i. Failure of the contractor to provide
services including physical access
to the enrollee in accordance with
the terms of this contract;
ii. Enrollee has filed a grievance with
the contractor pursuant to the
applicable grievance procedure and
has not received
V-23
a response within the specified time
period stated therein,or in a
shorter time period required by
federal law;
iii. Documented grievance, by the
enrollee against the contractor's
plan without satisfaction.
iv. Enrollee is subject to enrollment
exemption as set forth in Article
5.3.2. If an exemption situation
exists within the contractor's plan
but another contractor can
accommodate the individual's needs,
a transfer may be granted.
v. Enrollee has substantially more
convenient access to a primary care
physician who participates in
another MCE in the same enrollment
area.
B. Voluntary Disenrollment. The contractor shall assure that
enrollees who disenroll voluntarily are provided with an
opportunity to identify, in writing, their reasons for
disenrollment. The contractor shall further:
1. Require the return, or invalidate the use of the
contractor's identification card; and
2. Forward a copy of the disenrollment request or refer
the beneficiary to DMAHS/HBC by the eighth (8th) day
of the month prior to the month in which
disenrollment is to become effective.
C. HBC Role. All enrollee requests to disenroll must be made
through the Health Benefits Coordinator. The contractor may
not induce, discuss or accept disenrollments. Any enrollee
seeking to disenroll should be directed to contact the HBC.
This applies to both mandatory and voluntary enrollees.
Disenrollment shall be completed by the HBC at facilities and
in a manner so designated by DMAHS.
D. Effective Date. The effective date of disenrollment or
transfer shall be no later than the first day of the month
immediately following the full calendar month the
disenrollment is initiated by DMAHS. Notwithstanding anything
herein to the contrary, the remittance tape, along with any
changes reflected in the weekly register or agreed upon by
DMAHS and the contractor in writing, shall serve as official
notice to the contractor of disenrollment of an enrollee.
5.10.3 DISENROLLMENT FROM THE CONTRACTOR'S PLAN AT THE CONTRACTOR'S REQUEST
A. Criteria for Contractor Disenrollment Request. The contractor
may recommend, with written documentation to DMAHS, the
disenrollment of an enrollee. In no
V-24
event may an enrollee be disenrolled due to health status or
need for health services. Enrollees may be disenrolled in any
of the following circumstances:
1. The contractor determines that the willful actions of
the enrollee are inconsistent with membership in the
contractor's plan, and the contractor has made and
provides DMAHS with documentation of at least three
attempts to reconcile the situation. Examples of
inconsistent actions include but are not limited to:
persistent refusal to cooperate with any
participating provider regarding procedures for
consultations or obtaining appointments (this does
not preclude an enrollee's right to refuse
treatment), intentional misconduct, willful refusal
to receive prior approval for non-emergency care;
willful refusal to comply with reasonable
administrative policies of the contractor, fraud, or
making a material misrepresentation to the
contractor. In no way can this provision be applied
to individuals on the basis of their physical
condition, utilization of services, age,
socio-economic status or mental disability.
2. The contractor becomes aware that the enrollee falls
into an aid category that is not set forth in Article
5.2 of this contract, has become ineligible for
enrollment pursuant to Article 5.3.1 of this
contract, or has moved to a residence outside of the
enrollment area covered by this contract.
B. Reasonable Efforts Prior to Disenrollment. Prior to
recommending disenrollment of an enrollee, the contractor
shall make a reasonable effort to identify for the enrollee
or, where applicable, an authorized person those actions that
have interfered with effective provision of covered medical
care and services, and to explain what actions or procedures
are acceptable. The contractor must allow the enrollee or,
where applicable, an authorized person sufficient opportunity
to comply with acceptable procedures prior to recommending
disenrollment. The contractor shall provide at least one
verbal and at least one written warning to the enrollee
regarding the implications of his/her actions.
If the enrollee, or, where applicable, an authorized person
fails to comply with acceptable procedures, the contractor
shall give at least thirty (30) days prior written notice to
the enrollee, or, where applicable, an authorized person, of
its intent to recommend disenrollment. The notice shall
include a written explanation of the reason the contractor
intends to request disenrollment, and advise the enrollee or,
where applicable, an authorized person of his/her right to
file a disenrollment grievance. The contractor shall give
DMAHS a copy of the notice and advise DMAHS immediately if the
enrollee or, where applicable, an authorized person files a
disenrollment grievance.
C. Disenrollment Appeals. The contractor shall notify DMAHS of
decisions related to all appeals filed by an enrollee or,
where applicable, an authorized person as a result of the
contractor's notice to an enrollee of its intent to recommend
disenrollment. If the enrollee has not filed an appeal or if
the contractor
V-25
determines that the appeal is unfounded, the contractor may
submit to the Office of Managed Health Care of DMAHS a
recommendation for disenrollment of the enrollee. The
contractor shall notify the enrollee in writing of such
request at the time it is filed with DMAHS.
DMAHS will decide within ten (10) business days after receipt
of the contractor's recommendation whether to disenroll the
enrollee and will provide a written determination and
notification of the right to a Fair Hearing to the enrollee
or, where applicable, an authorized person and the contractor.
D. The DMAHS shall review each involuntary disenrollment and may
require an in-depth review by State staff, including but not
limited to patient and provider interviews, medical record
review, and home assessment to determine with the enrollee
what plan of action would serve the best interests of the
enrollee (and family as applicable.)
5.10.4 TERMINATION
A. Enrollees shall be terminated from the contractor's plan
whenever:
1. The contract between the contractor and DMAHS is
terminated for any reason;
2. The enrollee loses Medicaid/NJ FamilyCare
eligibility;
3. Nonpayment of premium for individuals eligible
through the NJ FamilyCare Program occurs;
4. DMAHS is notified that the enrollee has moved outside
of the enrollment area that the contractor does not
service;
5. The enrollee requires more than thirty (30) days of
service from a post-acute facility, in which case the
contractor shall provide health care services to the
enrollee through the last day of the month following
the enrollee's admission to the facility.
B. For enrollees covered by the contractor's plan who are
eligible through the Division of Youth and Family Services and
who move to a residence outside of the enrollment area covered
by this contract:
1. The DYFS representative will immediately contact the
HBC.
2. The HBC will process the enrollee's disenrollment and
transfer the enrollee to a new contractor; or
disenroll the enrollee to the fee-for-service
coverage under DMAHS.
V-26
3. The contractor shall continue to provide services to
the enrollee until the enrollee is disenrolled from
the contractor's plan.
C. Loss of Medicaid or NJ FamilyCare Eligibility. When an
enrollee's coverage is terminated due to a loss of Medicaid or
NJ FamilyCare eligibility, the contractor shall offer to the
enrollee the opportunity to convert the enrollee's membership
to a non-group, non-Medicaid enrollment, consistent with
conversion privileges offered to other groups enrolled in the
contractor.
D. In no event shall an enrollee be disenrolled due to health
status, need for health services, or pre-existing medical
conditions.
5.11 TELEPHONE ACCESS
A. Twenty-Four Hour Coverage. The contractor shall maintain a
twenty-four (24) hours per day, seven (7) days per week
toll-free telephone answering system that will respond in
person (not voice mail) and will include Telecommunication
Device for the Deaf (TDD) or Tech Telephone (TT) systems.
Telephone staff shall be adequately trained and staffed and
able to promptly advise enrollees of procedures for emergency
and urgent care. The telephone answering system must be
available at no cost to the enrollees for local and
long-distance calls from within or out-of-state.
B. The contractor shall maintain toll-free telephone access to
the contractor for the enrollees at a minimum from 8:00 a.m.
to 5:00 p.m. on Monday through Friday, for calls concerning
administrative or routine care services.
C. After Hours Response. The contractor shall have standards for
PCP and on-call medical/dental professional response to after
hours phone calls from enrollees or other medical/dental
professionals providing services to an enrollee (including,
but not limited to emergency department staff). The telephone
response time shall not exceed two (2) hours, except for
emergencies which require immediate response from the PCP.
D. Protocols.
1. Contractor. The contractor shall develop and use
telephone protocols for all of the following
situations:
a. Answering the volume of enrollee telephone
inquiries on a timely basis.
i. Enrollees shall wait no more than
five (5) minutes on hold.
b. Identifying special enrollee needs e.g.,
wheelchair and interpretive linguistic
needs. (See also Article 4.5.)
V-27
c. Triage for medical and dental conditions and
special behavioral needs for non-compliant
individuals who are mentally deficient.
d. Response time for telephone call-back
waiting times: after hours telephone care
for non-emergent, symptomatic issues -
within thirty (30) to forty-five (45)
minutes; same day for non-symptomatic
concerns; fifteen (15) minutes for crisis
situations.
2. Providers. The contractor shall monitor and require
its providers to develop and use telephone protocols
for all of the following situations:
a. Answering the enrollee telephone inquiries
on a timely basis.
b. Prioritizing appointments.
c. Scheduling a series of appointments and
follow-up appointments as needed by an
enrollee.
d. Identifying and rescheduling broken and
no-show appointments.
e. Identifying special enrollee needs while
scheduling an appointment, e.g., wheelchair
and interpretive linguistic needs. (See also
Article 4.5.)
f. Triage for medical and dental conditions and
special behavioral needs for non-compliant
individuals who are mentally deficient.
g. Response time for telephone call-back
waiting times: after hours telephone care
for non-emergent, symptomatic issues -
within thirty (30) to forty-five (45)
minutes; same day for non-symptomatic
concerns; fifteen (15) minutes for crisis
situations.
h. Scheduling continuous availability and
accessibility of professional, allied, and
supportive medical/dental personnel to
provide covered services within normal
working hours. Protocols shall be in place
to provide coverage in the event of a
provider's absence.
E. The contractor shall maintain a P-Factor of P7 or less for
calls to Member Services and shall submit the P-Factor report
in Section A.5.1 of the Appendices.
5.12 APPOINTMENT AVAILABILITY
The contractor shall have policies and procedures to ensure the
availability of medical, mental health/substance abuse (for DDD
clients) and dental care appointments in accordance with the following
standards:
V-28
A. Emergency Services. Immediately upon presentation at a service
delivery site.
B. Urgent Care. Within twenty-four (24) hours. An urgent,
symptomatic visit is an encounter with a health care provider
associated with the presentation of medical signs that require
immediate attention, but are not life-threatening.
C. Symptomatic Acute Care. Within seventy-two (72) hours. A
non-urgent, symptomatic office visit is an encounter with a
health care provider associated with the presentation of
medical signs, but not requiring immediate attention.
D. Routine Care. Within twenty-eight (28) days. Non-symptomatic
office visits shall include but shall not be limited to:
well/preventive care appointments such as annual gynecological
examinations or pediatric and adult immunization visits.
E. Specialist Referrals. Within four (4) weeks or shorter as
medically indicated. A specialty referral visit is an
encounter with a medical specialist that is required by the
enrollee's medical condition as determined by the enrollee's
Primary Care Provider (PCP). Emergency appointments must be
provided within 24 hours of referral.
F. Urgent Specialty Care. Within twenty-four (24) hours of
referral.
G. Baseline Physicals for New Adult Enrollees. Within one
hundred-eighty (180) calendar days of initial enrollment.
H. Baseline Physicals for New Children Enrollees and Adult
Clients of DDD. Within ninety (90) days of initial enrollment,
or in accordance with EPSDT guidelines.
I. Prenatal Care. Enrollees shall be seen within the following
timeframes:
1. Three (3) weeks of a positive pregnancy test (home or
laboratory)
2. Three (3) days of identification of high-risk
3. Seven (7) days of request in first and second
trimester
4. Three (3) days of first request in third trimester
J. Routine Physicals. Within four (4) weeks for routine physicals
needed for school, camp, work or similar.
K. Lab and Radiology Services. Three (3) weeks for routine
appointments; fortyeight (48) hours for urgent care.
V-29
L. Waiting Time in Office. Less than forty-five (45) minutes.
M. Initial Pediatric Appointments. Within three (3) months of
enrollment. The contractor shall attempt to contact and
coordinate initial appointments for all pediatric enrollees.
N. For dental appointments, the contractor shall be able to
provide:
1. Emergency dental treatment no later than forty-eight
(48) hours, or earlier as the condition warrants, of
injury to sound natural teeth and surrounding tissue
and follow-up treatment by a dental provider.
2. Urgent care appointments within three days of
referral.
3. Routine non-symptomatic appointments within thirty
(30) days of referral.
O. For MH/SA appointments, the contractor shall provide:
1. Emergency services immediately upon presentation at a
service delivery site.
2. Urgent care appointments within twenty-four (24)
hours of the request.
3. Routine care appointments within ten (10) days of the
request.
P. Maximum Number of Intermediate/Limited Patient Encounters.
Four (4) per hour for adults and four (4) per hour for
children.
Q. For SSI and New Jersey Care - ABD elderly and disabled
enrollees, the contractor shall ensure that each new enrollee
or, as appropriate, authorized person is contacted to offer an
Initial Visit to the enrollee's selected PCP. Each new
enrollee shall be contacted within forty-five (45) days of
enrollment and offered an appointment date according to the
needs of the enrollee, except that each enrollee who has been
identified through the enrollment process as having special
needs shall be contacted within ten (10) business days of
enrollment and offered an expedited appointment.
5.13 APPOINTMENT MONITORING PROCEDURES
A. Contractor shall monitor the adequacy of its appointment
processes and reduce the unnecessary use of alternative
methods such as emergency room visits. Contractor shall
monitor and institute policies that an enrollee's waiting time
at the PCP or specialist office is no more than forty-five
(45) minutes, except when the provider is unavailable due to
an emergency. Contractor shall have written policies and
procedures, about which it educates its provider network,
about appointment time requirements. Contractor shall have
established written
V-30
procedures for disseminating its appointment standards to the
network, shall monitor compliance with appointment standards,
and shall have a corrective action plan when appointment
standards are not met.
B. The contractor shall have established policies and procedures
for monitoring and evaluating appointment scheduling for all
PCPs which shall include, but is not limited to, the
following:
1. A methodology for monitoring:
a. Enrollee waiting time for receipt of both
urgent and routine appointments
b. Availability of appointments
c. Providers with whom enrollees regularly
experience long waiting times
d. Broken and no-show appointments
2. A description of the policies and procedures for
addressing appointment problems that may occur and
the plan for corrective action if any of the
above-referenced items are not met.
5.14 CULTURAL AND LINGUISTIC NEEDS
The contractor shall participate in the Department's Cultural and
Linguistic Competency Task Force, and cooperate in a study to review
the provision of culturally competent services.
The contractor shall address the relationship between culture,
language, and health care outcomes through, at a minimum, the following
Cultural and Linguistic Service requirements.
A. Physical and Communication Access. The contractor shall
provide documentation regarding the availability of and access
procedures for services which ensure physical and
communication access to: providers and any contractor related
services (e.g. office visits, health fairs); customer service
or physician office telephone assistance; and, interpreter,
TDD/TT services for individuals who require them in order to
communicate. Document availability of interpreter, TDD/TT
services.
B. Twenty-four (24)-Hour Interpreter Access. The contractor shall
provide Twentyfour (24)-hour access to interpreter services
for all enrollees including the deaf or hard of hearing at
provider sites within the contractor's network, either through
telephone language services or in-person interpreters to
ensure that enrollees are
V-31
able to communicate with the contractor and providers and
receive covered benefits. The contractor shall identify and
report the linguistic capability of interpreters or bilingual
employed and contracted staff (clinical and non-clinical). The
contractor shall provide professional interpreters when needed
where technical, medical, or treatment information is to be
discussed, or where use of a family member or friend as
interpreter is inappropriate. Family members, especially
children, should not be used as interpreters in assessments,
therapy and other situations where impartiality is critical.
The contractor shall provide for training of its health care
providers on the utilization of interpreters.
C. Interpreter Listing. Throughout the term of this contract, the
contractor shall maintain a current list of interpreter
agencies/interpreters who are "on call" to provide interpreter
services.
D. Language Threshold. In addition to interpreter services, the
contractor will provide other linguistic services to a
population of enrollees if they exceed five (5) percent of
those enrolled in the contractor's Medicaid/NJ FamilyCare line
of business or two hundred (200) enrollees in the contractor's
plan, whichever is greater.
E. The contractor shall provide the following services to the
enrollee groups identified in D above.
1. Key Points of Contact
a. Medical/Dental: Advice and urgent care
telephone, face to face encounters with
providers
b. Non-medical: Enrollee assistance,
orientations, and appointments
2. Types of Services
a. Translated signage
b. Translated written materials
c. Referrals to culturally and linguistically
appropriate community services programs
F. Community Advisory Committee. Contractor shall implement and
maintain community linkages through the formation of a
Community Advisory Committee (CAC) with demonstrated
participation of consumers (with representatives of each
Medicaid/NJ FamilyCare eligibility category- See Article 5.2),
community advocates, and traditional and safety net providers.
The contractor shall ensure that the committee
responsibilities include advisement on educational and
V-32
operational issues affecting groups who speak a primary
language other than English and cultural competency.
G. Group Needs Assessment. Contractor shall assess the linguistic
and cultural needs of its enrollees who speak a primary
language other than English. The findings of the assessment
shall be submitted to DMAHS in the form of a plan entitled,
"Cultural and Linguistic Services Plan" at the end of year one
of the contract. In the plan, the contractor will summarize
the methodology, findings, and outline the proposed services
to be implemented, the timeline for implementation with
milestones, and the responsible individual. The contractor
shall ensure implementation of the plan within six months
after the beginning of year two of the contract. The
contractor shall also identify the individual with overall
responsibility for the activities to be conducted under the
plan. The DMAHS approval of the plan is required prior to its
implementation.
H. Policies and Procedures. The contractor shall address the
special health care needs of all enrollees. The contractor
shall incorporate in its policies and procedures the values of
(1) honoring enrollees' beliefs, (2) being sensitive to
cultural diversity, and (3) fostering respect for enrollees'
cultural backgrounds. The contractor shall have specific
policy statements on these topics and communicate them to
providers and subcontractors.
I. Mainstreaming. The contractor shall be responsible for
ensuring that its network providers do not intentionally
segregate DMAHS enrollees from other persons receiving
services. Examples of prohibited practices, based on race,
color, creed, religion, sex, age, national origin, ancestry,
marital status, sexual preference, income status, program
membership or physical or mental disability, include, but may
not be limited to, the following:
1. Denying or not providing to an enrollee any covered
service or access to a facility.
2. Providing to an enrollee a similar covered service in
a different manner or at a different time from that
provided to other enrollees, other public or private
patients or the public at large.
3. Subjecting an enrollee to segregation or separate
treatment in any manner related to the receipt of any
covered service.
4. Assigning times or places for the provision of
services.
5. Closing a provider panel to DMAHS beneficiaries but
not to other patients.
V-33
J. Resolution of Cultural Issues. The contractor shall
investigate and resolve access and cultural sensitivity issues
identified by contractor staff, State staff, providers,
advocate organizations, and enrollees.
5.15 ENROLLEE COMPLAINTS AND GRIEVANCES
5.15.1 GENERAL REQUIREMENTS
A. DMAHS Approval. The contractor shall draft and disseminate a
system and procedure which has the prior written approval of
DMAHS for the receipt and adjudication of complaints and
grievances by enrollees. The grievance policies and procedures
shall be in accordance with N.J.A.C. 8:38 et seq. and with the
modifications that are incorporated in the contract. The
contractor shall not modify the grievance procedure without
the prior approval of DMAHS, and shall provide DMAHS with a
copy of the modification. The contractor's grievance
procedures shall provide for expeditious resolution of
grievances by contractor personnel at a decision-making level
with authority to require corrective action, and will have
separate tracks for administrative and utilization management
grievances. (For the utilization management
complaints/grievance process, see Article 4.6.4C.)
The contractor shall review the grievance procedure at
reasonable intervals, but no less than annually, for the
purpose of amending same as needed, with the prior written
approval of the DMAHS, in order to improve said system and
procedure.
The contractor's system and procedure shall be available to
both Medicaid beneficiaries and NJ FamilyCare beneficiaries.
All enrollees have available the complaint and grievance
process under the contractor's plan, the Department of Health
and Senior Services and, for Medicaid beneficiaries, the
Medicaid Fair Hearing process. Individuals eligible solely
through NJ FamilyCare Plans B, C, and D do not have the right
to a Medicaid Fair Hearing.
B. Complaints. The contractor shall have procedures for
receiving, responding to, and documenting resolution of
enrollee complaints that are received orally and are of a less
serious or formal nature. Complaints that are resolved to the
enrollee's satisfaction on the day of receipt do not require a
formal written response or notification. The contractor shall
call back an enrollee within twenty-four hours of the initial
contact if the contractor is unavailable for any reason or the
matter cannot be readily resolved during the initial contact.
Any complaint that is not resolved timely shall be treated as
a grievance, in accordance with requirements defined in
Article 5.15.3.
C. HBC Coordination. The contractor shall coordinate its efforts
with the health benefits coordinator including referring the
enrollee to the HBC for assistance as needed in the management
of the complaint/grievance procedures.
V-34
D. DMAHS Intervention. DMAHS shall have the right to intercede on
an enrollee's behalf at any time during the contractor's
complaint/grievance process whenever there is an indication
from the enrollee, or, where applicable, authorized person, or
the HBC that a serious quality of care issue is not being
addressed timely or appropriately. Additionally, the enrollee
may be accompanied by a representative of the enrollee's
choice to any proceedings and grievances.
E. Legal Rights. Nothing in this Article shall be construed as
removing any legal rights of enrollees under State or federal
law, including the right to file judicial actions to enforce
rights.
5.15.2 NOTIFICATION TO ENROLLEES OF GRIEVANCE PROCEDURE
A. The contractor shall provide all enrollees or, where
applicable, an authorized person, upon enrollment in the
contractor's plan, and annually thereafter, pursuant to this
contract, with a concise statement of the contractor's
grievance procedure and the enrollees' rights to a hearing by
the Independent Utilization Review Organization (IURO) per
NJAC 8:38-8.7 as well as their right to pursue the Medicaid
Fair Hearing process described in N.J.A.C. 10:49-10.1 et seq.
The information shall be provided through an annual mailing, a
member handbook, or any other method approved by DMAHS. The
contractor shall prepare the information orally and/or in
writing in English, Spanish, and other bilingual translations
and a format accessible to the visually impaired, such as
Braille, large print, or audio tapes.
B. Written information to enrollees regarding the grievance
process shall include at a minimum:
1. Notification that copies of written grievances will
be sent to DMAHS for monitoring
2. Identification of who is responsible for processing
and reviewing grievances
3. Information to enrollees on how to file
complaints/grievances
4. Local or toll-free telephone number for filing of
complaints/grievances
5. Information on obtaining grievance forms and copies
of grievance procedures for each primary
medical/dental care site
6. Expected timeframes for acknowledgment of receipt of
grievances
7. Expected timeframes for disposition of grievances
8. Extensions of the grievance process if needed and
time frames
V-35
9. Fair hearing procedures including the Medicaid
enrollee's right to access the Medicaid Fair Hearing
process at any time to request resolution of a
grievance
10. DHSS process for use of Independent Utilization
Review Organization (IURO)
C. A description of the process under which an enrollee may
appeal denials of authorization shall include at a minimum:
1. Title of person responsible for processing appeal
2. Title of person(s) responsible for resolution of
appeal
3. Time deadlines for notifying enrollee of appeal
resolution
4. The right to request a Medicaid Fair Hearing/DHSS
IURO processes where applicable to specific enrollee
eligibility categories
5.15.3 GRIEVANCE PROCEDURES
A. Availability. The contractor's grievance procedure shall be
available to all enrollees or, where applicable, an authorized
person, or permit a provider acting on behalf of an enrollee
and with the enrollee's consent, to challenge the denials of
coverage of services or denials of payment for services. The
procedure shall assure that grievances may be filed verbally
directly with the contractor.
B. The grievance procedure shall be in accordance with N.J.A.C.
8:38 et seq.
C. DMAHS shall have the right to submit comments to the
contractor regarding the merits or suggested resolution of any
grievance.
By the first and the fifteenth of every month the contractor
shall mail/fax all enrollee grievance/appeal requests directly
to the DMAHS. DMAHS will log and monitor the grievance process
through each stage. In case of verbal filing, the contractor
shall submit a written statement of the grievance to DMAHS.
By the first and the fifteenth of every month the contractor
shall send a copy to DMAHS of the dates of each stage of the
grievance/appeal process as well as its findings at each stage
of the grievances/appeals process simultaneously with
notification to the enrollee. If the contractor finds against
the enrollee, the denial shall present the enrollee's appeal
rights to the contractor, as well as the right to a Medicaid
Fair Hearing (except for NJ FamilyCare Plans B, C and D) and
the right to the DHSS' IURO process.
V-36
D. Time Limits to File. The contractor may provide reasonable
time limits within which enrollees must file grievances, but
such time period shall not be less than sixty (60) days from
the date of the incident giving rise to the grievance.
5.15.4 PROCESSING GRIEVANCES
A. Staffing. The contractor shall have an adequate number of
staff to receive and assist with enrollee grievances by phone,
in person and by mail. All staff involved in the receipt,
investigation and resolution of complaints shall be trained on
the contractor's policies and procedures and shall treat all
enrollees with dignity and respect.
B. Grievance Forms. If the contractor uses a grievance form, the
contractor must make available written grievance forms in the
enrollee's primary language in accordance with the
multilingual definition. Such forms shall be readily available
through the contractor upon request by telephone or in
writing. The contractor shall mail the form within five (5)
work days of receiving a telephone or written request for a
form. The contractor shall permit grievances to be filed in
writing, either on the contractor's form or in any other
written format, by fax, or verbally. For purposes of this
section the contractor may use an approved translation service
to translate grievance forms in an enrollee's primary language
in order to meet the timeframes of this contract provision. A
copy of the translated form shall be sent to DMAHS for post
review.
C. Confidentiality. The contractor shall have written policies
and procedures to assure enrollee confidentiality and
reasonable privacy throughout the complaint and grievance
process.
D. Non-discrimination. The contractor shall have written policies
and procedures to assure that the contractor or any provider
or agent of the contractor shall not discriminate against an
enrollee or attempt to disenroll an enrollee for filing a
complaint or grievance against the contractor.
E. Documentation. Upon receipt of a grievance, the contractor's
staff shall record the date of receipt, a written summary of
the problem, the response given, the resolution effected, if
any, and the department or staff personnel to whom the
grievance has been routed. See Article 5.15.5 for further
information on records maintenance.
F. Tracking System. The contractor shall maintain a separate
complaint log as well as a grievance tracking and resolution
system for Medicaid/ NJ FamilyCare enrollees. The tracking
system shall categorize complaints or grievances according to
type of issue, standardize a system for routing complaints or
grievances to operational department(s) for the dual purpose
of resolving specific complaints or grievances and for
improving the contractor's operating procedures, indicate the
status and locus of each open grievance, send all requisite
notices to
V-37
enrollees within the appropriate timeframe, and log in the
final resolution of each grievance. The tracking system shall
differentiate between medical/dental and administrative
complaints and grievances.
5.15.5 RECORDS MAINTENANCE
A. The contractor shall develop and maintain a separate complaint
log tracking and resolution system for Medicaid and NJ
FamilyCare enrollees for issues not requiring a formal
grievance hearing. The system shall be made accessible to the
State for review.
B. A grievance log to document all verbal (telephone or in
person) and written grievances and resolutions shall be
maintained. The grievance log shall be available in the office
of the contractor. The grievance log shall include the
following information:
1. A log number
2. The date and time the grievance is filed with the
contractor or provider
3. The name of the enrollee filing the grievance
4. The name of the contractor, provider or staff person
receiving the grievance
5. A description of the grievance or problem
6. A description of the action taken by the contractor
or provider to investigate and resolve the grievance
7. The proposed resolution by the contractor or provider
8. The name of the contractor, provider or staff person
responsible for resolving the grievance
9. The date of notification to the enrollee of the
proposed resolution
C. The contractor shall develop and maintain policies for the
following:
1. Collection and analysis of grievance data
2. Frequency of review of the grievance system
3. File maintenance
4. Protecting the anonymity of the grievant.
V-38
5.16 MARKETING
5.16.1 GENERAL PROVISIONS - CONTRACTOR'S RESPONSIBILITIES
A. The DMAHS' enrollment agent, health benefits coordinator
(HBC), will outreach and educate Medicaid and NJ FamilyCare
beneficiaries (or, where applicable, an authorized person),
and assist eligible beneficiaries (or, where applicable, an
authorized person), in selection of a MCE. Direct marketing or
discussion by the contractor to a Medicaid or NJ FamilyCare
beneficiary already enrolled in another contractor shall not
be permitted; direct marketing to non-enrolled Medicaid
beneficiaries will be limited and only allowed in locations
specified by DMAHS. The duties of the HBC will include, but
are not limited to, education, enrollment, disenrollment,
transfers, assistance through the contractor's grievance
process and other problem resolutions with the contractor, and
communications. The contractor shall cooperate with the HBC in
developing information about its plan for dissemination to
Medicaid/NJ FamilyCare beneficiaries.
1. Active face-to-face marketing is prohibited:
a. To New Jersey Care...Special Medicaid
Programs for Pregnant Women and Children;
b. To DYFS-supervised individuals;
c. At County Welfare Agency offices;
d. At open areas (other than designated
events); and
e. To AFDC/TANF beneficiaries and
AFDC/TANF-related beneficiaries.
2. Active face-to-face marketing will be allowed:
a. Only at times, events, and locations
specified and approved by DMAHS. Examples of
permissible venues include provider sites,
health fairs, and community centers.
b. To NJ FamilyCare populations.
c. To the ABD population.
B. Marketing activities that shall be permitted include:
1. Media advertising limited to billboards, bus and
newspaper advertisements, posters, literature display
stands, radio and television advertising.
V-39
2. Fulfillment of potential enrollee requests to the
contractor for general information, brochure and/or
provider directories that will be mailed to the
beneficiary.
C. All marketing plans, procedures, presentations, and materials
shall be accurate and shall not mislead, confuse, or defraud
either the enrollee, providers or DMAHS. If such
misrepresentation occurs, the contractor shall hold harmless
the State in accordance with Article 7.33 and shall be subject
to damages described in Article 7.16.
D. The contractor shall be required to submit to DMAHS for prior
written approval a complete marketing plan that adheres to
DMAHS' policies and procedures. Written or audio-visual
marketing materials, e.g., ads, flyers, posters,
announcements, and letters, and marketing scripts, public
information releases to be distributed to or prepared for the
purpose of informing Medicaid beneficiaries, and subsequent
revisions thereto, and promotional items shall be approved by
DMAHS prior to their use. If the contractor develops new or
revised marketing materials, it shall submit them to DMAHS for
review and approval prior to any dissemination. The contractor
shall not, under any circumstances, use marketing material
that has not been approved by DMAHS.
E. The DMAHS will consult with a medical care advisory committee
in the review of pertinent marketing materials and will
respond within 45 days with either an approval, denial, or
request for additional information or modifications.
F. The contractor shall distribute all approved marketing
materials throughout all enrollment areas for which it is
contracted to provide services.
G. All marketing materials that will be used by marketing agents
for every type of marketing presentation shall be prior
approved by DMAHS. The contractor shall coordinate and submit,
on a quarterly basis, to DMAHS and its agents, all of its
schedules, plans, activities by month and informational
materials for community education and outreach programs. The
contractor shall work in cooperation with community-based
groups and shall participate in such activities as health
fairs and other community events. The contractor shall make
every effort to ensure that all materials and outreach
provided by them provide both physical and communication
accessibility. This outreach should go beyond traditional
venues and any health fairs or community events should be held
in accessible facilities.
1. For those instances where marketing is allowed,
contractors shall submit schedules to the DMAHS at
least five (5) days prior to the activity taking
place. The schedules can be submitted in any format,
but must include the full name of the marketing
representative, the name and full address of the
location where marketing is being conducted, the
date(s) and beginning and ending times of the
activity. All schedules will be reviewed and must
V-40
be approved in writing by the DMAHS. PLANS MAY NOT
COMMENCE ANY MARKETING ACTIVITY WITHOUT PRIOR DMAHS
APPROVAL.
H. With the exception allowed under Article 5.16.1I, neither the
contractor nor its marketing representatives may put into
effect a plan under which compensation, reward, gift, or
opportunity are offered to eligible enrollees as an inducement
to enroll in the contractor's plan other than to offer the
health care benefits from the contractor pursuant to this
contract. The contractor is prohibited from influencing an
individual's enrollment with the contractor in conjunction
with the sale of any other insurance.
I. The contractor may offer promotional give-aways that shall not
exceed a combined total of $10 to any one individual or family
for marketing purposes. Giveaways and premiums that have DMAHS
approval may be distributed at approved events. These items
shall be limited to items that promote good health behavior
(e.g., toothbrushes, immunization schedules). For NJ
FamilyCare, other promotional items shall be considered with
prior approval by DMAHS.
J. The contractor shall ensure that marketing representatives are
appropriately trained and capable of performing marketing
activities in accordance with terms of this contract, N.J.A.C.
11:17, 11:2-11, 11:4-17, 8:38-13.2, N.J.S.A. 17:22 A-1,
26:2J-16, and the marketing standards described in Article
5.16.
K. The contractor shall ensure that marketing representatives are
versed in and adhere to Medicaid policy regarding beneficiary
enrollment and disenrollment as stated in 42 C.F.R. Section
434.27. This policy includes, but is not limited to,
requirements that enrollees do not experience unreasonable
barriers to disenroll, and that the contractor shall not act
to discriminate on the basis of adverse health status or
greater use or need for health care services.
L. Door-to-door canvassing, telephone, telemarketing, or "cold
call" marketing of enrollment activities, by the contractor
itself or an agent or independent contractor thereof, shall
not be permitted. For NJ FamilyCare (Plans B, C, D),
telemarketing shall be permitted after review and prior
approval by DMAHS of the contractor's marketing plan, scripts
and methods to use this approach.
M. Contractor employees or agents shall not present themselves
unannounced at an enrollee's home for marketing or
"educational" purposes. This shall not limit such visits for
medical emergencies, urgent medical care, clinical outreach,
and health promotion for known enrollees.
N. Under no conditions shall a contractor use DMAHS's
client/enrollee data base or a provider's patient/customer
database to identify and market its plan to Medicaid or NJ
FamilyCare beneficiaries. No lists of Medicaid/NJ FamilyCare
beneficiary names, addresses, telephone numbers, or
Medicaid/NJ FamilyCare numbers of potential Medicaid/NJ
FamilyCare enrollees shall be obtained by a contractor
V-41
under any circumstances. Neither shall the contractor violate
confidentiality by sharing or selling enrollee lists or
enrollee/beneficiary data with other persons or organizations
for any purpose other than performance of the contractor's
obligations pursuant to this contract. For NJ FamilyCare and
ABD marketing only, general population lists such as census
tracts are permissible for marketing outreach after review and
prior approval by DMAHS.
O. The contractor shall allow unannounced, on-site monitoring by
DMAHS of its enrollment presentations to prospective
enrollees, as well as to attend scheduled, periodic meetings
between DMAHS and contractor marketing staff to review and
discuss presentation content, procedures, and technical
issues.
P. The contractor shall explain that all health care benefits as
specified in Article 4.1 must be obtained through a PCP.
Q. The contractor shall periodically review and assess the
knowledge and performance of its marketing representatives.
R. The contractor shall assure culturally competent presentations
by having alternative mechanisms for disseminating information
and must receive acknowledgment of the receipt of such
information by the beneficiary.
S. Individual Medicaid beneficiaries shall be able to contact the
contractor for information, and the contractor may respond to
such a request.
T. Incentives.
1. The contractor may provide an incentive program to
its enrollees based on health/educational activities
or for compliance with health related
recommendations. The incentive program may include,
but is not limited to:
a. Health related gift items
b. Gift certificates in exchange for
merchandise
Cash or redeemable coupons with a cash value are
prohibited.
2. The contractor's incentive program shall be proposed
in writing and prior approved by DMAHS.
U. Periodic Survey of Enrollees.
1. The contractor shall quarterly survey and report
results to DMAHS of new enrollees, in person, by
phone, or other means, on a random basis to verify
V-42
the enrollees' understanding of the contractor's
procedures and services availability.
2. The contractor shall quarterly survey enrollees on
reasons for disenrollment who voluntarily
disenroll/transfer at time of disenrollment/transfer
from contractor's plan.
V. All marketing materials, plans and activities shall be prior
approved by DMAHS.
5.16.2 STANDARDS FOR MARKETING REPRESENTATIVES
A. General Requirements
1. Only a trained marketing representative of the
contractor's plan who meets the DHS, DHSS, and DBI
requirements shall be permitted to market and to
enroll prospective NJ FamilyCare and ABD enrollees.
All marketing representatives shall be registered
with both the Department of Banking and Insurance
(DBI) and the Division of Medical Assistance and
Health Services (DMAHS). Delegation of enrollment
functions, such as to the office staff of a
subcontracting provider of service, shall not be
permitted.
2. The contractor shall submit to DMAHS no less
frequently than once a month, a listing of the
contractor's marketing representatives. Marketing
schedules shall be submitted at least five days in
advance of marketing activities. Information on each
marketing representative shall include the names,
three digit Identification Numbers, and marketing
locations.
3. All marketing representatives shall wear an
identification tag that has been prior approved by
DMAHS with a photo identification that must be
prominently displayed when the marketing
representative is performing marketing activities.
The tag shall be at least three inches (3") by five
inches (5") and shall display the marketing
representative's name, the name of the contractor,
and a three-digit identification number.
4. In those counties where enrollment is in a voluntary
stage, marketing representatives shall not state or
imply that enrollment may be made mandatory in the
future in an attempt to coerce enrollment.
5. Canvassing shall not be permitted.
6. Outbound telemarketing shall not be permitted. For NJ
FamilyCare (Plans B, C, D), telemarketing shall be
permitted after review and prior approval by DMAHS of
the contractor's marketing plan, script, and methods
to use this approach.
V-43
7. Marketing in or around a County Welfare Agency (CWA)
office shall not be permitted. The term "in and
around the CWA" is defined as being in an area where
the marketing representative can be seen from the CWA
office and/or where the CWA facility can be seen. The
fact that an obstructed view prohibits the marketing
activities from being seen shall not mitigate this
prohibition.
8. No more than two (2) marketing representatives shall
approach a Medicaid/NJ FamilyCare beneficiary at any
one time.
9. Marketing representatives shall not encourage clients
to disenroll from another contractor's plan or assist
an enrollee of another MCE in completing a
disenrollment form from the other MCE.
10. Marketing representatives shall ask the prospective
enrollee about existing relationships with physicians
or other health care providers. The prospective
enrollees shall be clearly informed as to whether
they will be able to continue to go to those
providers as enrollees of the contractor's plan
and/or if the Medicaid program will pay for continued
services with such providers.
11. Marketing representatives shall secure the signature
of new enrollees (head of household) on a statement
indicating that an explanation has been provided to
them regarding the important points of the
contractor's plan and have understood its procedures.
A parent or, where applicable, an authorized person,
shall enroll minors and ABD beneficiaries, when
appropriate, and sign the statement of understanding.
However, the contractor may accept an application
from pregnant minors and minors living totally on
their own who have their own Medicaid ID numbers as
head of their own household.
12. Prior to approval of this contract by HCFA, the
contractor's staff or agents are prohibited from
marketing to, contacting directly or indirectly, or
enrolling Medicaid beneficiaries.
13. Marketing representatives shall not state or imply
that continuation of Medicaid benefits is contingent
upon enrollment in the contractor's plan.
14. Attendance by the contractor's marketing
representatives at State-sponsored training sessions
is required at the contractor's own expense.
B. Commissions/Incentive Payments
1. Commissions/incentive payments may not be based on
enrollment numbers alone but shall include other
criteria, such as but not limited to,
V-44
the retention period of enrollees enrolled (at least
three (3) months), member satisfaction, and education
by the marketing representative.
a. The contractor shall also review
disenrollment information/surveys and all
complaints/grievances specifically
referencing marketing staff.
2. Marketing commissions (including cash, prizes,
contests, trips, dinners, and other incentives) shall
not exceed thirty (30) percent of the
representative's monthly salary.
C. Enrollment Inducements
1. The contractor's marketing representatives and other
contractor's staff are prohibited from offering or
giving cash or any other form of compensation to a
Medicaid beneficiary as an inducement or reward for
enrolling in the contractor's plan.
2. Promotional items, gifts, "give-aways" for marketing
purposes shall be permitted, but will be limited to
items that promote good health behavior (e.g.,
toothbrushes, immunization schedules). However, the
combined total of such gifts or gift package shall
not exceed an amount of $10 to any one individual or
family. Such items:
a. Shall be offered to the general public for
marketing purposes whether or not an
individual chooses to enroll in the
contractor's plan.
b. Shall only be given at the time of marketing
presentations and may not be a continuous,
periodic activity for the same individual,
e.g., monthly or quarterly give-aways, as an
inducement to remain enrolled.
c. Shall not be in the form of cash.
For NJ FamilyCare, other promotional items shall be
considered with prior approval by DMAHS.
3. Raffles shall not be allowed.
D. Sanctions
Violations of any of the above may result in any one or
combination of the following:
1. Cessation or reduction of enrollment including auto
assignment.
V-45
2. Reduction or elimination of marketing and/or
community event participation.
3. Enforced special training/re-training of marketing
representatives including, but not limited to,
business ethics, marketing policies, effective sales
practices, and State marketing policies and
regulations.
4. Referral to the Department of Banking and Insurance
for review and suspension of commercial marketing
activities.
5. Application of assessed damages by the State.
6. Referral to the Secretary of the United States
Department of Health and Human Services for civil
money penalties.
7. Termination of contract.
8. Referral to the New Jersey Division of Criminal
Justice Department of Justice as warranted.
V-46
ARTICLE SIX: PROVIDER INFORMATION
6.1 GENERAL
The contractor shall provide information to all contracted providers
about the Medicaid/NJ FamilyCare managed care program in order to
operate in full compliance with the contract and all applicable federal
and State regulations. The contractor shall monitor provider knowledge
and understanding of program requirements, and take corrective actions
to ensure compliance with such requirements.
6.2 PROVIDER PUBLICATIONS
A. Provider Manual. The contractor shall issue a Provider Manual
and Bulletins or other means of provider communication to the
providers of medical/dental services. The manual and bulletins
shall serve as a source of information to providers regarding
Medicaid covered services, policies and procedures, statutes,
regulations, telephone access and special requirements to
ensure all contract requirements are being met. Alternative to
provider manuals shall be prior approved by DMAHS.
The contractor shall provide all of its providers with, at a
minimum, the following information:
1. Description of the Medicaid/NJ FamilyCare managed
care program and covered populations
2. Scope of Benefits
3. Modifications to Scope of Benefits
4. Emergency Services Responsibilities, including
responsibility to educate enrollees regarding the
appropriate use of emergency services
5. EPSDT program services and standards
6. Grievance procedures for both enrollee and provider
7. Medical necessity standards as well as practice
guidelines or other criteria that will be used in
making medical necessity decisions. Medical necessity
decisions must be in accordance with the definition
in Article 1 and based on peer-reviewed publications,
expert medical opinion, and medical community
acceptance.
8. Practice protocols/guidelines, including in
particular guidelines pertaining to treatment of
chronic/complex conditions common to the enrolled
populations if utilized by the contractor to monitor
and/or evaluate
VI-1
provider performance. Practice guidelines may be
included in a separate document.
9. The contractor's policies and procedures
10. PCP responsibilities
11. Other provider/subcontractors' responsibilities
12. Prior authorization and referral procedures
13. Description of the mechanism by which a provider can
appeal a contractor's service decision through the
DHSS' Independent Utilization Review Organization
process
14. Protocol for encounter data element reporting/records
15. Procedures for screening and referrals for the MH/SA
services
16. Medical records standards
17. Payment policies
B. Bulletins. The contractor shall develop and disseminate
bulletins as needed to incorporate any and all changes to the
Provider Manual. All bulletins shall be mailed to the State at
least three (3) calendar days prior to publication or mailing
to the providers or as soon as feasible. The Department shall
have the right to issue and/or modify the bulletins at any
time. If the DHS determines that there are factual errors or
misleading information, the contractor shall be required to
issue corrected information in the manner determined by the
DHS.
C. Timeframes. Within twenty (20) calendar days after the
contractor places a newly enrolled provider in an active
status, the contractor shall furnish the provider with a
current Provider Manual, all related bulletins and the
contractor's methodology for supplying encounter data.
D. The contractor shall provide a Provider Manual to the
Department. All updates of the manual shall also be provided
to the Department on a timely basis.
E. The Provider Manual and all policies and procedures shall be
reviewed at least annually to ensure that the contractor's
current practices and contract requirements are reflected in
the written policies and procedures.
VI-2
6.3 PROVIDER EDUCATION AND TRAINING
A. Initial Training. The contractor shall ensure that all
providers receive sufficient training regarding the managed
care program in order to operate in full compliance with
program standards and all applicable federal and State
regulations. At a minimum, all providers shall receive initial
training in managed care services, the contractor's policies
and procedures, and information about the needs of enrollees
with special needs. Ongoing training shall be provided as
deemed necessary by either the contractor or the State in
order to ensure compliance with program standards.
Subjects for provider training shall be tailored to the needs of the
contractor's plan's target groups. Listed below are some
examples of topics for training:
1. Identification and management of polypharmacy.
2. Identification and treatment of depression among
elderly people and people with disabilities.
3. Identification and treatment of alcohol/substance
abuse.
4. Identification of abuse and neglect.
5. Coordination of care with long-term services, mental health
and substance abuse providers, including instruction regarding
policies and procedures for maintaining the centralized member
record.
6. Skills to assist elderly people and people with
disabilities in coping with loss.
7. Cultural sensitivity to providing health care to
various ethnic groups.
B. Ongoing Training. The contractor shall continue to provide
communications and guidance for PCPs, specialty providers, and
others about the health care needs of enrollees with special
needs and xxxxxx cultural sensitivity to the diverse
populations enrolled with the contractor.
6.4 PROVIDER TELEPHONE ACCESS
A. The contractor shall maintain a mechanism by which providers
can access the contractor by telephone. The contractor shall
maintain policies and procedures for staffing and training the
allocated personnel, including the hours of operation, days of
the week and numbers of personnel available, and the telephone
number to the providers. Telephone access to the contractor
shall be available to providers, at a minimum, from 8:00 a.m.
to 5:00 p.m., Monday through Friday.
VI-3
B. Response time. The contractor shall respond to after hours
telephone calls regarding medical care within the following
timeframes: fifteen (15) minutes for crisis situations;
forty-five (45) minutes for non-emergent, symptomatic issues;
same day for non-symptomatic concerns.
C. At no time shall providers wait more than five (5) minutes on
hold.
6.5 PROVIDER GRIEVANCES AND APPEALS
A. Payment Disputes. The contractor shall establish and utilize a
procedure to resolve billing, payment, and other
administrative disputes between health care providers and the
contractor for any reason including, but not limited to: lost
or incomplete claim forms or electronic submissions; requests
for additional explanation as to services or treatment
rendered by a health care provider; inappropriate or
unapproved referrals initiated by the providers; or any other
reason for billing disputes. The procedure shall include an
appeal process and require direct communication between the
provider and the contractor and shall not require any action
by the enrollee.
B. Complaint, Grievances and Appeal. The contractor shall
establish and maintain provider complaint, grievance and
appeals procedures for any provider who is not satisfied with
the contractor's policies and procedures, or with a decision
made by the contractor, or disagrees with the contractor as to
whether a service, supply, or procedure is a covered benefit,
is medically necessary, or is performed in the appropriate
setting. The contractor procedure shall satisfy the following
minimum standards:
1. The contractor shall have in place an informal
complaint process which network providers can use to
make verbal complaints, to ask questions, and get
problems resolved without going through the formal,
written grievance process.
2. The contractor shall have in place a formal grievance
and appeal process which network providers and
non-participating providers can use to complain in
writing.
3. Such procedures shall not be applicable to any
disputes that may arise between the contractor and
any provider regarding the terms, conditions, or
termination or any other matter arising under
contract between the provider and contractor.
C. The contractor shall log, track and respond to provider
complaints and grievances.
D. The contractor shall submit quarterly a Provider
Grievances/Complaints Report. All provider grievances shall be
summarized, with actions and recommendations of the Medical or
Dental Director and QA Committee (if involved) clearly stated.
VI-4
The summary report shall include, but not be limited to, the
following data elements:
1. Total number of all provider grievances and
complaints received
2. Number of unresolved (pending) grievances and
complaints
3. Category of the grievance or complaint, including,
but not limited to:
a. Denials of requested services prior
authorizations
b. Denials of specialty referrals
c. Enrollee allocation inequities
E. The contractor shall notify providers of the mechanism to
appeal a contractor service decision on behalf of an enrollee,
with the enrollee's consent, through the DHSS' Independent
Utilization Review Organization process and that the provider
is not entitled to request a Medicaid administrative law
hearing.
VI-5
ARTICLE SEVEN: TERMS AND CONDITIONS (ENTIRE CONTRACT)
7.1 CONTRACT COMPONENTS
The Contract, Attachments, Schedules, Appendices, Exhibits, and any
amendments determine the work required of the contractor and the terms
and conditions under which said work shall be performed.
No other contract, oral or otherwise, regarding the subject matter of
this contract shall be deemed to exist or to bind any of the parties or
vary any of the terms contained in this contract.
7.2 GENERAL PROVISIONS
A. HCFA Approval. This contract is subject to approval by the
Health Care Financing Administration (HCFA) and shall not be
effective absent such approval. In addition, this contract is
subject to HCFA's grant of a 1915(b) waiver to mandate
enrollment of children with special health care needs.
B. General. The contractor agrees that it shall carry out its
obligations as herein provided in a manner prescribed under
applicable federal and State laws, regulations, codes, and
guidelines including New Jersey licensing regulations, the
Medicaid, NJ KidCare and NJ FamilyCare State Plans, and in
accordance with procedures and requirements as may from time
to time be promulgated by the United States Department of
Health and Human Services. These include:
1. 42 U.S.C. Section 1396 et seq.
2. 42 C.F.R., Parts 417, 434, 440, 455, 1000
3. 45 C.F.R., Part 74
4. N.J.S.A. 30:4D-1 et seq.
5. N.J.S.A. 30:4I-1 et seq.
6. N.J.S.A. 30:4J-1 et seq.
7. N.J.S.A. 26:2J-1 et seq.
8. N.J.A.C. 10:74 et seq.
9. N.J.A.C. 10:49 et seq.
10. N.J.A.C. 10:79 et seq.
VII-1
11. N.J.A.C. 10:78-11
12. New Jersey Medicaid, NJ KidCare, and NJ FamilyCare
State Plans
13. 1915(b) Waiver
14. N.J.A.C. 8:38 et seq. and amendments thereof, and the
contractor shall comply with the higher standard
contained in N.J.A.C. 8:38 et seq. or this contract.
15. N.J.S.A. 59:13 et seq.
16. The federal and State laws and regulations above have
been cited for reader ease. They are available for
review at the New Jersey State Library, 000 Xxxx
Xxxxx Xxxxxx, Xxxxxxx, Xxx Xxxxxx 00000. However,
whether cited or not, the contractor is obligated to
comply with all applicable laws and regulations and,
in turn, is responsible for ensuring that its
providers and subcontractors comply with all laws and
regulations.
17. Neither the contractor nor its employees, providers,
or subcontractors shall violate, or induce others to
violate, any federal or state laws or regulations, or
professional licensing board regulations.
C. Applicable Law and Venue. This contract and any and all
litigation arising there from or related thereto shall be
governed by the applicable laws, regulations, and rules of
evidence of the State of New Jersey without reference to
conflict of laws principles. The contractor shall agree and
submit to the jurisdiction of the courts of the State of New
Jersey should any dispute concerning this contract arise, and
shall agree that venue for any legal proceeding against the
State shall be in Xxxxxx County.
D. Medicaid Provider. The contractor shall be a Medicaid provider
and a health maintenance organization with a Certificate of
Authority to operate government programs in New Jersey.
E. Significant Changes. The contractor shall report to the
Contracting Officer (See Article 7.5) immediately all
significant changes that may affect the contractor's
performance under this contract.
F. Provider Enrollment Process. The contractor shall comply with
the Medicaid provider enrollment process including the
submission of the HCFA 1513 Form.
G. Conflicts in Provisions. The contractor shall advise DMAHS of
any conflict of any provision of this contract with any
federal or State law or regulation. The contractor is required
to comply with the provisions of the federal or State law or
VII-2
regulation until such time as the contract may be amended.
(See also Article 7.11.)
Any provision of this contract that is in conflict with the
above laws, regulations, or federal Medicaid statutes,
regulations, or HCFA policy guidance is hereby amended to
conform to the provisions of those laws, regulations, and
federal policy. Such amendment of the contract shall be
effective on the effective date of the statutes or regulations
necessitating it and will be binding on the parties even
though such amendment may not have been reduced to writing and
formally agreed upon and executed by the parties.
H. Compliance with Codes. The contractor shall comply with the
requirements of the New Jersey Uniform Commercial Code, the
latest National Electrical Code, the Building Officials & Code
Administrators International, Inc. (B.O.C.A.) Basic Building
Code, and the Occupational Safety and Health Administration to
the extent applicable to the contract.
I. Corporate Authority. All New Jersey corporations shall obtain
a Certificate of Incorporation from the Office of the New
Jersey Secretary of State prior to conducting business in the
State of New Jersey.
If a contractor is a corporation incorporated in a state other
than New Jersey, the contractor shall obtain a Certificate of
Authority to do business from the Office of the Secretary of
State of New Jersey prior to execution of the contract. The
contractor shall provide either a certification or
notification of filing with the Secretary of State.
If the contractor is an individual, partnership or joint
venture not residing in this State or a partnership organized
under the laws of another state, then the contractor shall
execute a power of attorney designating the Secretary of State
as his true and lawful attorney for the sole purpose of
receiving process in any civil action which may arise out of
the performance of this contract or agreement. This
appointment of the Secretary of State shall be irrevocable and
binding upon the contractor, his heirs, executors,
administrators, successors or assigns. Within ten (10) days of
receipt of this service, the Secretary of State shall forward
same to the contractor at the address designated in the
contract.
J. Contractor's Warranty. By signing this contract, the
contractor warrants and represents that no person or selling
agency has been employed or retained to solicit or secure the
contract upon an agreement or understanding for a commission,
percentage, brokerage or contingent fee, except bona fide
employees or bona fide established commercial or selling
agencies maintained by the contractor for the purpose of
securing business. The penalty for breach or violation of this
provision may result in termination of the contract without
the State being liable for damages, costs and/or attorney fees
or, in the Department's
VII-3
discretion, a deduction from the contract price or
consideration the full amount of such commission, percentage,
brokerage or contingent fee.
X. XxxXxxxx Principles. The contractor shall comply with the
XxxXxxxx principles of nondiscrimination in employment and
have no business operations in Northern Ireland as set forth
in N.J.S.A. 52:34-12.1.
L. Ownership of Documents. All documents and records, regardless
of form, prepared by the contractor in fulfillment of the
contract shall be submitted to the State and shall become the
property of the State.
M. Publicity. Publicity and/or public announcements pertaining to
the project shall be approved by the State prior to release.
See Article 5.16 regarding Marketing.
N. Taxes. Contractor shall maintain, and produce to the
Department upon request, proof that all appropriate federal
and State taxes are paid.
7.3 STAFFING
In addition to complying with the specific administrative requirements
specified in Articles Two through Six and Eight, the contractor shall
adhere to the standards delineated below.
A. The contractor shall have in place the organization,
management and administrative systems necessary to fulfill all
contractual arrangements. The contractor shall demonstrate to
DMAHS' satisfaction that it has the necessary staffing, by
function and qualifications, to fulfill its obligations under
this contract which include at a minimum:
- A designated administrative liaison for the Medicaid
contract who shall be the main point of contact
responsible for coordinating all administrative
activities for this contract ("Contractor's
Representative"; See also Article 7.5 below)
- A medical director who shall be a New Jersey licensed
physician (M.D. or D.O.)
- Financial officer(s) or accounting and budgeting
officer
- QM/UR coordinator who is a New Jersey-licensed
registered nurse or physician
- Prior authorization staff sufficient to authorize
medical care twenty-four (24) hours per day/seven (7)
days per week
VII-4
- Designated Medicaid care manager(s) who shall be
available to DMAHS medical staff to respond to
medically related problems, complaints, and emergent
or urgent situations
- A full-time Care Management Supervisor who is a New
Jersey-licensed physician or has a Bachelor's degree
in nursing and has a minimum of four (4) years of
experience serving enrollees with special needs. The
Care Management Supervisor shall be responsible for
the management and supervision of the Care Management
staff.
- Member services staff
- Provider services staff
- Encounter reporting staff/claims processors
- Grievance coordinator
- Adequate administrative and support staff
B. Staff Changes. The contractor shall inform the DMAHS, in
writing, within seven (7) days of key administrative staffing
changes (listed in A) in any of the positions noted in this
Article.
C. Training. The contractor shall ensure that all staff have
appropriate training, education, experience, and orientation
to fulfill the requirements of the positions they hold and
shall verify and document that it has met this requirement.
D. DMAHS Meetings. The contractor's CEO, president, or
DHS-approved representative shall be required to attend
DHS-sponsored contractor CEO dinners. No substitutes will be
permitted. The Contractor's Representative, as hereinafter
defined, shall be required to attend DHS-sponsored contractor
Roundtable sessions.
7.4 RELATIONSHIPS WITH DEBARRED OR SUSPENDED PERSONS PROHIBITED
Pursuant to Section 1932(d)(a) of the Social Security Act (42 U.S.C.
Section 1396u-2(d)(a)):
A. The contractor shall not have a director, officer, partner, or
person with beneficial ownership of more than five (5) percent
of the contractor's equity who has been debarred or suspended
from participating in procurement activities under the Federal
Acquisition Regulation or from participating in nonprocurement
activities under regulations issued pursuant to Executive
Order No. 12549 or under guidelines implementing such order.
VII-5
B. The contractor shall not have an employment, consulting, or
any other agreement with a debarred or suspended person (as
defined in Article 7.4A above) for the provision of items or
services that are significant and material to the contractor's
contractual obligation with the State.
C. The contractor shall certify to DMAHS that it meets the
requirements of this Article prior to initial contracting with
the Department and at any time there is a changed circumstance
from the last such certification. The contractor shall, among
other sources, consult with the Excluded Parties List, which
can be obtained from the General Services Administration.
D. If the contractor is found to be non-compliant with the
provisions concerning affiliation with suspended or debarred
individuals, DMAHS:
1. Shall notify the Secretary of the US Department of
Health and Human Services of such non-compliance;
2. May continue the existing contract with the
contractor unless the Secretary (in consultation with
the Inspector General of the US Department of Health
and Human Services [DHHS]) directs otherwise; and
3. May not renew or otherwise extend the duration of an
existing contract with the contractor unless the
Secretary (in consultation with the Inspector General
of the DHHS) provides to DMAHS and to Congress a
written statement describing compelling reasons that
exist for renewing or extending the contract.
E. The contractor shall agree and certify it does not employ or
contract, directly or indirectly, with:
1. Any individual or entity excluded from Medicaid
participation under Sections 1128 (42 U.S.C. Section
1320a-7) or 1128A (42 U.S.C. Section 1320a-7a) of the
Social Security Act for the provision of health care,
utilization review, medical social work, or
administrative services or who could be excluded
under Section 1128(b)(8) of the Social Security Act
as being controlled by a sanctioned individual;
2. Any entity for the provision of such services
(directly or indirectly) through an excluded
individual or entity;
3. Any individual or entity excluded from Medicaid or NJ
FamilyCare participation by DMAHS;
4. Any individual or entity discharged or suspended from
doing business with the State of New Jersey; or
VII-6
5. Any entity that has a contractual relationship
(direct or indirect) with an individual convicted of
certain crimes as described in Section 1128(b)(8) of
the Social Security Act.
F. The contractor shall obtain, whenever issued, available State
listings and notices of providers, their contractors,
subcontractors, or any of the aforementioned individuals or
entities, or their owners, officers, employees, or associates
who are suspended, debarred, disqualified, terminated, or
otherwise excluded from practice and/or participation in the
fee-for-service Medicaid program. Upon verification of such
suspension, debarment, disqualification, termination, or other
exclusion, the contractor shall immediately act to terminate
the provider from participation in this program. Termination
for loss of licensure, criminal convictions, or any other
reason shall coincide with the effective date of termination
of licensure or the Medicaid program's termination effective
date whichever is earlier.
7.5 CONTRACTING OFFICER AND CONTRACTOR'S REPRESENTATIVE
A. The Department shall designate a single administrator,
hereafter called the "Contracting Officer." The Contracting
Officer shall be appointed by the Commissioner of DHS. The
Contracting Officer shall make all determinations and take all
actions as are appropriate under this contract, subject to the
limitations of applicable federal and New Jersey laws and
regulations. The Contracting Officer may delegate his/her
authority to act to an authorized representative through
written notice to the contractor.
B. The contractor shall designate a single administrator,
hereafter called the Contractor's Representative, who shall be
an employee of the contractor. The Contractor's Representative
shall make all determinations and take all actions as are
appropriate to implement this contract, subject to the
limitations of the contract, and to federal and New Jersey
laws and regulations. The Contractor's Representative may
delegate his or her authority to act to an authorized
representative through written notice to the Contracting
Officer. The Contractor's Representative shall have direct
managerial and administrative responsibility and control over
all aspects of the contract and shall be empowered to legally
bind the contractor to all agreements reached with the
Department.
C. The Contractor's Representative shall be designated in writing
by the contractor no later than the first day on which the
contract becomes effective.
D. The Department shall have the right to approve or disapprove
the Contractor's Representative.
VII-7
7.6 AUTHORITY OF THE STATE
The State is the ultimate authority under this contract to:
A. Establish, define, or determine the reasonableness, the
necessity and the level and scope of covered benefits under
the managed care program administered in this contract or
coverage for such benefits, or the eligibility of enrollees or
providers to participate in the managed care program, or any
aspect of reimbursement to providers, or of operations.
B. Establish or interpret policy and its application related to
the above.
7.7 EQUAL OPPORTUNITY EMPLOYER
The contractor shall, in all solicitations or advertisements for
employees placed by or on behalf of the contractor, state that it is an
equal opportunity employer, and shall send to each labor union or
representative of workers with which it has a collective bargaining
agreement or other contract or understanding, a notice to be provided
by the Department advising the labor union or workers' representative
of the contractor's commitments as an equal opportunity employer and
shall post copies of the notice in conspicuous places available to
employees and applicants for employment.
7.8 NONDISCRIMINATION REQUIREMENTS
The contractor shall comply with the following requirements regarding
nondiscrimination:
A. The contractor shall and shall require its providers and
subcontractors to accept assignment of an enrollee and not
discriminate against eligible enrollees because of race,
color, creed, religion, ancestry, marital status, sexual
orientation, national origin, age, sex, physical or mental
handicap in accordance with Title VI of the Civil Rights Act
of 1964, 42 U.S.C. Section 2000d, Section 504 of the
Rehabilitation Act of 1973, 29 U.S.C. Section 794, the
Americans with Disabilities Act of 1990 (ADA), 42 U.S.C.
Section 12131 and rules and regulations promulgated pursuant
thereto, or as otherwise provided by law or regulation.
B. ADA Compliance. The contractor shall and shall require its
providers or subcontractor to comply with the requirements of
the Americans with Disabilities Act (ADA). In providing health
care benefits, the contractor shall not directly or
indirectly, through contractual, licensing, or other
arrangements, discriminate against Medicaid/NJ FamilyCare
beneficiaries who are qualified disabled individuals covered
by the provisions of the ADA (See also Article 4.5.2 for a
description of the contractor's ADA compliance plan).
A "qualified individual with a disability" defined pursuant to
42 U.S.C. Section 12131 is an individual with a disability
who, with or without reasonable modifications to
VII-8
rules, policies, or practices, the removal of architectural,
communication, or transportation barriers, or the provision of
auxiliary aids and services, meets the essential eligibility
requirements for the receipt of services or the participation
in programs or activities provided by a public entity (42
U.S.C. Section 12131).
The contractor shall submit to DMAHS a written certification
that it is conversant with the requirements of the ADA, that
it is in compliance with the law, and that it has assessed its
provider network and certifies that the providers meet ADA
requirements to the best of the contractor's knowledge. The
contractor shall survey its providers of their compliance with
the ADA using a standard survey document that will be
developed by the State. Survey attestation shall be kept on
file by the contractor and shall be available for inspection
by the DMAHS. The contractor warrants that it will hold the
State harmless and indemnify the State from any liability
which may be imposed upon the State as a result of any failure
of the contractor to be in compliance with the ADA. Where
applicable, the contractor shall abide by the provisions of
Section 504 of the federal Rehabilitation Act of 1973, as
amended, 29 U.S.C. Section 794, regarding access to programs
and facilities by people with disabilities.
C. The contractor shall and shall require its providers and
subcontractors to not discriminate against eligible persons or
enrollees on the basis of their health or mental health
history, health or mental health status, their need for health
care services, amount payable to the contractor on the basis
of the eligible person's actuarial class, or pre-existing
medical/health conditions.
D. The contractor shall and shall require its providers and
subcontractors to comply with the Civil Rights Act of 1964 (42
U.S.C. Section 2000d), the regulations (45 C.F.R. Parts 80 &
84) pursuant to that Act, and the provisions of Executive
Order 11246, Equal Opportunity, dated September 24, 1965, the
New Jersey anti-discrimination laws including those contained
within N.J.S.A. 10:2-1 through N.J.S.A. 10:2-4, N.J.S.A.
10:5-1 et seq. and N.J.S.A. 10:5-38, and all rules and
regulations issued thereunder, and any other laws,
regulations, or orders which prohibit discrimination on
grounds of age, race, ethnicity, mental or physical
disability, sexual or affectional orientation or preference,
marital status, genetic information, source of payment, sex,
color, creed, religion, or national origin or ancestry. The
contractor shall not discriminate against any employee engaged
in the work required to produce the services covered by this
contract, or against any applicant for such employment because
of race, creed, color, national origin, age, ancestry, sex,
marital status, religion, disability or sexual or affectional
orientation or preference.
E. The contractor shall not discriminate with respect to
participation, reimbursement, or indemnification as to any
provider who is acting within the scope of the provider's
license or certification under applicable State law, solely on
the basis of such license or certification. This paragraph
shall not be construed to prohibit an organization from
including providers only to the extent necessary to meet the
VII-9
needs of the organization's enrollees or from establishing any
measure designed to maintain quality and control costs
consistent with the responsibilities of the organization.
F. Scope. This non-discrimination provision shall apply to but
not be limited to the following: recruitment or recruitment
advertising, hiring, employment upgrading, demotion, or
transfer, lay-off or termination, rates of pay or other forms
of compensation, and selection for training, including
apprenticeship included in PL 1975, Chapter 127 as attached
hereto and made a part hereof.
G. Grievances. The contractor shall forward to the Department
copies of all grievances alleging discrimination against
enrollees because of race, color, creed, sex, religion, age,
national origin, ancestry, marital status, sexual or
affectional orientation, physical or mental handicap for
review and appropriate action within three (3) business days
of receipt by the contractor.
7.9 INSPECTION RIGHTS
The contractor shall allow the New Jersey Department of Human Services,
the US Department of Health and Human Services (DHHS), and other
authorized State agencies, or their duly authorized representatives, to
inspect or otherwise evaluate the quality, appropriateness, and
timeliness of services performed under the contract, and to inspect,
evaluate, and audit any and all books, records, and facilities
maintained by the contractor and its providers and subcontractors,
pertaining to such services, at any time during normal business hours
(and after business hours when deemed necessary by DHS or DHHS) at a
New Jersey site designated by the Contracting Officer. Pursuant to
N.J.S.A. 10:49-9.8m inspections of contractors may be unannounced with
or without cause, and inspections of providers and subcontractors may
be unannounced for cause. Books and records include, but are not
limited to, all physical records originated or prepared pursuant to the
performance under this contract, including working papers, reports,
financial records and books of account, medical records, dental
records, prescription files, provider contracts and subcontracts,
credentialing files, and any other documentation pertaining to medical,
dental, and nonmedical services to enrollees. Upon request, at any time
during the period of this contract, the contractor shall furnish any
such record, or copy thereof, to the Department or the Department's
External Review Organization within thirty (30) days of the request. If
the Department determines, however, that there is an urgent need to
obtain a record, the Department shall have the right to demand the
record in less than thirty (30) days, but no less than twenty-four (24)
hours.
Access shall be undertaken in such a manner as to not unduly delay the
work of the contractor and/or its provider(s) or subcontractor(s). The
right of access herein shall include onsite visits by authorized
designees of the State.
The contractor shall also permit the State, at its sole discretion, to
conduct onsite inspections of facilities maintained by the contractor,
its providers and subcontractors, prior to approval of their use for
providing services to enrollees.
VII-10
7.10 NOTICES/CONTRACT COMMUNICATION
All notices or contract communication under this contract shall be in
writing and shall be validly and sufficiently served by the State upon
the contractor, and vice versa, if addressed and mailed by certified
mail, delivered by overnight courier or hand-delivered to the following
addresses:
For DHS:
Contracting Officer
Division of Medical Assistance and Health Services
X.X. Xxx 000
Xxxxxxx, XX 00000-0000
The contractor shall specify the name of the Contractor's
Representative and official mailing address for all formal
communications. The name and address of the individual appears in
Appendix D.6 and is incorporated herein by reference.
7.11 TERM
7.11.1 CONTRACT DURATION AND EFFECTIVE DATE
The performance, duties, and obligations of the parties hereto shall
commence on the effective date, provided that at the effective date the
Director and the contractor agree that all procedures necessary to
implement this contract are ready and shall continue for a period of
nine (9) months thereafter unless suspended or terminated in accordance
with the provisions of this contract. The initial nine (9) month period
shall be known as the "original term" of the contract. The effective
date of the contract shall be October 1, 2000.
7.11.2 AMENDMENT, EXTENSION, AND MODIFICATION
A. The contract may be amended, extended, or modified by written
contract duly executed by the Director and the contractor. Any
such amendment, extension or modification shall be in writing
and executed by the parties hereto. It is mutually understood
and agreed that no amendment of the terms of the contract
shall be valid unless reduced to writing and executed by the
parties hereto, and that no oral understandings,
representations or contracts not incorporated herein nor any
oral alteration or variations of the terms hereof, shall be
binding on the parties hereto. Every such amendment,
extension, or modification shall specify the date its
provisions shall be effective as agreed to by the Department
and the contractor. Any amendment, extension, or modification
is not effective or binding unless approved, in writing, by
duly authorized officials of DHS, HCFA, and any other entity,
as required by law or regulation.
VII-11
B. This contract may be extended for successive twelve (12) month
periods beyond the original term of the contract whenever the
Division supplies the contractor with at least ninety (90)
days advance notice of such intent and if a written amendment
to extend the contract is obtained from both parties. This
successive twelve (12) month period shall be known as an
"extension period" of the contract. In addition, ninety (90)
days prior to the contract expiration, the Director shall
provide the contractor with the proposed capitation rates for
the extension period.
C. In the event that the capitation rates for the extension
period are not provided ninety (90) days prior to the contract
expiration, the contract will be extended at the existing rate
which shall be an interim rate. After the execution of the
succeeding rate amendment, a retroactive rate adjustment will
be made to bring the interim rate to the level established by
that amendment.
D. The contractor shall begin providing services to all
populations covered under this contract on October 1, 2000.
The State shall pay the contractor the capitation rates set
forth in Appendix C, except for the following premium groups:
1. DDD With Medicare
2. DDD Without Medicare (ABD)
3. DDD Without Medicare (non-ABD)
4. AIDS - ABD With Medicare
5. AIDS & DDD - ABD With Medicare
6. AFDC - AIDS
7. AFDC - AIDS & DDD
8. Blind/Disabled With Medicare, < 45 M & F
9. Blind/Disabled With Medicare, 45+ M & F
For those enrollees who are members of the contractor's plan
as of October 1, 2000 and who are subsequently identified by
the State as members of one of the above premium groups, the
State may initially pay the contractor the following
capitation rates:
-------------------------------------------------------------------------------------
PREMIUM GROUP INTERIM RATE
-------------------------------------------------------------------------------------
DDD With Medicare Aged with Medicare
-------------------------------------------------------------------------------------
DDD Without Medicare (ABD) ABD (including AIDS) Without Medicare
-------------------------------------------------------------------------------------
DDD Without Medicare (non-ABD) ABD (including AIDS) Without Medicare
-------------------------------------------------------------------------------------
AIDS - ABD With Medicare ABD (including AIDS) Without Medicare
-------------------------------------------------------------------------------------
AIDS & DDD - ABD With Medicare ABD (including AIDS) Without Medicare
-------------------------------------------------------------------------------------
AFDC - AIDS ABD (including AIDS) Without Medicare
-------------------------------------------------------------------------------------
AFDC - AIDS & DDD ABD (including AIDS) Without Medicare
-------------------------------------------------------------------------------------
Blind/Disabled With Medicare, < 45 M & F Aged With Medicare
-------------------------------------------------------------------------------------
Blind/Disabled With Medicare, 45+ M & F Aged With Medicare
-------------------------------------------------------------------------------------
The State shall retroactively adjust these payments to reflect
the premium rate for these enrollees.
VII-12
E. Nothing in this Article shall be construed to prevent the
Director by amendment to the contract from extending the
contract on a month to month basis under the existing rates
until such a time that the Director provides revised
capitation rates pursuant to Article 7.11.2B.
7.12 TERMINATION
A. Change of Circumstances. Where circumstances and/or the needs
of the State significantly change or the contract is otherwise
deemed by the Director to no longer be in the public interest,
the DMAHS may terminate this contract upon no less than thirty
(30) days notice to the contractor.
B. Emergency Situations. In cases of emergency the Department may
shorten the time periods of notification.
C. For Cause. DMAHS shall have the right to terminate this
contract, without liability to the State, in whole or in part
if the contractor:
1. Takes any action or fails to prevent an action that
threatens the health, safety or welfare of any
enrollee, including significant marketing abuses;
2. Takes any action that threatens the fiscal integrity
of the Medicaid program;
3. Has its certification suspended or revoked by DOBI,
DHSS, and/or any federal agency or is federally
debarred or excluded from federal procurement and
non-procurement contracts;
4. Materially breaches this contract or fails to comply
with any term or condition of this contract that is
not cured within twenty (20) working days of DMAHS'
request for compliance;
5. Violates state or federal law;
6. Becomes insolvent; or
7. Brings a proceeding voluntarily, or has a proceeding
brought against it involuntarily, under the
Bankruptcy Act.
D. Notice and Hearing. Except as provided in A and B above, DMAHS
shall give the contractor ninety (90) days advance, written
notice of termination of this contract, with an opportunity to
protest said termination and/or request an informal hearing.
This notice shall specify the applicable provisions of this
contract and the effective date of termination, which shall
not be less than will
VII-13
permit an orderly disenrollment of enrollees to the Medicaid
fee-for-service program or transfer to another managed care
program.
E. Contractor's Right to Terminate for Material Breach. The
contractor shall have the right to terminate this contract in
the event that DMAHS materially breaches this contract or
fails to comply with any material term or condition of this
contract that is not cured within twenty (20) working days of
the contractor's request for compliance. In such event, the
contractor shall give DMAHS written notice specifying the
reason for and the effective date of the termination, which
shall not be less than will permit an orderly disenrollment of
enrollees to the Medicaid fee-for-service program or transfer
to another managed care program and in no event shall be less
than ninety (90) days from the end of the twenty (20) day
working day cure period. The effective date of termination is
subject to DMAHS concurrence and approval.
F. Contractor's Right to Terminate for Act of God. The contractor
shall have the right to terminate this contract if the
contractor is unable to provide services pursuant to this
contract because of a natural disaster and/or an Act of God to
such a degree that enrollees cannot obtain reasonable access
to services within the contractor's organization, and, after
diligent efforts, the contractor cannot make other provisions
for the delivery of such services. The contractor shall give
DMAHS, within forty-five (45) days after the disaster, written
notice of any such termination that specifies:
1. The reasons for the termination, with appropriate
documentation of the circumstances arising from a
natural disaster or Act of God that precludes
reasonable access to services;
2. The contractor's attempts to make other provisions
for the delivery of services; and
3. The requested effective date of the termination,
which shall not be less time than will permit an
orderly disenrollment of enrollees to the Medicaid
fee-for-service program or transfer to another
managed care program. The effective date of
termination is subject to DMAHS concurrence and
approval.
G. Reduction in Funding. In the event that State and federal
funding for the payment of services under this contract is
reduced so that payments to the contractor cannot be made in
full, this contract shall terminate, without liability to the
State, unless both parties agree to a modification of the
obligations under this contract. The effective date of such
termination shall be ninety (90) days after the contractor
receives written notice of the reduction in payment, unless
available funds are insufficient to continue payments in full
during the ninety (90) day period, in which case the
Department shall give the contractor written notice of the
earlier date upon which the contract shall terminate.
VII-14
H. It is hereby understood and agreed by both parties that this
contract shall be effective and payments by DMAHS made to the
contractor subject to the availability of State and federal
funds. It is further agreed by both parties that this contract
can be renegotiated or terminated, without liability to the
State in order to comply with state and federal requirements
for the purpose of maximizing federal financial participation.
I. Upon termination of this contract, the contractor shall comply
with the closeout procedures in Article 7.13.
J. Rights and Remedies. The rights and remedies of the Department
provided in this Article shall not be exclusive and are in
addition to all other rights and remedies provided by law or
under this contract.
7.13 CLOSEOUT REQUIREMENTS
A. A closeout period shall begin one hundred-twenty (120) days
prior to the last day the contractor is responsible for
operating under this contract. During the closeout period, the
contractor shall work cooperatively with, and supply program
information to, any subsequent contractor and DMAHS. Both the
program information and the working relationships between the
two contractors shall be defined by DMAHS.
B. The contractor shall be responsible for the provision of
necessary information and records, whether a part of the MCMIS
or compiled and/or stored elsewhere, to the new contractor
and/or DMAHS during the closeout period to ensure a smooth
transition of responsibility. The new contractor and/or DMAHS
shall define the information required during this period and
the time frames for submission. Information that shall be
required includes but is not limited to:
1. Numbers and status of complaints and grievances in
process;
2. Numbers and status of hospital authorizations in
process, listed by hospital;
3. Daily hospital logs;
4. Prior authorizations approved and disapproved;
5. Program exceptions approved;
6. Medical cost ratio data;
7. Payment of all outstanding obligations for medical
care rendered to enrollees;
VII-15
8. All encounter data required by this contract; and
9. Information on beneficiaries in treatment plans who
will require continuity of care consideration.
C. All data and information provided by the contractor shall be
accompanied by letters, signed by the responsible authority,
certifying to the accuracy and completeness of the materials
supplied. The contractor shall transmit the information and
records required under this Article within the time frames
required by the Department. The Department shall have the
right, in its sole discretion, to require updates to these
data at regular intervals.
D. The new contractor shall reimburse any reasonable costs
associated with the contractor providing the required
information or as mutually agreed upon by the two contractors.
The contractor shall not charge more than a cost mutually
agreed upon by the contractor and DMAHS or as mutually agreed
upon by the two contractors. If program operations are
transferred to DMAHS, no such fees shall be charged by the
contractor nor paid by DMAHS. Under no circumstances shall a
Medicaid beneficiary be billed for any record transfer.
E. The contractor shall continue to be responsible for provider
and enrollee toll free numbers and after-hours calls until the
last day of the closeout period. The new contractor shall bear
financial responsibility for costs incurred in modifying the
toll free number telephone system. The contractor shall, in
good faith, negotiate a contract with the new contractor to
coordinate/transfer the toll free number responsibilities, and
will provide space at the contractor's current business
address including access to necessary records, and information
for the new contractor during a due diligence review period.
F. Effective two (2) weeks prior to the last day of the closeout
period, the contractor shall work cooperatively with the new
contractor to process service authorization requests received.
The contractor shall be financially responsible for approved
requests when the service is provided on or before the last
day of the closeout period or if the service is provided
through the date of discharge or thirty-one (31) days after
the cancellation or termination of this contract for enrollees
who remain hospitalized after the last day of the transition
period. Disputes between the contractor and the new contractor
regarding service authorizations shall be resolved by DMAHS.
G. The contractor shall continue to provide all required reports
during the closeout period.
H. Runout Requirements - General. Runout for this Managed Care
Contract shall consist of the processing, payment and monetary
reconciliation(s) necessary regarding all enrollees, claims
for payment from the contractor's provider
VII-16
network, appeals by both providers and/or enrollees, and final
reports which identify all expenditures, up to and including
the last month of capitated payment made to the contractor.
I. The contractor shall complete the processing and payment of
claims generated during the life of the contract.
J. Runout Requirements - Items of Concern.
1. Information and documentation that the Department
deems necessary under this Article, to effect a
smooth Turnover to a successor contractor, shall be
required to be submitted on a monthly basis. The
Department shall have the right to require updates to
this data at regular intervals.
2. Any other information or data, within the parameters
of this Managed Care Contract, deemed necessary by
the Department to assist in the reprocurement of the
contract including where applicable, but not limited
to, duplicate copies of x-rays, charting and lab
reports, and copies of actual documents and
supporting documentation, etc., relevant to access,
quality of care, and enrollee history shall be
provided to DMAHS.
K. Runout Requirements - Final Transition. During the final
forty-five (45) days before the end of the closeout period,
the terminating and successor contractors shall share
operational responsibilities, as delineated below:
1. Record Sharing. The contractor shall make available
and/or require its providers to make available to the
Department copies of medical/dental records, patient
files, and any other pertinent information, including
information maintained by any subcontractor or
sub-subcontractor, necessary for efficient care
management of enrollees, as determined by the
Director. Under no circumstances shall a Medicaid
enrollee be billed for this service.
2. Enrollee Notification. The terminating and successor
contractors shall notify enrollees of the pending
transition, with all notices to be submitted to DMAHS
for review and approval before mail out.
L. Post-Operations Period. The post-operations period shall begin
at 12:00 a.m. the day after the last day of the closeout
period. During the post-operations period, the contractor
shall no longer be responsible for the operation of the
program. Obligations of the contractor under this contract
that are applicable to the post-operations period will apply
whether or not they are enumerated in this Article.
1. The contractor shall maintain local telephone access
for providers during the first six (6) months of the
post-operations period.
VII-17
2. The contractor shall be financially responsible for
the resolution of beneficiary complaints and
grievances timely filed prior to the last day of the
post-operations period.
3. The contractor shall have a continuing obligation to
provide any required reports during the closeout and
post-operations periods.
4. The contractor shall refill prescriptions to cover a
minimum of ten (10) days beyond the contract
termination date, unless other arrangements are made
with the receiving contractor and approved by DMAHS.
5. The contractor shall provide DME for a minimum of the
first thirty (30) days of the post-operations period,
unless other arrangements are made with the receiving
contractor and approved by DMAHS.
a. Customized DME is considered to belong to
the enrollee and stays with the enrollee
when there is a change of contractors.
b. Non-customized DME may be reclaimed by the
contractor when the enrollee no longer
requires the equipment if a system is in
place for refurbishing and reissuing the
equipment. If no such system is in place,
the non-customized DME shall be considered
the property of the enrollee.
6. The contractor shall, within sixty days after the end
of the closeout period, account for and return any
and all funds advanced by the Department for coverage
of enrollees for periods subsequent to the effective
date of post-operations.
7. The contractor shall submit to the Department within
ninety (90) days after the end of the closeout period
an annual report for the period through which
services are rendered, and a final financial
statement and audit report including at a minimum,
revenue and expense statements relating to this
contract, and a complete financial statement relating
to the overall lines of business of the contractor
prepared by a Certified Public Accountant or a
licensed public accountant.
M. In the event of termination of the contract by DMAHS, such
termination shall not affect the obligation of contractor to
indemnify DMAHS for any claim by any third party against the
State or DMAHS arising from contractor's performance of this
contract and for which contractor would otherwise be liable
under this contract.
VII-18
7.14 MERGER/ACQUISITION REQUIREMENTS
A. General Information. In addition to any other information
otherwise required by the State, a contractor that intends to
merge with or be acquired by another entity ("non-surviving
contractor") shall provide the following information and
documents to DHS, and copies to DHSS and DOBI, one
hundred-twenty (120) days prior to the effective date of the
merger/acquisition:
1. The basic details of the sale, including the name of
the acquiring legal entity, the date of the sale and
a list of all owners with five (5) percent or more
ownership.
2. The source of funds for the purchase.
3. A Certificate of Authority modification.
4. Any changes in the provider network, including but
not limited to a comparison of hospitals that no
longer will be available under the new network, and
comparison of PCPs and specialists participating and
not participating in both HMOs.
5. Submit a draft of the asset purchase agreement to
DHS, DHSS, and DOBI for prior approval prior to
execution of the document.
6. The closing date for the merger/acquisition, which
shall occur prior to the required notification to
enrollees, i.e. no later than forty-five (45) days
prior to effective date of transition of enrollees.
7. Submit a copy of all information, including all
financials, sent to/required by DHSS and DOBI.
B. General Requirements. The non-surviving contractor shall:
1. Comply with the provisions of Article 7.13, Closeout;
and
2. Meet and complete all outstanding issues, reporting
requirements (including but not limited to encounter
data reporting, quality assurance studies, financial
reports, etc.)
C. Medicaid Beneficiary Notification. By no later than sixty (60)
days, the non-surviving contractor shall prepare and submit,
in English and Spanish, to the DMAHS, letters and other
materials which shall be mailed to its enrollees no later than
forty-five (45) days prior to the effective date of transfer
in order to assist them in making an informed decision about
their health and needs. Separate notices shall be prepared for
mandatory populations and voluntary populations. The letter
should contain the following, at a minimum:
VII-19
1. From the non-surviving contractor:
a. The basic details of the sale, including the
name of the acquiring legal entity, and the
date of the sale.
b. Any major changes in the provider network,
including at minimum a comparison of
hospitals that no longer will be available
under the network, if that is the case.
c. For each enrollee, a representation whether
that individual's primary care provider
under the non-surviving contractor's plan
will be available under the acquiring
contractor's plan. When the PCP is no longer
available under the acquiring contractor's
plan, the enrollee shall be advised to call
the HBC to see what other MCE the PCP
participates in.
d. In those cases where a primary dentist is
selected under the non-surviving
contractor's plan, a representation whether
each individual's primary dentist under the
non-surviving contractor's plan will be
available under the acquiring contractor's
plan.
e. Information on beneficiaries in treatment
plans and the status of any continuing
medical care being rendered under the
non-surviving contractor's plan, how that
treatment will continue, and time frames for
transition from the non-surviving
contractor's plan to the acquiring
contractor's plan.
f. Any changes in the benefits/procedures
between the non-surviving contractor's plan
and the acquiring contractor's plan,
including for example, eye care and glasses
benefits, over-the-counter drugs, and
referral procedures, etc.
g. Toll free telephone numbers for the HBC and
the acquiring entity where enrollees'
questions can be answered.
h. A time frame of not less than two weeks
(fourteen days) for the beneficiary to make
a decision about staying in the acquiring
contractor's plan, or switching to another
MCE (for mandatory beneficiaries). The time
frame should incorporate the monthly cutoff
dates established by the DMAHS and the HBC
for the timely and accurate production of
Medicaid identification cards.
i. For voluntary populations, the letter should
indicate the option to revert to the
fee-for-service system.
VII-20
2. From the acquiring contractor:
a. If the acquiring contractor wishes to send
welcoming letters, it shall submit for prior
approval to DMAHS, all welcoming letters and
information it will send to the new
enrollees no later than thirty (30) days
prior to the effective date of transfer.
b. The acquiring contractor may not, either
directly or indirectly, contact the
enrollees of the non-surviving contractor,
prior to the enrollees conversion
(approximately ten (10) days prior to the
effective date of transfer).
Any returned mail should be re-sent two additional times. If
the mail to a beneficiary is returned three times, the name,
the Medicaid identification number and last know address
should be submitted to the DMAHS for research to determine a
more current address.
D. Provider Notification. By no later than ninety (90) days prior
to the effective date of transfer, the non-surviving
contractor shall notify its providers of the pending sale or
merger, and of hospitals, specialists and laboratories that
will no longer be participating as a result of the
merger/acquisition.
E. Marketing/Outreach.
1. The acquiring contractor may not make any unsolicited
home visits or telephone calls to enrollees of the
non-surviving contractor, before the effective date
of coverage under the acquiring contractor's plan.
2. Coincident with the date that enrollee notification
letters are sent to those enrollees affected by the
merger/acquisition, the non-surviving contractor
shall no longer be offered as an option to either new
enrollees or to those seeking to transfer from other
plans. DMAHS shall approve all enrollee notification
letters, and they shall be mailed by the
non-surviving contractor. Marketing by the
non-surviving contractor shall also cease on that
date.
F. Provider Network. The acquiring contractor shall supply the
DMAHS and the HBC with an updated provider network fifty (50)
days prior to the effective date of transfer on a diskette
formatted in accordance with the procedures set forth in
Section A.4.1 of the Appendices. Additionally, the acquiring
contractor shall furnish to the DMAHS individual provider
capacity analyses and how the provider/enrollee ratio limits
will be maintained in the new entity. This network information
shall be furnished before the enrollee notification letters
are to be sent. Such letters shall not be mailed until there
is a clear written notification by the DMAHS that the provider
network information meets all of the DMAHS
VII-21
requirements. The network submission shall include all
required provider types listed in Article 4, shall be
formatted in accordance with specifications in Article 4 and
Section A.4.1 of the Appendices, and shall include a list of
all providers who decline participation with the acquiring
contractor and new providers who will participate with the
acquiring contractor. The acquiring contractor shall submit
weekly updates through the ninety (90) day period following
the effective date of transfer.
G. Administrative.
1. The non-surviving contractor shall inform DMAHS of
the corporate structure it will assume once all
enrollees are transitioned to the acquiring
contractor. Additionally, an indication of the time
frame that this entity will continue to exist shall
be provided.
2. The contract of the non-surviving contractor is not
terminated until the transaction (acquisition or
merger) is approved, enrollees are placed, and all
outstanding issues with DOBI, DHSS, and DHS are
resolved. Some infrastructure shall exist for up to
one year beyond the last date of services to
enrollees in order to fulfill remaining contractual
requirements.
3. The acquiring contractor and the non-surviving
contractor shall maintain their own separate
administrative structure and staff until the
effective date of transfer.
7.15 SANCTIONS
In the event DMAHS finds the contractor to be out-of-compliance with
program standards, performance standards or the terms or conditions of
this contract, the Department shall issue a written notice of
deficiency, request a corrective action plan and/or specify the manner
and timeframe in which the deficiency is to be cured. If the contractor
fails to cure the deficiency as ordered, the Department shall have the
right to exercise any of the administrative sanction options described
below, in addition to any other rights and remedies that may be
available to the Department. The type of action taken shall be in
relation to the nature and severity of the deficiency:
A. Suspend enrollment of beneficiaries in contractor's plan.
B. Notify enrollees of contractor non-performance and permit
enrollees to transfer to another MCE.
C. Reduce or eliminate marketing and/or community event
participation.
D. Terminate the contract, under the provisions of the preceding
Article.
E. Cease auto-assignment of new enrollees.
VII-22
F. Refuse to renew the contract.
G. Impose and maintain temporary management in accordance with
Section 1932(e)(2) of the Social Security Act during the
period in which improvements are made to correct violations.
H. In the case of inappropriate marketing activities, referral
may also be made to the Department of Banking and Insurance
for review and appropriate enforcement action.
I. Require special training or retraining of marketing
representatives including, but not limited to, business
ethics, marketing policies, effective sales practices, and
State marketing policies and regulations, at the contractor's
expense.
J. In the event the contractor becomes financially impaired to
the point of threatening the ability of the State to obtain
the services provided for under the contract, ceases to
conduct business in the normal course, makes a general
assignment for the benefit of creditors, or suffers or permits
the appointment of a receiver for its business or its assets,
the State may, at its option, immediately terminate this
contract effective the close of business on the date
specified.
K. Refuse to consider for future contracting a contractor that
fails to submit encounter data on a timely and accurate basis.
L. Refer the matter to the US Department of Justice, the US
Attorney's Office, the New Jersey Division of Criminal
Justice, and/or the New Jersey Division of Law as warranted.
M. Refer the matter to the applicable federal agencies for civil
money penalties.
N. Refer the matter to the New Jersey Division of Civil Rights
where applicable.
O. Exclude the contractor from participation in the Medicaid
program.
P. Refer the matter to the New Jersey Division of Consumer
Affairs.
The contractor may appeal the imposition of sanctions or damages in
accordance with Article 7.18.
VII-23
7.16 LIQUIDATED DAMAGES PROVISIONS
7.16.1 GENERAL PROVISIONS
It is agreed by the contractor that:
A. If contractor does not provide or perform the requirements
referred to or listed in this provision, damage to the State
may result.
B. Proving such damages shall be costly, difficult, and
time-consuming.
C. Should the State choose to impose liquidated damages, the
contractor shall pay the State those damages for not providing
or performing the specified requirements; if damages are
imposed, collection shall be from the date the State placed
the contractor on notice or as may be specified in the written
notice.
D. Additional damages may occur in specified areas by prolonged
periods in which contractor does not provide or perform
requirements.
E. The damage figures listed below represent a good faith effort
to quantify the range of harm that could reasonably be
anticipated at the time of the making of the contract.
F. The Department may, at its discretion, withhold capitation
payments in whole or in part, or offset with advanced notice
liquidated damages from capitation payments owed to the
contractor.
G. The DHS shall have the right to deny payment or recover
reimbursement for those services or deliverables which have
not been performed and which due to circumstances caused by
the contractor cannot be performed or if performed would be of
no value to the State. Denial of the amount of payment shall
be reasonably related to the amount of work or deliverable
lost to the State.
H. The DHS shall have the right to recover incorrect payments to
the contractor due to omission, error, fraud or abuse, or
defalcation by the contractor. Recovery to be made by
deduction from subsequent payments under this contract or
other contracts between the State and the contractor, or by
the State as a debt due to the State or otherwise as provided
by law.
I. Whenever the State determines that the contractor failed to
provide one (1) or more of the medically necessary covered
contract services, the State shall have the right to withhold
a portion of the contractor's capitation payments for the
following month or subsequent months, such portion withheld to
be equal to the amount of money the State shall pay to provide
such services along with administrative costs of making such
payment. Any other harm to the State or the
VII-24
beneficiary/enrollee shall be calculated and applied as a
damage. The contractor shall be given written notice prior to
the withholding of any capitation payment.
J. The contractor shall submit a written corrective action plan
for any deficiency identified by the Department in writing
within five (5) business days from the date of receipt of the
Department's notification or within a time determined by the
Department depending on the nature of the issue. For each day
beyond that time that the Department has not received an
acceptable corrective action plan, monetary damages in the
amount of one hundred dollars ($100) per day for five (5) days
and two hundred fifty ($250) per day thereafter will be
deducted from the capitation payment to the contractor. The
contractor shall implement the corrective action plan
immediately from time of Department notification of the
original problem pending approval of the final corrective
action plan. The damages shall be applied for failure to
implement the corrective action plan from the date of original
State notification of the problem. Corrective action plans
apply to each of the areas in this Article for potential
liquidated damages and the time period allowed shall be at the
sole discretion of the DMAHS.
K. Self-Reporting of Failures and Noncompliance. Any monetary
damages that otherwise would be assessed pursuant to this
Article of this contract, may be reduced, at the State's
option, if the contractor reports the failure or noncompliance
in written detail to DMAHS prior to notice of the
noncompliance from the Department. The amount of the reduction
shall be no more than ninety (90) percent of the total value
of the monetary damages.
L. Nothing in this provision shall be construed as relieving the
contractor from performing any other contract duty not listed
herein, nor is the State's right to enforce or to seek other
remedies for failure to perform any other contract duty hereby
diminished.
7.16.2 MANAGED CARE OPERATIONS, TERMS AND CONDITIONS, AND PAYMENT PROVISIONS
During the life of the contract, the contractor shall provide or
perform each of the requirements as stated in the contract.
Except as provided for elsewhere in this Article (i.e., the other
liquidated damages provisions in this Article take precedence), for
each and every contractor requirement not provided or performed as
scheduled, or if a requirement is provided or performed inaccurately or
incompletely, the Department, if it intends to impose liquidated
damages, shall notify the contractor in writing that the requirement
was not provided or performed as specified and that liquidated damages
will be assessed accordingly.
The contractor shall have fifteen (15) business days from the date of
such written notice from the Department, or longer if the Department so
allows, or through a corrective action plan approved by DHS to provide
or perform the requirement as specified.
VII-25
Liquidated Damages:
If the contractor does not provide or perform the requirement within
fifteen (15) business days of the written notice, or longer if allowed
by the Department, or through an approved corrective action plan, the
Department may impose liquidated damages of $250 per requirement per
day for each day the requirement continues not to be provided or
performed. If after fifteen (15) additional days from the date the
Department imposes liquidated damages, the requirement still has not
been provided or performed, the Department, after written notice to the
contractor, may increase the liquidated damages to $500 per requirement
per day for each day the requirement continues to be unprovided or
unperformed.
7.16.3 TIMELY REPORTING REQUIREMENTS
The contractor shall produce and deliver timely reports within the
specified timeframes and descriptions in the contract including
information required by the ERO. Reports shall be produced and
delivered on both a scheduled and mutually agreed upon on-request basis
according to the schedule established by DMAHS.
Liquidated Damages:
For each late report, the Department shall have the right to impose
liquidated damages of $250 per day per report until the report is
provided. For any late report that is not delivered after thirty (30)
days or such longer period as the Department shall allow, the
Department, after written notice, shall have the right to increase the
liquidated damages assessment to $500 per day per report until the
report is provided.
7.16.4 ACCURATE REPORTING REQUIREMENTS
Every report due the State shall contain sufficient and accurate
information and in the approved media format to fulfill the State's
purpose for which the report was generated.
If the Department imposes liquidated damages, it shall give the
contractor written notice of a report that is either insufficient or
inaccurate and that liquidated damages will be assessed accordingly.
After such notice, the contractor shall have fifteen (15) business
days, or such longer period as the Department may allow, to correct the
report.
Encounter data shall be accurate and complete, i.e., have no missing
encounters or required data elements.
Liquidated Damages:
If the contractor fails to correct the report within the fifteen (15)
business days, or such longer period as the Department may allow, the
Department shall have the right to impose liquidated damages of $250
per day per report until the corrected report is
VII-26
delivered. If the report remains uncorrected for more than thirty (30)
days from the date liquidated damages are imposed, the Department,
after written notice, shall have the right to increase the liquidated
damages assessment to $500 per day per report until the report is
corrected.
An amount of $1 may be assessed for each missing or omitted encounter.
In addition, $1 per encounter or encounter data element may be assessed
for any pending encounter or error that is not corrected and returned
to DMAHS within thirty (30) days after notification by DMAHS that the
data are incomplete or incorrect. The Department shall have the right
to calculate the total number of missing or omitted encounters and
encounter data by extrapolating from a sample of missing or omitted
encounters and encounter data.
7.16.5 TIMELY PAYMENTS TO MEDICAL PROVIDERS
The contractor shall process claims in accordance with New Jersey laws
and regulations and shall be subject to damages pursuant to such laws
and regulations. In addition, pursuant to this contract the Department
may assess liquidated damages if the contractor does not process (pay
or deny) claims within the following timeframes: ninety (90) percent of
all claims (the totality of claims received whether contested or
uncontested) submitted electronically by medical providers within
thirty (30) days of receipt; ninety (90) percent of all claims filed
manually within forty (40) days of receipt; ninety-nine (99) percent of
all claims, whether submitted electronically or manually, within sixty
(60) days of receipt; and one hundred (100) percent of all claims
within ninety (90) days of receipt. Claims processed for providers
under investigation for fraud or abuse and claims suppressed pursuant
to Article 8.9 (regarding PIPs) are not subject to these requirements.
The amount of time required to process a paid claim shall be computed
in days by comparing the initial date of receipt with the check mailing
date. The amount of time required to process a denied claim (whether
all or part of the claim is denied) shall be computed in days by
comparing the date of initial receipt with the denial notice mailing
date. Claims processed during the quarter shall be reported in required
categories through the Claims Lag report (See Section A.7.6 of the
Appendices (Table 4A and B)). Table 4A shall be used to report claims
submitted manually and Table 4B shall be used to report claims
submitted electronically.
Liquidated Damages:
Liquidated damages may be assessed if the contractor does not meet the
above requirements on a quarterly basis. Based on the
contractor-reported information on the claims lag reports, the
Department shall determine for each time period (thirty (30)/forty
(40), sixty (60), and ninety (90) days) the actual percentage of claims
processed (electronic and manual claims shall be added together). This
number shall be subtracted from the percentage of claims the contractor
should have processed in the particular time period. The difference
shall be expressed in points. For example, if the contractor only
processed eighty-eight (88) percent of electronic claims within thirty
(30) days and
VII-27
eighty-eight (88) percent of manual claims within forty (40) days, it
shall be considered to be two (2) points short for that time period.
The points that the contractor is short for each of the three time
periods shall be added together. This sum shall then be multiplied
times .0004 times the capitation payments received by the contractor
during the quarter at issue to arrive at the liquidated damages amount.
No offset shall be given if a criterion is exceeded. DMAHS reserves the
right to audit and/or request detail and validation of reported
information. DMAHS shall have the right to accept or reject the
contractor's report and may substitute reports created by DMAHS if
contractor fails to submit reports or the contractor's reports are
found to be unacceptable.
7.16.6 CONDITIONS FOR TERMINATION OF LIQUIDATED DAMAGES
Except as waived by the Contracting Officer, no liquidated damages
imposed on the contractor shall be terminated or suspended until the
contractor issues a written notice of correction to the Contracting
Officer certifying the correction of condition(s) for which liquidated
damages were imposed and until all contractor corrections have been
subjected to system testing or other verification at the discretion of
the Contracting Officer. Liquidated damages shall cease on the day of
the contractor's certification only if subsequent testing of the
correction establishes that, indeed, the correction has been made in
the manner and at the time certified to by the contractor.
A. The contractor shall provide the necessary system time to
system test any correction the Contracting Officer deems
necessary.
B. The Contracting Officer shall determine whether the necessary
level of documentation has been submitted to verify
corrections. The Contracting Officer shall be the sole judge
of the sufficiency and accuracy of any documentation.
C. System corrections shall be sustained for a reasonable period
of at least ninety (90) days from State acceptance; otherwise,
liquidated damages may be reimposed without a succeeding grace
period within which to correct.
D. Contractor use of resources to correct deficiencies shall not
be allowed to cause other system problems.
7.16.7 EPSDT & LEAD SCREENING PERFORMANCE STANDARDS
A. EPSDT Screening
1. The contractor shall ensure that it has achieved an
eighty (80) percent participation rate for the twelve
(12)-month contract period. "Participation" is
defined as one initial or periodicity visit and will
be measured using encounter data. If the contractor
has not achieved the eighty (80) percent
participation rate by the end of the twelve-month
VII-28
period, it shall submit a corrective action plan to
DMAHS within thirty (30) days of notification by
DMAHS of its actual participation rate. DMAHS shall
have the right to conduct a follow-up onsite review
and/or impose financial damages for non-compliance.
a. Mandatory Sanction. Failure of the contractor to
achieve the minimum screening rate shall require the
following refund of capitation paid:
i. Achievement of a 50 percent to less than 60
percent EPSDT screening, dental visit and
immunization rate (the lowest measured rate
of each of the components of EPSDT
screening, i.e., periodic exam, immunization
rate, and dental screening rate, shall be
considered to be the rate for EPSDT
participation and the basis for the
sanction): refund of $1 per enrollee for all
enrollees under age 21 not screened.
ii. Achievement of a 40 percent to less than 50
percent EPSDT screening, dental visit, and
immunization rate: refund of $2 per enrollee
for all enrollees under age 21 not screened.
iii. Achievement of a 30 percent to less than 40
percent EPSDT screening, dental visit and
immunization rate: refund of $3 per enrollee
for all enrollees under age 21 not screened.
iv. Achievement of less than 30 percent: refund
of $4 per enrollee for all enrollees under
age 21 not screened.
b. Discretionary Sanction. The DMAHS shall have the
right to impose a financial or administrative
sanction if the contractor's performance screening
rate is between sixty (60) - seventy (70) percent.
The DMAHS, in its sole discretion, may impose a
sanction after review of the contractor's corrective
action plan and ability to demonstrate good faith
efforts to improve compliance.
2. Failure to achieve and maintain the required
screening rate shall result in the Local Health
Departments being permitted to screen the
contractor's pediatric members. The cost of these
screenings shall be paid by the DMAHS to the LHD, and
the screening cost shall be deducted from the
contractor's capitation rate in addition to the
damages imposed as a result of failure to achieve
EPSDT performance standards.
3. Mandatory sanctions may be offset when the contractor
demonstrates improved compliance. The Division, in
its sole discretion, may reduce the sanction amount
by $1 for each twelve (12) point improvement over
prior reporting period performance rate. Offsets
shall not reduce the financial sanction amount to
below $1 per enrollee not screened.
VII-29
B. Blood Lead Screening
1. The contractor shall ensure that it has achieved an
eighty (80) percent blood lead screening rate of
its enrollees under three years of age during a
twelve (12)- month contract period. Blood lead
screening is described in Article 4 and shall be
measured using encounter data. If the contractor
has not achieved the eighty (80) percent blood lead
screening rate by the end of the twelve (12)-month
period, it shall submit a corrective action plan to
DMAHS within thirty (30) days of notification by
DMAHS of its actual blood lead level screening
rate. DMAHS shall have the right to conduct a
follow-up onsite review and/or impose financial
damages for non-compliance.
a. Mandatory sanction. Failure of the contractor to
achieve sixty (60) percent screening rate shall
require the following refund of capitation paid:
i Achievement of a 50 percent to less than 60
percent lead screening rate: refund of $2
per enrollee for all enrollees under age 3
not screened.
ii Achievement of a 40 percent to less than 50
percent lead screening rate: refund of $3
per enrollee for all enrollees under age 3
not screened.
iii Achievement of a 30 percent to less than 40
percent lead screening rate: refund of $4
per enrollee for all enrollees under age 3
not screened.
iv Achievement of less than 30 percent lead
screening rate: refund of $5 per enrollee
for all enrollees under age 3 not screened.
b. Discretionary sanction. The DMAHS shall have the
right to impose a financial or administrative
sanction if the contractor's performance screening
rate is between sixty (60) - seventy (70) percent.
The DMAHS, in its sole discretion, may impose a
sanction after review of the contractor's corrective
action plan and ability to demonstrate good faith
efforts to improve compliance.
C. The contractor must demonstrate continuous quality improvement
in achieving the performance standards for EPSDT and lead
screenings as stated in Article 4. The Division shall, in its
sole discretion, determine the appropriateness of contractor
proposed corrective action and the imposition of any other
financial or administrative sanctions in addition to those set
out above.
VII-30
7.16.8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CIVIL MONEY PENALTIES
7.16.8.1 FEDERAL STATUTES
Pursuant to 42 U.S.C. Section 1396b(m)(5)(A), the Secretary of the
Department of Health and Human Services may impose substantial monetary
and/or criminal penalties on the contractor when the contractor:
A. Fails to substantially provide an enrollee with required
medically necessary items and services, required under law or
under contract to be provided to an enrolled beneficiary, and
the failure has adversely affected the enrollee or has
substantial likelihood of adversely affecting the enrollees.
B. Imposes premiums or charges on enrollees in violation of this
contract, which provides that no premiums, deductibles,
co-payments or fees of any kind may be charged to Medicaid
enrollees.
C. Engages in any practice that discriminates among enrollees on
the basis of their health status or requirements for health
care services by expulsion or refusal to re-enroll an
individual or engaging in any practice that would reasonably
be expected to have the effect of denying or discouraging
enrollment by eligible persons whose medical condition or
history indicates a need for substantial future medical
services.
D. Misrepresents or falsifies information that is furnished to 1)
the Secretary, 2) the State, or 3) to any person or entity.
E. Fails to comply with the requirements for physician incentive
plans found in 42 U.S.C. Section 1876(i)(8), Section B.7.1 of
the Appendices, and at 42 C.F.R. Section 417.479, or fails to
submit to the Division its physician incentive plans as
required or requested in 42 C.F.R. Section 434.70.
7.16.8.2 FEDERAL PENALTIES
A. The Secretary may provide, in addition to any other remedies
available under the law, for any of the following remedies:
1. Civil money penalties of not more than $25,000 for
each determination above; or,
with respect to a determination under Article
7.16.8.1C or 1D, above, of not more than $100,000
for each such determination; plus,
VII-31
with respect to a determination under Article
7.16.8.1B above, double the amount charged in
violation of such Article (and the excess amount
charged shall be deducted from the penalty and
returned to the individual concerned); and the
Secretary may seek criminal penalties; and plus,
with respect to a determination under Article
7.16.8.1C above, $15,000 for each individual not
enrolled as a result of a practice described in such
Article.
2. Suspension of enrollment of individuals after the
date the Secretary notifies the Division of a
determination to assess damages as described in
Article 7.16.8.2A above, and until the Secretary is
satisfied that the basis for such determination has
been corrected and is not likely to recur, or
3. Suspension of payment to the contractor for
individuals enrolled after the date the Secretary
notifies the Division of a determination under
Article 7.16.8.2A above and until the Secretary is
satisfied that the basis for such determination has
been corrected and is not likely to recur.
B. The contractor shall be responsible to pay any costs incurred
by the State as a result of the Secretary denying payment to
the State under 42 U.S.C. Section 1396(m)(5)(B)(ii). The State
shall have the right to offset such costs from amounts
otherwise due to the contractor.
C. Determination by the Division/Secretary regarding the amount
of the penalty and assessment for failure to comply with
physician incentive plans shall be in accordance with 42
C.F.R. Section 1003.106, i.e., the extent to which the failure
to provide medically necessary services could be attributed to
a prohibited inducement to reduce or limit services under a
physician incentive plan and the harm to the enrollee which
resulted or could have resulted from such failure. It would be
considered an aggravating factor if the contracting
organization knowingly or routinely engaged in any prohibited
practice which acted as an inducement to reduce or limit
medically necessary services provided with respect to a
specific enrollee in the contractor's plan.
7.17 STATE SANCTIONS
DMAHS shall have the right to impose any of the sanctions and damages
authorized or required by N.J.S.A. 30:4D-1 et seq., N.J.A.C. 10:49-1 et
seq., or federal statute or regulation against the contractor or its
providers or subcontractors pursuant to this contract. The DMAHS shall
have the right to withhold and/or offset any payments otherwise due to
the contractor pursuant to such sanctions and damages.
VII-32
7.18 APPEAL PROCESS
In order to appeal the DMAHS imposition of any sanctions or damages,
the contractor shall request review by and submit supporting
documentation first to the Executive Director, Office of Managed Health
Care (OMHC), within twenty (20) days of receipt of notice. The
Executive Director, OMHC, shall issue a response within thirty (30)
days of receipt of the contractor's submissions. Thereafter, the
contractor may obtain a second review by the Director by filing the
request for review with supporting documentation and copy of the
Executive Director's decision within twenty (20) days of the
contractor's receipt of the Executive Director's decision. The
imposition of sanctions and damages is not automatically stayed pending
appeal. Pending final determination of any dispute hereunder, the
contractor shall proceed diligently with the performance of this
contract and in accordance with the Contracting Officer's direction.
7.19 ASSIGNMENTS
The contractor shall not, without the Department's prior written
approval, assign, delegate, transfer, convey, sublet, or otherwise
dispose of this contract; of the contractor's administrative or
management operations/service under this contract; of the contractor's
right, title, interest, obligations or duties under this contract; of
the contractor's power to execute the contract; or, by power of
attorney or otherwise, of any of the contractor's rights to receive
monies due or to become due under this contract. The contractor shall
retain obligations and responsibilities as stated under this contract
or under state or federal law or regulations.
All requests shall be submitted in writing, including all
documentation, contracts, agreements, etc., at least 90 days prior to
the anticipated implementation date, to DMAHS for prior approval. DMAHS
approval shall also be contingent on regulatory agency review and
approval. Any assignment, transfer, conveyance, sublease, or other
disposition without the Department's consent shall be void and subject
this contract to immediate termination by the Department without
liability to the State of New Jersey.
7.20 CONTRACTOR CERTIFICATIONS
7.20.1 GENERAL PROVISIONS
With respect to any report, invoice, record, papers, documents, books
of account, or other contract-required data submitted to the Department
in support of an invoice or documents submitted to meet contract
requirements, including, but not limited to, proofs of insurance and
bonding, Lobbying Certifications and Disclosures, Conflict of Interest
Disclosure Statements and/or Conflict of Interest Avoidance Plans,
pursuant to the requirements of this contract, the Contractor's
Representative or his/her designee shall certify that the report,
invoice, record, papers, documents, books of account or other contract
required data is current, accurate, complete and in full compliance
with legal and contractual requirements to the best of that
individual's knowledge and belief.
VII-33
7.20.2 CERTIFICATION SUBMISSIONS
Where in this contract there is a requirement that the contractor
"certify" or submit a "certification," such certification shall be in
the form of an affidavit or declaration under penalty of perjury dated
and signed by the Contractor's Representative or his/her designee.
7.20.3 ENVIRONMENTAL COMPLIANCE
The contractor shall comply with all applicable environmental laws,
rules, directives, standards, orders, or requirements, including but
not limited to, Section 306 of the Clean Air Act (42 U.S.C. Section
1857(h)), Section 508 of the Clean Water Act (33 U.S.C. Section 1368),
Executive Order 11738, and the Environmental Protection Agency (EPA)
regulations (40 C.F.R., Part 15) that prohibit the use of the
facilities included on the EPA List of Violating Facilities.
7.20.4 ENERGY CONSERVATION
The contractor shall comply with any applicable mandatory standards and
policies relating to energy efficiency that are contained in the state
energy conservation plan issued in compliance with the Energy Policy
and Conservation Act of 1975 (Public L. 94- 165) and any amendments to
the Act.
7.20.5 INDEPENDENT CAPACITY OF CONTRACTOR
The parties agree that the contractor is an independent contractor, and
that the contractor, its agents, officers, and employees act in an
independent capacity and not as officers or employees or agents of the
State, the Department or any other government entity.
7.20.6 NO THIRD PARTY BENEFICIARIES
Nothing in this contract is intended or shall confer upon anyone, other
than the parties hereto, any legal or equitable right, remedy or claim
against any of the parties hereto.
7.20.7 PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING
A. The contractor agrees, pursuant to 31 U.S.C. Section 1352 and
45 C.F.R. Part 93, that no federal appropriated funds have
been paid or will be paid to any person by or on behalf of the
contractor for the purpose of influencing or attempting to
influence an officer or employee of any agency, a member of
Congress, an officer or employee of Congress, or an employee
of a member of Congress in connection with the award of any
federal contract, the making of any federal grant, the making
of any federal loan, the entering into of any cooperative
contract, or the extension, continuation, renewal, amendment,
or modification of any federal contract, grant loan, or
cooperative contract. The contractor shall complete and
VII-34
submit the "Certification Regarding Lobbying", as attached in
Section A.7.1 of the Appendices.
B. If any funds other than federal appropriated funds have been
paid or will be paid by the contractor to any person for the
purpose of influencing or attempting to influence an officer
or employee of any agency, a member of Congress, an officer or
employee of Congress, or an employee of a member of Congress
in connection with the award of any federal contract, the
making of any federal grant, the making of any federal loan,
the entering into of any cooperative contract, or the
extension, continuation, renewal, amendment, or modification
of any federal contract, grant, loan, or cooperative contract,
and the contract exceeds $100,000, the contractor shall
complete and submit Standard Form LLL-"Disclosure of Lobbying
Activities" in accordance with its instructions.
C. The contractor shall include the provisions of this Article in
all provider and subcontractor contracts under this contract
and require all participating providers or subcontractors
whose contracts exceed $100,000 to certify and disclose
accordingly to the contractor.
7.21 REQUIRED CERTIFICATE OF AUTHORITY
During the term of the contract, the contractor shall maintain a
Certificate of Authority (COA) from the Department of Health and Senior
Services and the Department of Banking and Insurance and function as a
Health Maintenance Organization in each of the counties in the
region(s) it is contracted to serve or for each of the counties as
approved in accordance with Article 2.H.
7.22 SUBCONTRACTS
In carrying out the terms of the contract, the contractor may elect to
enter into subcontracts with other entities for the provision of health
care services and/or administrative services as defined in Article 1.
In doing so, the contractor shall, at a minimum, be responsible for
adhering to the following criteria and procedures.
A. All subcontracts shall be in writing and shall be submitted to
DMAHS for prior approval at least 90 days prior to the
anticipated implementation date. DMAHS approval shall also be
contingent on regulatory agency review and approval.
B. The Department shall prior approve all provider contracts and
all subcontracts.
C. All provider contracts and all subcontracts shall include the
terms in Section B.7.2 of the Appendices,
Provider/Subcontractor Contract Provisions.
D. The contractor shall monitor the performance of its
subcontractors on an ongoing basis and ensure that performance
is consistent with the contract between the contractor and the
Department.
VII-35
E. Unless otherwise provided by law, contractor shall not cede or
otherwise transfer some or all financial risk of the
contractor to a subcontractor.
7.23 SET-OFF FOR STATE TAXES AND CHILD SUPPORT
Pursuant to N.J.S.A 54:49-19, if the contractor is entitled to payment
under the contract at the same time as it is indebted for any State tax
(or is otherwise indebted to the State) or child support, the State
Treasurer may set off payment by the amount of the indebtedness.
7.24 CLAIMS
The contractor shall have the right to request an informal hearing
regarding disputes under this contract by the Director, or the designee
thereof. This shall not in any way limit the contractor's or State's
right to any remedy pursuant to New Jersey law.
7.25 MEDICARE RISK CONTRACTOR
To maximize coordination of care for dual eligibles while promoting the
efficient use of public funds, the contractor:
A. Is recommended to be a Medicare+Choice contractor.
B. Shall serve all eligible populations.
7.26 TRACKING AND REPORTING
As a condition of acceptance of a managed care contract, the contractor
shall be held to the following reporting requirements:
A. The contractor shall develop, implement, and maintain a system
of records and reports which include those described below and
shall make available to DMAHS for inspection and audit any
reports, financial or otherwise, of the contractor and require
its providers or subcontractors to do the same relating to
their capacity to bear the risk of potential financial losses
in accordance with 42 C.F.R. Section 434.38. Except where
otherwise specified, the contractor shall provide reports on
hard copy, computer diskette or via electronic media using a
format and commonly-available software as specified by DMAHS
for each report.
B. The contractor shall maintain a uniform accounting system that
adheres to generally accepted accounting principles for
charging and allocating to all funding resources the
contractor's costs incurred hereunder including, but not
limited to, the American Institute of Certified Public
Accountants (AICPA) Statement of Position 89-5 "Financial
Accounting and Reporting by Providers of Prepaid Health Care
Services".
VII-36
C. The contractor shall submit financial reports including, among
others, rate cell grouping costs, in accordance with the
timeframes and formats contained in Section A of the
Appendices.
D. The contractor shall provide its primary care practitioners
with quarterly utilization data within forty-five (45) days of
the end of the program quarter comparing the average medical
care utilization data of their enrollees to the average
medical care utilization data of other managed care enrollees.
These data shall include, but not be limited to, utilization
information on enrollee encounters with PCPs, children who
have not received an EPSDT examination or a blood lead
screening, specialty claims, prescriptions, inpatient stays,
and emergency room use.
E. The contractor shall collect and analyze data to implement
effective quality assurance, utilization review, and peer
review programs in which physicians and other health care
practitioners participate. The contractor shall review and
assess data using statistically valid sampling techniques
including, but not limited to, the following:
Primary care practitioner audits; specialty audits; inpatient
mortality audits; quality of care and provider performance
assessments; quality assurance referrals; credentialing and
recredentialing; verification of encounter reporting rates;
quality assurance committee and subcommittee meeting agendas
and minutes; enrollee complaints, grievances, and follow-up
actions; providers identified for trending and sanctioning,
including providers with low blood lead screening rates;
special quality assurance studies or projects; prospective,
concurrent, and retrospective utilization reviews of inpatient
hospital stays; and denials of off-formulary drug requests.
F. The contractor shall prepare and submit to DMAHS quarterly
reports to be reported by hard copy and diskette in a format
and software application system determined by DMAHS,
containing summary information on the contractor's operations
for each quarter of the program (See Section A.7 of the
Appendices, Tables 1 through 18). These reports shall be
received by DMAHS no later than forty-five (45) calendar days
after the end of the quarter. After a grace period of five (5)
calendar days, for each calendar day after a due date that
DMAHS has not yet received at a prescribed location a report
that fulfills the requirements of any one item, assessment for
damages equal to one half month's negotiated blended
capitation rate that would normally be owed by DMAHS to the
contractor for one recipient shall be applied. The damages
shall be applied as an offset to subsequent payments to the
contractor.
The contractor shall be responsible for continued reporting
beyond the term of the contract because of lag time in
submitting source documents by providers.
VII-37
G. The contractor may submit encounter reports daily but must
submit encounter reports at least quarterly. However,
encounter reports will be processed by DMAHS' fiscal agent no
more frequently than monthly. All encounters shall be reported
to DMAHS within seventy-five (75) days of the end of the
quarter in which they are received by the contractor and
within one year plus seventy-five (75) days from the date of
service.
H. The contractor shall semi-annually report its staffing
positions including the names of supervisory personnel
(Director level and above and the QM/UR personnel),
organizational chart, and any position vacancies in these
major areas.
I. The contractor shall report, semi-annually, number of appeals
received from hospitals, physicians, other providers and
enrollees and, for enrollees, average call waiting times, and
number of abandoned calls.
J. The contractor shall submit, quarterly, information pertaining
to the obstetrical HealthStart programs, as specified by the
Department of Health and Senior Services.
K. DMAHS shall have the right to create additional reporting
requirements at any time as required by applicable federal or
State laws and regulations, as they exist or may hereafter be
amended and incorporated into this contract.
L. Reports that shall be submitted on an annual or semi-annual
basis, as specified in this contract, shall be due within
sixty (60) days of the close of the reporting period, unless
specified otherwise.
7.27 FINANCIAL STATEMENTS
7.27.1 AUDITED FINANCIAL STATEMENTS (GAAP BASIS)
The contractor shall submit audited annual financial statements
prepared in accordance with Generally Accepted Accounting Principles
(GAAP) certified by an independent public accountant, no later than
June 1, for the immediately preceding calendar year for the contractor
and any company that is a financial guarantor for the contractor
completed in accordance with N.J.S.A. 8:38-11.6, "Financial Reporting
Requirements." In addition to meeting requirements as stated in
N.J.S.A. 8:38-11.6, the audited financial statements of the contractor
shall include an opinion supported by adequate testing by the
independent public accountant as to the accuracy and accounting
principles used in reporting Medicaid specific financial information
required by this contract. This includes but is not limited to
quarterly expense statements, Medical Cost Ratio information, cost
allocations made to the Medicaid contract, and claims processing
information reported to the DMAHS. The contractor shall authorize the
independent accountant to allow representatives of the Department, upon
written request, to inspect any and all working papers related to the
preparation of the audit report.
VII-38
7.27.2 FINANCIAL STATEMENTS (SAP)
Contractor shall submit to DMAHS all quarterly and annual financial
statements and annual supplements in accordance with Statutory
Accounting Principles (SAP) required in N.J.A.C. 8:38-11.6. Submissions
to DMAHS shall be on the same time frame described in N.J.A.C. 8:38-14,
i.e., quarterly reports are due the fifteenth (15th)day of the second
month following the quarter end and statutory unaudited statement and
the annual supplemental are due March 1 covering the preceding calendar
year. Such information shall be subject to the confidentiality
provisions in Article 7.40.
7.28 FEDERAL APPROVAL AND FUNDING
This managed care contract shall not be implemented until and unless
all necessary federal approval and funding have been obtained.
7.29 CONFLICT OF INTEREST
A. No contractor shall pay, offer to pay, or agree to pay, either
directly or indirectly, any fee, commission, compensation,
gift, gratuity, or other thing of value of any kind to any
State officer or employee or special State officer or
employee, as defined by N.J.S.A. 52:13D-13b and e, in the
Department or any other agency with which such contractor
transacts or offers or proposes to transact business, or to
any member of the immediate family, as defined by N.J.S.A.
52:13D-13i, of any such officer or employee, or partnership,
firm or corporation with which they are employed or
associated, or in which such officer or employee has an
interest within the meaning of N.J.S.A. 52:13D-13g.
B. The solicitation of any fee, commission, compensation, gift,
gratuity or other thing of value by any State officer or
employee or special State officer or employee from any State
contractor shall be reported in writing forthwith by the
contractor to the Attorney General and the Executive
Commission on Ethical Standards.
C. No contractor may, directly or indirectly, undertake any
private business, commercial or entrepreneurial relationship
with, whether or not pursuant to employment, contract or other
agreement, express or implied, or sell any interest in such
contractor to any State officer or employee or special State
officer or employee having any duties or responsibilities in
connection with the purchase, acquisition or sale of any
property or services by or to any State agency or any
instrumentality thereof, or with any person, firm or entity
with which he is employed or associated or in which he has an
interest within the meaning of N.J.S.A. 52:13D-13g. Any
relationships subject to this provision shall be reported in
writing forthwith to the Executive Commission on Ethical
Standards which may grant a waiver of this restriction upon
application of the State officer or employee or special State
officer or employee upon a finding that the present or
VII-39
proposed relationship does not present the potential, actual
or appearance, of a conflict of interest.
D. No contractor shall influence, or attempt to influence or
cause to be influenced, any State officer or employee or
special State officer or employee in his official capacity in
any manner which might tend to impair the objectivity or
independence of judgment of said officer or employee.
E. No contractor shall cause or influence, or attempt to cause or
influence, any State officer or employee or special State
officer or employee to use, or attempt to use, his official
position to secure unwarranted privileges or advantages for
the contractor or any other person.
F. The provisions cited above in this Article shall not be
construed to prohibit a State officer or employee or special
State officer or employee from receiving gifts from or
contracting with the contractor under the same terms and
conditions as are offered or made available to members of the
general public subject to any guidelines the Executive
Commission on Ethical Standards may promulgate.
7.30 RECORDS RETENTION
A. The contractor hereby agrees to maintain an appropriate
recordkeeping system (See Section B.4.14 of the Appendices)
for services to enrollees and further require its providers
and subcontractors to do so. Such system shall collect all
pertinent information relating to the medical management of
each enrolled beneficiary; and make that information readily
available to appropriate health professionals and the
Department. Records shall be retained for the later of
1. Five (5) years from the date of service, or
2. Three (3) years after final payment is made under the
contract or subcontract and all pending matters are
closed.
B. If an audit, investigation, litigation, or other action
involving the records is started before the end of the
retention period, the records shall be retained until all
issues arising out of the action are resolved or until the end
of the retention period, whichever is later. Records shall be
made accessible at a New Jersey site, and on request to
agencies of the State of New Jersey and the federal
government. For enrollees covered by the contractor's plan who
are eligible through the Division of Youth and Family
Services, records shall be kept in accordance with the
provisions under N.J.S.A. 9:6-8.10a and 9:6-8:40 and
consistent with need to protect the enrollee's
confidentiality. All providers and subcontractors shall comply
with, and all provider contracts and subcontracts shall
contain the requirements stated in this paragraph. (See also
Article 7.40, "Confidentiality".)
VII-40
C. If contractor's enrollees disenroll from the contractor's
plan, the contractor shall require participating providers to
release medical records of enrollees as may be directed by the
enrollee, authorized representatives of the Department and
appropriate agencies of the State of New Jersey and of the
federal government. Release of records shall be consistent
with the provision of confidentiality expressed in Article
7.40 and at no cost to the enrollee.
7.31 WAIVERS
Nothing in the contract shall be construed to be a waiver by the State
of any warranty, expressed or implied, except as specifically and
expressly stated in writing executed by the Director. Further, nothing
in the contract shall be construed to be a waiver by the State of any
remedy available to the State under the contract, at law or equity
except as specifically and expressly stated in writing executed by the
Director. A waiver by the State of any default or breach shall not
constitute a waiver of any subsequent default or breach.
7.32 CHANGE BY THE CONTRACTOR
The contractor shall not make any enhancements, limitations, or changes
in benefits or benefits coverage; any changes in definition or
interpretation of benefits; or any changes in the administration of the
managed care program related to the scope of benefits, allowable
coverage for those benefits, eligibility of enrollees or providers to
participate in the program, reimbursement methods and/or schedules to
providers, or substantial changes to contractor operations without the
express, written direction or approval of the State. The State shall
have the sole discretion for determining whether an amendment is
required to effect a change (e.g., to provide additional services).
7.33 INDEMNIFICATION
A. The contractor agrees to indemnify and hold harmless the
State, its officers, agents and employees, and the enrollees
and their eligible dependents from any and all claims or
losses accruing or resulting from contractor's negligence to
any participating provider or any other person, firm, or
corporation furnishing or supplying work, services, materials,
or supplies in connection with the performance of this
contract.
B. The contractor agrees to indemnify and hold harmless the
State, its officers, agents, and employees, and the enrollees
and their eligible dependents from liability deriving or
resulting from the contractor's insolvency or inability or
failure to pay or reimburse participating providers or any
other person, firm, or corporation furnishing or supplying
work, services, materials, or supplies in connection with the
performance of this contract.
C. The contractor agrees further that it shall require under all
provider contracts that, in the event the contractor becomes
insolvent or unable to pay the participating
VII-41
provider, the participating provider shall not seek
compensation for services rendered from the State, its
officers, agents, or employees, or the enrollees or their
eligible dependents.
D. The contractor agrees further that it shall indemnify and hold
harmless the State, its officers, agents, and employees, and
the enrollees and their eligible dependents from any and all
claims for services for which the contractor receives monthly
capitation payments, and shall not seek payments other than
the capitation payments from the State, its officers, agents,
and/or employees, and/or the enrollees and/or their eligible
dependents for such services, either during or subsequent to
the term of the contract.
E. The contractor agrees further to indemnify and hold harmless
the State, its officers, agents and employees, and the
enrollees and their eligible dependents, from all claims,
damages, and liability, including costs and expenses, for
violation of any proprietary rights, copyrights, or rights of
privacy arising out of the contractor's or any participating
provider's publication, translation, reproduction, delivery,
performance, use, or disposition of any data furnished to it
under this contract, or for any libelous or otherwise unlawful
matter contained in such data that the contractor or any
participating provider inserts.
F. The contractor shall indemnify the State, its officers, agents
and employees, and the enrollees and their eligible dependents
from any injury, death, losses, damages, suits, liabilities
judgments, costs and expenses and claim of negligence or
willful acts or omissions of the contractor, its officers,
agents and employees, subcontractors, participating providers,
their officers, agents or employees, or any other person for
any claims arising out of alleged violation of any State or
federal law or regulation. The contractor shall also indemnify
and hold the State harmless from any claims of alleged
violations of the Americans with Disabilities Act by the
contractor, its subcontractors or providers.
G. The contractor agrees to pay all losses, liabilities, and
expenses under the following conditions:
1. The parties who shall be entitled to enforce this
indemnity of the contractor shall be the State, its
officials, agents, employees, and representatives,
including attorneys or the State Attorney General,
other public officials, Commissioner and DHS
employees, any successor in office to any of the
foregoing individuals, and their respective legal
representatives, heirs, and beneficiaries.
2. The losses, liabilities and expenses that are
indemnified shall include but not be limited to the
following examples: judgments, court costs, legal
fees, the costs of expert testimony, amounts paid in
settlement, and all other costs of any type whether
or not litigation is commenced. Also covered are
investigation expenses, including but not limited to,
the costs
VII-42
of utilizing the services of the contracting agency
and other State entities incurred in the defense and
handling of said suits, claims, judgments, and the
like, and in enforcing and obtaining compliance with
the provisions of this paragraph whether or not
litigation is commenced.
3. Nothing in this contract shall be considered to
preclude an indemnified party from receiving the
benefits of any insurance the contractor may carry
that provides for indemnification for any loss,
liability, or expense that is described in this
contract.
4. The contractor shall do nothing to prejudice the
State's right to recover against third parties for
any loss, destruction of, or damage to the
contracting agency's property. Upon the request of
the DHS or its officials, the contractor shall
furnish the DHS all reasonable assistance and
cooperation, including assistance in the prosecution
of suits and the execution of instruments of
assignment in favor of the contracting agency in
obtaining recovery.
5. Indemnification includes but is not limited to, any
claims or losses arising from the promulgation or
implementation of the contractor's policies and
procedures, whether or not said policies and
procedures have been approved by the State, and any
claims of the contractor's wrong doing in
implementing DHS policies.
7.34 INVENTIONS
Inventions, discoveries, or improvements of computer programs developed
pursuant to this contract by the contractor, and paid for by DMAHS in
whole or in part, shall be the property of DMAHS.
7.35 USE OF CONCEPTS
The ideas, knowledge, or techniques developed and utilized through the
course of this contract by the contractor, or jointly by the contractor
and DMAHS, for the performance under the contract, may be used by
either party in any way they may deem appropriate. However, such use
shall not extend to pre-existing intellectual property of the
contractor or DMAHS that is patented, copyrighted, trademarked or
service marked, which shall not be used by another party unless a
license is granted.
7.36 PREVAILING WAGE
The New Jersey Prevailing Wage Act, PL 1963, Chapter 150, is hereby
made a part of this contract, unless it is not within the contemplation
of the Act. The contractor's signature on the contract is a guarantee
that neither the contractor nor any providers or subcontractors it
might employ to perform the work covered by this contract is listed or
is on record in the Office of the Commissioner of the New Jersey
Department of Labor and
VII-43
Industry as one who has failed to pay prevailing wages in accordance
with the provisions of this Act.
7.37 DISCLOSURE STATEMENT
The contractor shall report ownership and related information to DMAHS
at the time of initial contracting, and yearly thereafter, and upon
request, to the Secretary of DHHS and the Inspector General of the
United States in accordance with federal and state law.
A. The contractor shall include full and complete information as
to the name and address of each person or corporation with a
five (5) percent or more ownership or controlling interest in
the contractor's plan, or any provider or subcontractor in
which the contractor has a five (5) percent or more ownership
interest (Section 1903(m)(2)(A) of the Social Security Act and
N.J.A.C. 10:49-19.2)
The contractor shall comply with this disclosure requirement
through submission of the HCFA-1513 Form whether federally
qualified or not.
B. If the contractor is not federally qualified, it shall
disclose to DMAHS at the time of contracting (and within ten
days of any change) information on types of transactions with
a "party in interest" as defined in Section 1318(b) of the
Public Health Service Act (Section 1903(m)(4)(A) of the Social
Security Act).
1. All contractor business transactions shall be
reported. This requirement shall not be limited to
transactions related only to serving the Medicaid
enrollees and applies at least to the following
transactions:
a. Any sale, exchange, or leasing of property
between the contractor and a "party in
interest";
b. Any furnishing for consideration of goods,
services or facilities between the
contractor and a "party in interest" (not
including salaries paid to employees for
services provided in the normal course of
their employment);
c. Any lending of money or other extension of
credit between the contractor and a "party
in interest"; and
d. Transactions or series of transactions
during any one fiscal year that are expected
to exceed the lesser of $25,000 or five (5)
percent of the total operating expenses of
the contractor.
2. The information that shall be disclosed regarding
transactions listed in B.1 above between the
contractor and a "party in interest" includes:
a. The name of the "party in interest" for each
transaction;
VII-44
b. A description of each transaction and the
quantity or units involved;
c. The accrued dollar value of each transaction
during the fiscal year; and
d. The justification of the reasonableness of
each transaction.
3. This information shall be reported annually to DMAHS
and shall also be made available, upon request, to
the Office of the Inspector General, the Comptroller
General and to the contractor's enrollees. DMAHS may
request that the information be in the form of a
consolidated financial statement for the organization
and entity (N.J.A.C. 10:49-19.2).
C. The contractor shall disclose the identity of any person who
has been convicted of certain offenses, as defined in Section
1126 of the Social Security Act. This includes any person who
has ownership or control interest in the contractor, or is an
agent or managing employee of the contractor and:
1. Has been convicted of a criminal offense related to
the delivery of an item or service under Medicare,
Medicaid, or title XXI;
2. Has been convicted of a criminal offense relating to
neglect or abuse of patients in connection with the
delivery of a health care item or service;
3. Has been convicted for an offense that occurred after
the date of the enactment of the Health Insurance
Portability and Accountability Act of 1996, in
connection with the delivery of a health care item or
service or omission in a health care program operated
by or financed in whole or in part by any Federal,
State, or local government agency, of a criminal
offense consisting of a felony relating to fraud,
theft, embezzlement, breach of fiduciary
responsibility, or other financial misconduct; or
4. Has been convicted for an offense that occurred after
the date of the enactment of the Health Insurance
Portability and Accountability Act of 1996 of a
criminal offense consisting of a felony relating to
the unlawful manufacture, distribution, prescription,
or dispensing of a controlled substance.
7.38 FRAUD AND ABUSE
7.38.1 ENROLLEES
A. Policies and Procedures. The contractor shall establish
written policies and procedures for identifying potential
enrollee fraud and abuse. Proven cases are to
VII-45
be referred to the Department for screening for advice and/or
assistance on follow-up actions to be taken. Referrals are to
be accompanied by all supporting case documentation.
B. Typical Cases. The most typical cases of fraud or abuse
include but are not limited to: the alteration of an
identification card for possible expansion of benefits; the
loaning of an identification card to others; use of forged or
altered prescriptions; and mis-utilization of services.
7.38.2 PROVIDERS
A. Policies and Procedures. The contractor shall establish
written policies and procedures for identifying,
investigating, and taking appropriate corrective action
against fraud and abuse (as defined in 42 C.F.R. Section
455.2) in the provision of health care services. The policies
and procedures will include, at a minimum:
1. Written notification to DMAHS within five (5)
business days of intent to conduct an investigation
or to recover funds, and approval from DMAHS prior to
conducting the investigation or attempting to recover
funds. Details of potential investigations shall be
provided to DMAHS and include the data elements in
Section A.7.2.B of the Appendices. Representatives of
the contractor may be required to present the case to
DMAHS. DMAHS, in consultation with the contractor,
will then determine the appropriate course of action
to be taken.
2. Incorporation of the use of claims and encounter data
for detecting potential fraud and abuse of services.
3. Reporting investigation results within twenty (20)
business days to DMAHS.
4. Specifications of, and reports generated by, the
contractor's prepayment and postpayment surveillance
and utilization review systems, including prepayment
and postpayment edits.
B. Distinct Unit. The contractor shall establish a distinct fraud
and abuse unit, separate from the contractor's utilization
review and quality of care functions. The unit can either be
part of the contractor's corporate structure, or operate under
contract with the contractor. The unit shall be staffed with
individuals with the qualifications and an
investigator-to-beneficiary ratio consistent, at a minimum,
with the Department of Banking and Insurance requirements for
fraud units within health insurance carriers or greater ratio
as needed to meet the demands.
C. Prepayment Monitoring. The contractor shall conduct prepayment
monitoring of its own network providers and subcontractors
when it believes fraud or abuse may be occurring.
VII-46
D. It shall be the responsibility of the contractor to report in
writing to DMAHS' Office of Program Integrity Administration
the following:
1. All cases of suspected fraud and abuse, using the
format described in Section A.7.2 of the Appendices;
2. Inappropriate or inconsistent practices by providers,
subcontractors, enrollees or employees or anyone who
can order or refer services, and related parties; and
3. Prepayment monitoring of a provider or a
subcontractor by the contractor.
E. DMAHS shall have the right to withhold from a contractor's
capitation payments an appropriate amount if DMAHS determines
that evidence of fraud or abuse exists relating to the
contractor, its providers, subcontractors, enrollees,
employees, or anyone who can order or refer services, and
related parties.
F. When DMAHS has withheld payment and/or initiated a recovery
action against one of the contractor's providers or
subcontractors or a withholding of payments action pursuant to
42 C.F.R. Section 455.23, DMAHS may require the contractor to
withhold payments to that provider or subcontractor and/or
forward those payments to DMAHS.
G. DMAHS may direct the contractor to monitor one of its
providers or subcontractors, or take such corrective action
with respect to that provider or subcontractor as DMAHS deems
appropriate, when, in the opinion of DMAHS, good cause exists.
H. Sanctions. Failure of the contractor to investigate and
correct fraud and abuse problems relating to its enrollees,
network providers or subcontractors, and to notify DMAHS
timely of same, may result in sanctions. Timely notification
is defined as within five (5) business days of identification
of the fraud and/or abuse and within twenty (20) business days
of the completion of an investigation. For purposes of this
subsection, the term "investigation" shall include prepayment
monitoring as described above.
DMAHS shall have the right to also impose sanctions and/or
withhold payments to the contractor (in accordance with
provisions of 42 C.F.R. Section 455.23) if it has reliable
evidence of fraud or willful misrepresentation relating to the
contractor's participation in the New Jersey Medicaid or NJ
FamilyCare program or if the contractor fails to initiate its
investigation of an identified fraud and/or abuse within one
year of identification.
VII-47
7.38.3 NOTIFICATION TO DMAHS
The contractor shall submit quarterly the report in Section A.7.2 of
the Appendices, Fraud & Abuse.
7.39 EQUALITY OF ACCESS AND TREATMENT/DUE PROCESS
A. Unless a higher standard is required by this contract, the
contractor shall provide and require its subcontractors and
its providers to provide the same level of medical care and
health services to DMAHS enrollees as to enrollees in the
contractor's plan under private or group contracts unless
otherwise required in this contract.
B. Enrollees shall be given equitable access, i.e., equal
opportunity and consideration for needed services without
exclusionary practices of providers or system design because
of gender, age, race, ethnicity, color, creed, religion,
ancestry, national origin, marital status, sexual or
affectional orientation or preference, mental or physical
disability, genetic information, or source of payment.
C. DMAHS shall assure that all due process safeguards that are
otherwise available to Medicaid/NJ FamilyCare beneficiaries
remain available to enrollees under this contract.
D. The contractor shall assure the provision of services,
notifications, preparation of educational materials in
appropriate alternative formats, for enrollees including the
blind, hearing impaired, people with cognitive or
communication impairments, and individuals who do not speak
English.
7.40 CONFIDENTIALITY
A. General. The contractor hereby agrees and understands that all
information, records, data, and data elements collected and
maintained for the operation of the contractor and the
Department and pertaining to enrolled persons, shall be
protected from unauthorized disclosure in accordance with the
provisions of 42 U.S.C. Section 1396(a)(7)(Section 1902(a)(7)
of the Social Security Act), 42 C.F.R. Part 431, subpart F,
N.J.S.A. 30:4D-7 (g) and N.J.A.C. 10:49-9.4. Access to such
information, records, data and data elements shall be
physically secured and safeguarded and shall be limited to
those who perform their duties in accordance with provisions
of this contract including the Department of Health and Human
Services and to such others as may be authorized by DMAHS in
accordance with applicable law. For enrollees covered by the
contractor's plan that are eligible through the Division of
Youth and Family Services, records shall be kept in accordance
with the provisions under N.J.S.A. 9:6-8.10a and 9:6-8:40 and
consistent with the need to protect the enrollee's
confidentiality.
VII-48
B. Enrollee-Specific Information. With respect to any
identifiable information concerning an enrollee under the
contract that is obtained by the contractor or its providers
or subcontractors, the contractor: (1) shall not use any such
information for any purpose other than carrying out the
express terms of this contract; (2) shall promptly transmit to
the Department all requests for disclosure of such
information; (3) shall not disclose except as otherwise
specifically permitted by the contract, any such information
to any party other than the Department without the
Department's prior written authorization specifying that the
information is releasable under 42 C.F.R. Section 431.300 et
seq., and (4) shall, at the expiration or termination of the
contract, return all such information to the Department or
maintain such information according to written procedures sent
the contractor by the Department for this purpose.
C. Employees. The contractor shall instruct its employees to keep
confidential information concerning the business of DMAHS, its
financial affairs, its relations with its enrollees and its
employees, as well as any other information which may be
specifically classified as confidential by law.
D. Medical records and management information data concerning
Medicaid/NJ FamilyCare beneficiaries enrolled pursuant to this
contract shall be confidential and shall be disclosed to other
persons within the contractor's organization only as necessary
to provide medical care and quality, peer, or grievance review
of medical care under the terms of this contract.
E. The provisions of this Article shall survive the termination
of this contract and shall bind the contractor so long as the
contractor maintains any individually identifiable information
relating to Medicaid/NJ FamilyCare beneficiaries.
F. If DMAHS receives a request pursuant to the Right To Know Law
for release of information concerning the contractor, DMAHS
shall determine what information is required by law to be
released and retain authority over the release of that
information. Prior to release of information that was
previously labeled by the contractor as "confidential" or
"proprietary," DMAHS shall notify the contractor, who may
apply to the Superior Court of New Jersey for a protective
order if the contractor opposes the release of information.
7.41 SEVERABILITY
If this contract contains any unlawful provision that is not an
essential part of the contract and that was not a controlling or
material inducement to enter into the contract, the provision shall
have no effect and, upon notice by either party, shall be deemed
stricken from the contract without affecting the binding force of the
remainder of the contract.
VII-49
7.42 CONTRACTING OFFICER AND CONTRACTOR'S REPRESENTATIVE
It is agreed that __________________, Director of DMAHS, or her
representative, shall serve as the Contracting Officer for the State
and that __________________ shall serve as the Contractor's
Representative. The Contracting Officer and the Contractor's
Representative each reserve the right to delegate such duties as may be
appropriate to others in the DMAHS's or contractor's employ.
Each party shall provide timely written notification of any change in
Contracting Officer or Contractor's Representative.
VII-50
ARTICLE EIGHT: FINANCIAL PROVISIONS
8.1 GENERAL INFORMATION
This Article includes financial requirements (including solvency and
insurance), medical cost ratio requirements, information on rates set
by the State, third party liability (TPL) requirements, general
capitation requirements, and provider payment requirements.
8.2 FINANCIAL REQUIREMENTS
8.2.1 COMPLIANCE WITH CERTAIN CONDITIONS
The contractor shall remain in compliance with the following conditions
which shall satisfy the Departments of Human Services, Banking and
Insurance (DOBI) and Health and Senior Services prior to this contract
becoming effective:
A. Provider Contracts Executed. The contractor has entered into
written contracts with providers in accordance with Article
Four of this contract.
B. No Judgment Preventing Implementation. No court order,
administrative decision, or action by any other
instrumentality of the United States government or the State
of New Jersey or any other state which prevents implementation
of this contract is outstanding.
C. Approved Certificate of Authority. The contractor has and
maintains an approved certificate of authority to operate as a
health maintenance organization in New Jersey from the DOBI
and the Department of Health and Senior Services for the
Medicaid population.
D. Compliance with All Solvency Requirements. The contractor
shall comply with and remain in compliance with minimum net
worth and fiscal solvency and reporting requirements of the
DOBI and the Department of Human Services, the federal
government, and this contract.
8.2.2 SOLVENCY REQUIREMENTS
The contractor shall maintain a minimum net worth in accordance with
N.J.A.C. 8:38-11 et seq.
The Department shall have the right to conduct targeted financial
audits of the contractor's Medicaid line of business. The contractor
shall provide the Department with financial data, as requested by the
Department, within a timeframe specified by the Department.
VIII-1
8.2.3 GENERAL PROVISIONS AND CONTRACTOR COMPLIANCE
The contractor shall comply with the following financial operations
requirements:
A. The contractor must establish and maintain (1) an office in
New Jersey, and (2) premium and claims accounts in a bank with
a principal office in New Jersey.
B. The contractor shall have a fiscally sound operation as
demonstrated by:
1. Maintenance of minimum net worth in accordance with
DOBI requirements (total line of business) and the
requirements outlined in Article 8.2.2.
2. Maintenance of a net operating surplus for Medicaid
line of business. If the contractor fails to earn a
net operating surplus during the most recent calendar
year, or does not maintain minimum net worth
requirements on a quarterly basis, it shall submit a
corrective plan of action within the time specified
by the Department. The plan is subject to the
approval of DMAHS. It must demonstrate how and when
minimum net worth requirements will be replenished
and present marketing and financial projections.
These must be supported by suitable back-up material.
The discussion must include possible alternative
funding sources, including the invoking of a parental
guarantee.
This plan shall include:
a. A detailed marketing plan with enrollment
projections for the next two years.
b. A projected balance sheet for the next two
years.
c. A projected statement of revenue and
expenses on an accrual basis for the next
two years.
d. A statement of cash flow projected for the
next two years.
e. A description of how to maintain capital
requirements and replenish net worth.
f. Sources and timing of new capital must be
specifically identified.
3. The contractor shall demonstrate it has sufficient
cash and adequate liquidity set aside (i.e.,
restricted) but accessible to the DOBI to meet
obligations as they become due, and which are
acceptable to DMAHS. The contractor shall comply with
DOBI requirements regarding cash
VIII-2
reserves and where restricted funds will be held (See
N.J.A.C. 8:38-11.3, Reserve Requirements).
8.3 INSURANCE REQUIREMENTS
The contractor shall maintain general comprehensive liability
insurance, products/completed operations insurance, premises/operations
insurance, unemployment compensation coverage, workmen's compensation
insurance, reinsurance, and malpractice insurance in such amounts as
determined necessary in accordance with state and federal statutes and
regulations, insuring all claims which may arise out of contractor
operations under the terms of this contract. The DMAHS shall be an
additional named insured with sixty (60) days prior written notice in
event of default and/or non-renewal of the policy. Proof of such
insurance shall be provided to and approved by DMAHS prior to the
provision of services under this contract and annually thereafter. No
policy of insurance provided or maintained under this Article shall
provide for an exclusion for the acts of officers.
8.3.1 INSURANCE CANCELLATION AND/OR CHANGES
In the event that any carrier of any insurance described in 8.4 or
8.4.2 exercises cancellation and/or changes, or cancellation or change
is initiated by the contractor, notice of such cancellation and/or
change shall be sent immediately to DMAHS for approval. At State's
option upon cancellation and/or change or lapse of such insurance(s),
DMAHS may withhold all or part of payments for services under this
contract until such insurance is reinstated or comparable insurance
purchased. The contractor is obligated to provide any services during
the period of such lapse or termination.
8.3.2 STOP-LOSS INSURANCE
At the discretion of the Departments of Banking and Insurance, Human
Services, and Health and Senior Services and notwithstanding the
requirements of N.J.A.C. 8:38-11.5 (b), the contractor may be required
to obtain, prior to this contract, and maintain "stop-loss" insurance
from a reinsurance company authorized to do business in New Jersey that
will cover medical costs that exceed a threshold per case for the
duration of the contract period. Any coverage other than stipulated
must be based on an actuarial review, taking into account geographic
and demographic factors, the nature of the clients, and state solvency
safeguard requirements.
All "stop-loss" insurance arrangements, including modifications, shall
be reviewed and prior approved by the Departments of Banking and
Insurance, Human Services, and Health and Senior Services. The
"stop-loss" insurance underwriter must meet the standards of financial
stability as set forth by the DOBI.
VIII-3
Contractors with sufficient reserves may choose self-insurance, subject
to approval by the Department of Human Services and the DOBI where
appropriate.
8.4 MEDICAL COST RATIO
8.4.1 MEDICAL COST RATIO STANDARD
The contractor shall maintain direct medical expenditures for enrollees
equal to or greater than eighty (80) percent of premiums paid in all
forms from the State. This medical cost ratio (MCR) shall apply to
annual periods from the contract effective date (if the contract ends
before the completion of an annual period, the MCR shall apply to that
shorter period). The MCR shall be based on reports completed by the
contractor and acceptable to the Department.
A. Direct Medical Expenditures. Direct medical expenditures are
the incurred costs of providing direct care to enrollees for
covered health care services as stated in Article 4.1. Costs
related to information and materials for general education and
outreach and/or administration are not considered direct
medical expenditures.
Personnel costs are generally considered to be administrative
in nature and must be reported as an administrative expense on
Tables 6a and 6b (Statement of Revenues and Expenses) on line
30 (Compensation). However, a portion of these costs may
qualify as direct medical expenditures, subject to prior
review and approval by the State. Those activities that the
contractor expects to generate these costs must be specified
and detailed in a Medical Cost Ratio - Direct Medical
Expenditures Plan which must be reviewed and approved by the
State. At the end of the reporting period, the contractor's
reporting shall be based only on the approved Medical Cost
Ratio - Direct Medical Expenditures Plan. In order to consider
these costs as Direct Medical Expenditures, the contractor
must complete Table 6c, entitled "Allowable Direct Medical
Expenditures," which will be used by the State to determine
the allowable portion of costs. The allowable components of
these personnel costs include the following activities:
1. Care Management. Allowable direct medical
expenditures for care management include: 1)
assessment(s) of an enrollee's risk factors; and 2)
development of Individual Health Care Plans. The
costs of performing these two allowable components
may be considered a direct medical expenditure for
purposes of calculating MCR.
2. The cost associated with the provision of a
face-to-face home visit by the contractor's clinical
personnel for the purpose of medical education or
anticipatory guidance can be considered a direct
medical expenditure.
3. Costs for activities required to achieve compliance
standards for EPSDT participation, lead screening,
and prenatal care as specified in Article IV may be
considered direct medical expenditures. The
contractor's reporting shall be
VIII-4
based only on the approved Medical Cost Ratio --
Direct Medical Expenditures Plan.
B. Calculation of MCR. The calculation of MCR will be made using
information submitted by each contractor on the quarterly
reports - Statement of Revenues and Expenses (Section A.7.8 of
the Appendices (Table 6)). The costs related to 8.4.1.A are to
be reported on Table 6c and the allowable amount will be added
to the calculation of Medical and Hospital Expenses. The sum
of all applicable quarters for Total Medical and Hospital
Expenses (line 28) less Coordination of Benefits (COB) (line
6) and less reinsurance recoveries (line 7) will be divided by
the sum of all applicable quarters of Medicaid/NJ FamilyCare
premiums (line 4) to arrive at the ratio.
8.4.2 EXEMPTIONS
An exemption may be granted to reduce the eighty (80) percent MCR
requirement to no lower than seventy-five (75) percent. Under no
circumstances will an exemption be granted to a contractor for MCR
below seventy-five (75) percent. An exemption may be granted if the
contractor meets all of the following established criteria:
A. Has no unresolved quality of care issues;
B. Has not received any pending or imposed sanctions;
C. Is in compliance with all reporting requirements;
D. Had no vacancies in key administrative positions for longer
than sixty (60) days;
E. Is in compliance with all corrective plans of action relating
to Medicaid activity imposed by the Departments of Human
Services, Banking and Insurance, or Health and Senior
Services;
F. Has demonstrated timely processing of claims during the
two-year contract period immediately prior to the reporting
period and has had no substantiated pattern of complaints from
providers for late payments; and
G. Has produced evidence to demonstrate compliance with education
and outreach provisions of the contract.
8.4.3 DAMAGES
The Department shall have the right to impose damages on a contractor
that has failed to maintain an appropriate MCR. The formula for
imposing damages follows:
VIII-5
ACTUAL MCR 1ST OFFENSE 2ND OFFENSE
---------------- ---------------- -------------------
80% or above NONE NONE
78.00-79.99% .15 times .15 times
underexpenditure underexpenditure
75.00-77.99% .50 times .50 times
underexpenditure underexpenditure
74.99 or below .90 times 1.00 times
underexpenditure underexpenditure
If the contractor fails to meet the MCR requirement and a penalty is
applied, a plan of corrective action will be required.
8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS
8.5.1 REGIONS
Rates for DYFS, NJ FamilyCare Plan A Parents/caretaker relatives with
children and adults without dependent children under the age of 19, NJ
FamilyCare Plans B, C and D, and the non risk-adjusted rates for AIDS
and clients of DDD are statewide. All other rates for each premium
group have been set for each of the following regions:
- Region 1: Bergen, Hudson, Hunterdon, Xxxxxx, Passaic,
Somerset, Sussex, and Xxxxxx counties
- Region 2: Essex, Union, Middlesex, and Xxxxxx counties
- Region 3: Atlantic, Burlington, Camden, Cape May, Cumberland,
Gloucester, Monmouth, Ocean, and Salem counties
Contractors may contract for one or more regions but, except as
provided in Article 2, may not contract for part of a region.
8.5.2 AFDC/TANF AND NJ FAMILYCARE PLAN A CHILDREN
The capitation rates for Aid to Families with Dependent Children
(AFDC)/Temporary Assistance for Needy Families (TANF) includes New
Jersey Care Pregnant Women and NJ FamilyCare Plan A children (age <19)
but excludes individuals who have AIDS or are clients of DDD. Rates
have been set for the following premium groups:
A. Males and females < 1 year
VIII-6
B. Males and females 1 year to 1.99 years
C. Males 2 to 20.99 years and females 2 to 14.99 years
D. Females 15 to 44.99 years
E. Males 21 to 44.99 years
F. Males and females 45 years and older
8.5.3 NJ FAMILYCARE PLAN A PARENTS/CARETAKERS
The capitation rates for NJ FamilyCare Plan A parents/caretakers,
excluding individuals with AIDS and clients of DDD, are in the
following premium groups:
A. Males 19 to 44.99 years
B. Females 19 to 44.99 years
C. Males and females 45 years and older
8.5.4 NJ FAMLYCARE PLAN A ADULTS WITHOUT DEPENDENT CHILDREN UNDER 19 YEARS OF
AGE
The capitation rates for NJ FamilyCare Plan A adults without dependent
children under 19 years of age, excluding individuals with AIDS and
clients of DDD, are in the following premium groups:
A. Males 19 to 44.99 years
B. Females 19 to 44.99 years
C. Males and females 45 years and older
8.5.5 NJ FAMILYCARE PLANS B & C
The capitation rates for NJ FamilyCare Plans B and C enrollees,
excluding individuals with AIDS are in the following premium groups:
A. Males and females < 1 year
B. Males and females 1 year to 1.99 years
VIII-7
C. Males and females 2 to 18.99 years
8.5.6 NJ FAMILYCARE PLAN D CHILDREN
The capitation rates for NJ FamilyCare Plan D children, excluding
individuals with AIDS, are in the following premium groups:
A. Males and females < 1 year
B. Males and females 1 year to 1.99 years
C. Males and females 2 to 18.99 years
8.5.7 NJ FAMILYCARE PLAN D PARENTS/CARETAKERS
The capitation rates for NJ FamilyCare Plan D parents/caretakers,
excluding individuals with AIDS, are in the following premium groups:
A. Males 19 to 44.99 years
B. Females 19 to 44.99 years
C. Males and Females 45 years and older
8.5.8 NJ FAMILYCARE PLAN D ADULTS WITHOUT DEPENDENT CHILDREN UNDER 23 YEARS
OLD
The capitation rates for NJ FamilyCare Plan D adults without dependent
children under 23 years old, excluding individuals with AIDS, are in
the following premium groups:
A. Males 19 to 44.99 years
B. Females 19 to 44.99 years
C. Males and Females 45 years and older
8.5.9 PREMIUM GROUPS FOR DYFS AND AGING OUT XXXXXX CHILDREN
The capitation rates for Division of Youth and Family Services,
excluding individuals with AIDS and clients of DDD, are in the
following premium groups:
A. Males and females < 1 year
B. Males and females 1 year to 1.99 years
C. Males and females 2 to 20.99 years
VIII-8
8.5.10 ABD WITHOUT MEDICARE
Compensation to the contractor for the ABD without Medicare will be
risk-adjusted using the Health Based Payments System (HBPS), which is
described in Article 8.6. Since the HBPS adjusts for regional
variations, a separate rate for each region is not necessary. In
addition, the HBPS adjusts for the diagnosis of AIDS; therefore,
separate AIDS rates are not necessary for this population. Finally, the
HBPS adjusts for age and sex so separate rates for age and sex within
this population are not necessary. Accordingly, the base rates to be
used for this population are as follows:
A. ABD without Medicare (non-DDD)
B. ABD-DDD without Medicare
8.5.11 ABD WITH MEDICARE
The capitation rates for the ABD with Medicare population, excluding
individuals with AIDS and clients of DDD, are in the following premium
groups:
A. Aged
B. Blind/Disabled <45
C. Blind/Disabled 45+
These rates are set by region and will not be risk-adjusted using the
HBPS.
8.5.12 CLIENTS OF DDD
The contractor shall be paid separate, statewide rates for subgroups of
the DDD population, excluding individuals with AIDS. These rates
include MH/SA services for the following premium groups:
A. ABD-DDD with Medicare
B. AFDC-DDD (includes DYFS, New Jersey Care Pregnant Women, and
NJ FamilyCare Plan A)
These rates will not be risk-adjusted using the HBPS.
8.5.13 PREMIUM GROUPS FOR ENROLLEES WITH AIDS
VIII-9
A. In an effort to more appropriately match payment to risk, the
contractor shall be paid capitation rates according to the
following statewide premium groups for enrollees with AIDS:
1. AFDC-AIDS (includes DYFS, New Jersey Care Pregnant
Women, and NJ FamilyCare Plans A (children and
parents/caretakers), B, and C individuals, NJ
FamilyCare Plan D children)
2. NJ FamilyCare AIDS Plan D parents/caretakers and
adults without dependent children under 23 years old
and Plan A adults without dependent children under 19
years old
3. ABD-AIDS with Medicare
4. ABD-DDD-AIDS with Medicare (includes a MH/SA add on
to the ABD-AIDS rate)
5. AFDC-DDD-AIDS (includes a MH/SA add on to the
AFDC-AIDS rate) Other eligible groups include DYFS,
New Jersey Care Pregnant Women and NJ FamilyCare Plan
A (children and parents/caretakers).
6. NJ FamilyCare Plan A adults without dependent
children under 19 years old, DDD-AIDS (includes MH/SA
add on to the NJ FamilyCare AIDS rate).
B. The contractor will be reimbursed double the AIDS rate, once
in a member lifetime, in the first month of payment for a
recorded diagnosis of AIDS, prospective and newly diagnosed.
This is a one-time-only-per-member payment, regardless of MCE.
8.5.14 SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME
Because costs for pregnancy outcomes were not included in the
capitation rates, the contractor shall be paid supplemental payments
for pregnancy outcomes for all eligibility categories.
Payment for pregnancy outcome shall be a single, predetermined lump sum
payment. This amount shall supplement the existing capitation rate
paid. The Department will make a supplemental payment to contractors
following pregnancy outcome. For purposes of this Article, pregnancy
outcome shall mean each live birth, still birth or miscarriage
occurring at the thirteenth (13th) or greater week of gestation. This
supplemental payment shall reimburse the contractor for its inpatient
hospital, antepartum, and postpartum costs incurred in connection with
delivery. Costs for care of the baby are not included. Payment shall be
made by the State to the contractor based on submission of appropriate
encounter data and use of a special indicator on the claim as specified
by DMAHS.
VIII-10
8.5.15 PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS
The contractor shall be paid separately for factor VIII and IX blood
clotting factors. Payment will be made by DMAHS to the contractor based
on: 1) submission of appropriate encounter data; and 2) prior
notification from the contractor to DMAHS of identification of
individuals with factor VIII or IX hemophilia. Payment for these
products will be the lesser of: 1) Average Wholesale Price (AWP) minus
10% and 2) rates paid by the contractor.
8.5.16 PAYMENT FOR HIV/AIDS DRUGS
The contractor shall be paid separately for protease inhibitors (First
Data Bank Specific Therapeutic Class Code W5C) and other
anti-retroviral agents (First Data Bank Specific Therapeutic Class Code
W5B) for all eligibility groups with the exception of NJ FamilyCare
Plan A adults without dependent children under the age of 19 and NJ
Family Care Plan D parents/caretakers and adults without dependent
children under the age of 23. Payment for protease inhibitors shall be
made by DMAHS to the contractor based on: 1) submission of appropriate
encounter data; and 2) prior notification from the contractor to DMAHS
of identification of individuals with HIV/AIDS. Payment for these
products will be the lesser of: 1) Average Wholesale Price (AWP) minus
10% and 2) rates paid by the contractor.
Individuals eligible through NJ FamilyCare with a program status code
of 380 and all children groups shall receive protease inhibitors and
other anti-retroviral agents under the contractor's plan. All other
individuals eligible through NJ FamilyCare with program status codes of
497-498, 300-301, 700-701 and 761-763 shall receive protease inhibitors
(First Data Bank Specific Therapeutic Class Code W5C) and other
anti-retrovirals (First Data Bank Specific Therapeutic Class Code W5B)
through Medicaid fee-for-service and the AIDS Drug Distribution Program
(ADDP).
8.5.17 EPSDT INCENTIVE PAYMENT
The contractor shall be paid separately, $10 for every documented
encounter record for an EPSDT screening examination. The contractor
shall be required to pass the $10 amount directly to the screening
provider.
The incentive payment shall be reimbursed for EPSDT encounter records
submitted in accordance with 1) procedure codes specified by DMAHS, and
2) EPSDT periodicity schedule.
VIII-11
8.5.18 ADMINISTRATIVE COSTS
The capitation rates, effective July 1, 2001, recognize costs for
anticipated contractor administrative expenditures due to Balanced
Budget Act regulations.
8.6 HEALTH BASED PAYMENT SYSTEM (HBPS) FOR THE ABD WITHOUT MEDICARE
POPULATION
A. The capitation rates for the ABD without Medicare population
account for the potential of the contractor receiving a
disproportionate number of higher cost beneficiaries. If a
traditional age and sex capitation model were used, the rates
may not adequately account for the difference in risk assumed
by each contractor. In order to account for this problem
diagnostic information, as well as age, sex, and
regional/geographic information, will be used to adjust the
capitation payments. This process is known as health based
capitation. By using this additional information, capitation
rates can more adequately match the payment with the risk of
the enrolled population.
In order to incorporate diagnostic information into the
analysis, a health-based system categorizes beneficiaries into
different diagnostic groups. The Chronic- Disability Payment
System (CDPS) grouper will be used to categorize the
beneficiaries. This information is then used to create a
unique case score for each individual. This individual
information is then aggregated to measure the health risk for
the contractor.
B. The following narrative describes the implementation plan for
a health-based capitation model in New Jersey:
1. Develop demographic capitation rates.
2. Develop payment weights for the diagnostic
categories. In order to estimate the prospective
medical cost for each beneficiary, a payment weight
for each diagnostic category is developed. These
payment weights identify how much an individual will
cost relative to an average beneficiary. For example,
an average cost beneficiary will have a case score of
1.0, while a higher cost beneficiary - for example, a
beneficiary with a high cost pulmonary condition -
will have a score of 1.26.
3. Compile a case score for each beneficiary. Using the
most recent historical FFS and managed care encounter
information, a look-up file will be created that
links each eligible beneficiary with a unique case
score. In order to develop this unique case score,
historical claims information will be run through the
CDPS grouper. The output from this process will
identify the beneficiaries' diagnostic categories.
Using this information and the payment weights
estimated in step 2, a case score is then
VIII-12
computed for each beneficiary. The following example
describes the process for an ABD beneficiary who is
not a client of DDD, is a forty-five (45) to
sixty-four (64) year old male beneficiary, and lives
in Region 3, with a medium-cost central nervous
system disorder and a high-cost pulmonary condition:
.45 Baseline (costs assigned to all beneficiaries - including
those in no diagnostic group)
.08 Male 45 - 64
.78 Medium Cost Central Nervous System Disorder
-.10 Region 3
1.26 High Cost Pulmonary Condition
----
2.47 Total Case Score
In this case, the beneficiary would have projected
medical costs 2.47 times the cost of an average
beneficiary.
4. Compute case mix values for each contractor and the
FFS program. After completing the preceding task, the
individual case scores are used to compute an
aggregate case mix for each contractor. This is done
by matching the individuals in the eligibility file
for each contractor with individuals' case scores. In
matching the eligibility files, some beneficiaries
may have either been eligible for an incomplete time
period or have not been eligible during the most
recent time period and would not have a computed
score. HMO beneficiaries without scores will be
assigned the contractor's average case mix. FFS
beneficiaries without scores will be assigned the
average case mix of 1.0.
After matching the eligibility file for the
contractor and the FFS program with the individual
case scores, an average case mix for the contractor
and the FFS program will be calculated. These
aggregate case mix values are then normalized to
ensure the program will be budget neutral. The
following chart describes the normalization process:
------------------------------------------------------------------------
CASE MIX NORMALIZED
CONTRACTOR SCORE POPULATION CASE MIX RATE
------------------------------------------------------------------------
Contractor A 1.3 1,000 1.3/1.07 = 1.21
------------------------------------------------------------------------
Contractor B 1.1 4,000 1.1/1.07 = 1.03
------------------------------------------------------------------------
Contractor C .9 4,000 .90/1.07 = .84
------------------------------------------------------------------------
FFS 1.4 1,000 1.4/1.07 = 1.31
------------------------------------------------------------------------
Total 1.07 10,000
(weighted
average)
------------------------------------------------------------------------
By normalizing the case mix scores, the State can
ensure the average cost for each beneficiary will not
exceed the average prospective cost estimated in step
1.
VIII-13
In order to determine the payment for the contractor,
the case mix rates for the contractor will be
multiplied by the base rate calculated in step 1. The
case mix rates will be updated periodically, as
deemed necessary.
5. Collect and validate contractor encounter data. The
following encounter information will be required to
develop individual case scores for each enrollee:
- Unique identifier code for each enrollee
- ICD-9 diagnosis code(s) for each encounter
6. Credibility adjustment. There may not be complete
confidence in the contractor's relative case mix
produced by encounter data. In this case, a
credibility rating can be used to blend the
contractor's case mix with the State's risk
assumption. For example, if the State assigns a
contractor a case mix credibility of fifty (50)
percent, the following formula is used to develop a
case mix rate for the contractor:
(.5)*(the contractor's relative case mix) +
(.5)*(State's risk adjustment)
The credibility factor will be based primarily on the
number of beneficiaries enrolled with the contractor.
8.7 THIRD PARTY LIABILITY
A. General. The contractor, and by extension its providers and
subcontractors, hereby agree to utilize, whenever available,
other public or private sources of payment for services
rendered to enrollees in the contractor's plan. "Third party",
for the purposes of this Article, shall mean any person or
entity who is or may be liable to pay for the care and
services rendered to a Medicaid beneficiary (See N.J.S.A.
30:4D-3m). Examples of a third party include a beneficiary's
health insurer, casualty insurer, a managed care organization,
Medicare, or an employer-administered ERISA plan. Federal and
State law requires that Medicaid payments be last dollar
coverage and should be utilized only after all other sources
of third party liability (TPL) are exhausted, subject to the
exceptions in Section F below.
B. Third Party Coverage Unknown. If coverage through health or
casualty insurance is not known or is unavailable at the time
the claim is filed, then the claim must be paid and
postpayment recovery must be initiated within six months from
the date of service.
C. Capitation Rates. The State has taken into account historical
and/or anticipated cost avoidance and recovery due to the
existence of liable third parties in setting
VIII-14
capitation rates and determining the payment amounts. These
factors do not include any reductions due to tort recoveries,
or to recoveries made by the State from the estates of
deceased Medicaid beneficiaries. In addition, future rates may
be based upon the contractor's actual or expected performance
involving TPL. Consequently, it is in the interests of both
the State and the contractor for the contractor to maximize
its revenue by fully exhausting all sources of available third
party coverage.
D. Categories. Third party resources are categorized as 1) health
insurance, 2) casualty insurance, 3) legal causes of action
for damages, and 4) estate recoveries.
1. Health Insurance. The contractor shall pursue and
collect payments from health insurers when health
insurance coverage is available, unless prior
approval to take other action is obtained from the
State. "Health insurance" shall include, but not be
limited to, coverage by any health care insurer, HMO,
Medicare, or an employer-administered ERISA plan.
Funds so collected shall be retained by the
contractor. In pursuing such recoveries, the
contractor may utilize the State's assignment and
subrogation authority to the extent permitted by
State law.
a. The State shall have the right to pursue,
collect, and retain payments from liable
health insurers if the contractor has failed
to initiate collection from the health
insurer within six (6) months from the date
of service. The contractor shall cooperate
with the State in all such collection
efforts, and shall also direct its providers
to do so.
2. Casualty Insurance. The contractor shall pursue and
collect payment from casualty insurance available to
the enrollee, unless prior approval to take other
action is obtained from the State. "Casualty
insurance" shall include, but not be limited to, no
fault auto insurance benefits, worker's compensation
benefits, and medical payments coverage through a
homeowner's insurance policy. Funds so collected
shall be retained by the contractor. In pursuing such
recoveries, the contractor may utilize the State's
assignment and subrogation authority to the extent
permitted by State law.
a. The State shall have the right to pursue,
collect, and retain casualty insurance
payments where the contractor has failed to
initiate collection within six (6) months
from the date of service.
3. Legal Causes of Action for Damages. The State shall
have the sole and exclusive right to pursue and
collect payments made by the contractor when a legal
cause of action for damages is instituted on behalf
of a Medicaid enrollee against a third party or when
the State receives notice that legal counsel has been
retained by or on behalf of any enrollee. The
VIII-15
contractor shall cooperate with the State in all
collection efforts, and shall also direct its
providers to do so. State collections identified as
contractor-related resulting from such legal actions
will be retained by the State.
4. Estate Recoveries. The State shall have the sole and
exclusive right to pursue and recover correctly paid
benefits from the estate of a deceased Medicaid
enrollee in accordance with federal and State law.
Such recoveries will be retained by the State.
E. Cost Avoidance.
1. When the contractor is aware of health or casualty
insurance coverage prior to paying for a health care
service, it shall avoid payment by rejecting a
provider's claim and directing that the claim be
submitted first to the appropriate third party, or by
directing its provider to withhold payments to a
subcontractor.
2. If insurance coverage is not available, or if one of
the exceptions to the cost avoidance rule discussed
below applies, then payment must be made and a claim
made against the third party, if it is determined
that the third party is or may be liable.
F. Exceptions to the Cost Avoidance Rule.
1. In the following situations, the contractor must
first pay its providers and then coordinate with the
liable third party, unless prior approval to take
other action is obtained from the State.
a. The coverage is derived from a parent whose
obligation to pay support is being enforced
by the Department of Human Services.
b. The claim is for prenatal care for a
pregnant woman or for preventive pediatric
services (including EPSDT services) that are
covered by the Medicaid program.
c. The claim is for labor, delivery, and
post-partum care and does not involve
hospital costs associated with the inpatient
hospital stay.
d. The claim is for a child who is in a DYFS
supported out of home placement.
e. The claim involves coverage or services
mentioned in 1.a, 1.b, 1.c, or 1.d, above in
combination with another service.
2. If the contractor knows that the third party will
neither pay for nor provide the covered service, and
the service is medically necessary, the contractor
VIII-16
shall neither deny payment for the service nor
require a written denial from the third party.
3. If the contractor does not know whether a particular
service is covered by the third party, and the
service is medically necessary, the contractor shall
contact the third party and determine whether or not
such service is covered rather than requiring the
enrollee to do so. Further, the contractor shall
require the provider or subcontractor to xxxx the
third party if coverage is available.
4. Postpayment recovery rather than cost avoidance is
necessary in cases where the contractor was not aware
of third party coverage at the time that services
were rendered or paid for, or was unable to cost
avoid, in accordance with the provisions of this
Article as applicable. Under these circumstances, the
contractor shall identify all potentially liable
third parties and pursue reimbursement from them,
unless prior approval to take other action is
obtained from the State. In pursuing such recoveries,
the contractor may utilize the State's assignment and
subrogation authority to the extent permitted by
State law. This provision shall not apply in the case
of any tort matter but rather the provisions of
Article 8.7D.3 shall be applicable.
G. Sharing of TPL Information by the State.
1. By the fifteenth (15th) day of every month, the State
may provide the contractor with a list of all known
health insurance coverage information for the purpose
of updating the contractor's files.
2. Additionally, the State may provide a quarterly
health insurer file to the contractor that will
contain all of the health insurers that the State has
on file and related information that is needed in
order to file TPL claims.
H. Sharing of TPL Information by the Contractor.
1. The contractor shall notify the State within thirty
(30) days after it learns that an enrollee has health
insurance coverage not reflected in the State's
health insurance coverage file, or casualty insurance
coverage, or of any change in an enrollee's health
insurance coverage. (See Section A.8.1 of the
Appendices.) The contractor shall impose a
corresponding requirement upon its servicing
providers to notify it of any newly discovered
coverage, or of any changes in an enrollee's health
insurance coverage.
2. When the contractor becomes aware that an enrollee
has retained counsel, who either may institute or has
instituted a legal cause of action for damages
against a third party, the contractor shall notify
the State in
VIII-17
writing, including the enrollee's name and Medicaid
identification number, date of accident/incident,
nature of injury, name and address of enrollee's
legal representative, copies of pleadings, and any
other documents related to the action in the
contractor's possession or control. This shall
include, but not be limited to (for each service date
on or subsequent to the date of the
accident/incident), the name of the provider,
practitioner or subcontractor, the enrollee's
diagnosis, the nature of the service provided to the
enrollee, and the amount paid to the provider (or to
a provider's authorized subcontractor) by the
contractor for each service. A form is available for
this purpose and is included in Section A.8.2 of the
Appendices.
3. The contractor shall notify the State within thirty
(30) days of the date it becomes aware of the death
of one of its Medicaid enrollees age fifty-five (55)
or older, giving the enrollee's full name, Social
Security Number, Medicaid identification number, and
date of death. The State will then determine whether
it can recover correctly paid Medicaid benefits from
the enrollee's estate.
4. The contractor agrees to cooperate with the State's
efforts to maximize the collection of third party
payments by providing to the State updates to the
information required by this Article.
I. Enrollment Exclusions and Contractor Liability for the Costs
of Care.
1. Any Medicaid beneficiary enrolled in or covered by
either a Medicare or commercial HMO will not be
enrolled by the contractor. The only exception to
this exclusion from enrollment is when the contractor
and the beneficiary's Medicare/commercial HMO are the
same. When beneficiaries are enrolled under this
exception, appropriate reductions will be made in the
State's capitation payments to the contractor.
2. If the contractor and the Medicaid beneficiary's
Medicare or commercial HMO are the same, the
contractor will be responsible for either:
a. Paying all cost-sharing expenses of the
Medicaid beneficiary; or
b. Addressing cost sharing in the contracts
with its providers in such a way that the
Medicaid beneficiary is not liable for any
cost-sharing expenses, subject to
subarticle 3 below.
3. If a Medicaid beneficiary otherwise covered by the
provisions of subarticle 2 above wishes to utilize a
provider outside of the Medicare or commercial HMO's
network, the HMO's rules apply. Failure to follow the
HMO's rules relieves both the contractor and the
State of any liability
VIII-18
for the cost of the care and services rendered to the
beneficiary, subject to subarticle 4 below.
4. The only exception to subarticle 3 above is if the
HMO's rules cannot be followed solely because
emergency services were provided by a non-
participating provider, practitioner, or
subcontractor because the services were immediately
required due to sudden or unexpected onset of a
medical condition. In this circumstance, the
contractor remains responsible for the cost of the
care and services rendered to the beneficiary.
5. If a Medicaid beneficiary enrolled with the
contractor is also enrolled in or covered by a health
or casualty insurer other than a Medicare or
commercial HMO, the contractor is fully responsible
for coordinating benefits so as to maximize the
utilization of third party coverage in accordance
with the provisions of this Article. The contractor
shall be responsible for payment of the enrollee's
coinsurance, deductibles, copayments, and other
cost-sharing expenses, but the contractor's total
liability shall not exceed what it would have paid in
the absence of TPL. The contractor shall coordinate
benefits and payments with the health or casualty
insurer for services authorized by the contractor,
but provided outside the contractor's plan. The
contractor remains responsible for the costs incurred
by the beneficiary with respect to care and services
which are included in the contractor's capitation
rate, but which are not covered or payable under the
health or casualty insurer's plan.
6. The State will continue to pay Medicare Part A and
Part B premiums for Medicare/Medicaid dual eligibles
and Qualified Medicare Beneficiaries.
7. Any references to Medicare coverage in this Article
shall apply to both Medicare/Medicaid dual eligibles
and Qualified Medicare Beneficiaries.
J. Other Protections for Medicaid Enrollees.
1. The contractor shall not impose, or allow its
participating providers or subcontractors to impose,
cost-sharing charges of any kind upon Medicaid
beneficiaries enrolled in the contractor's plan
pursuant to this contract. This Article does not
apply to individuals eligible solely through the NJ
FamilyCare Program Plan C or D, for whom providers
will be required to collect cost-sharing for certain
services.
2. The contractor's obligations under this Article shall
not be imposed upon the enrollees, although the
contractor shall require enrollees to cooperate in
the identification of any and all other potential
sources of payment for services. Instances of
non-cooperation shall be referred to the State.
VIII-19
3. The contractor shall neither encourage nor require a
Medicaid enrollee to reduce or terminate TPL
coverage.
4. Unless otherwise permitted or required by federal and
State law, health care services cannot be denied to a
Medicaid enrollee because of a third party's
potential liability to pay for the services, and the
contractor shall ensure that its cost avoidance
efforts do not prevent an enrollee from receiving
medically necessary services.
8.8 COMPENSATION/CAPITATION CONTRACTUAL REQUIREMENTS
A. Contractor Compensation. Compensation to the contractor shall
consist of monthly capitation payments, supplemental payments
per pregnancy outcome/delivery, certain blood products for
hemophilia factors VIII & IX disorders, and payment for
certain HIV/AIDS drugs. Contractors must agree to enroll all
non-exempt Aged, Blind and Disabled and NJ FamilyCare
beneficiaries to qualify to serve AFDC/TANF beneficiaries.
B. Capitation Payment Schedule. DMAHS hereby agrees to pay the
capitation by the fifteenth (15th) day of any month during
which health care services will be available to an enrollee;
provided that information pertaining to enrollment and
eligibility, which is necessary to determine the amount of
said payment, is received by DMAHS within the time limitation
contained in Article 5 of this contract.
C. Upper Payment Limit and Cost-Effectiveness. The contractor
shall receive monthly capitation payments, for a defined scope
of services to be furnished to a defined number of enrollees,
for providing the services contained in the Benefits Package
described in Article 4.1 of this contract. Such payments will
not exceed the upper payment limit, established by DMAHS,
pursuant to 42 C.F.R. Part 447, which is the cost of providing
those services on a fee-for-service basis to an actuarially
equivalent, non-enrolled population group. The contractor is
not entitled to receive payments that exceed the upper payment
limit. In addition, the contractor is not entitled to payments
that would cause the State to exceed the cost-effectiveness
established in its 1915(b) waiver.
D. Adjustments and Renegotiation of Capitation Rates. Capitation
rates are prospective in nature and will not be adjusted
retroactively or subject to renegotiation during the contract
period except as explicitly noted in the contract. Capitation
rates will be paid only for eligible beneficiaries enrolled
during the period for which the adjusted capitation payments
are being made. Payments provided for under the contract will
be denied for new enrollees when, and for so long as, payments
for those enrollees is denied by HCFA under 42 C.F.R.
434.67(e).
VIII-20
E. Payment by State Fiscal Agent. The State fiscal agent will
make payments to the contractor.
F. Payment in Full. The monthly capitation payments plus
supplemental payments for pregnancy outcomes and payment for
certain HIV/AIDS drugs and blood clotting factors VIII and IX
to the contractor shall constitute full and complete payment
to the contractor and full discharge of any and all
responsibility by the Division for the costs of all services
that the contractor provides pursuant to this contract.
G. Payments to Providers. Payments shall not be made on behalf of
an enrollee to providers of health care services other than
the contractor for the benefits covered in Article Four and
rendered during the term of this contract.
H. Time Period for Capitation Payment per Enrollee. The monthly
capitation payment per enrollee is due to the contractor from
the effective date of an enrollee's enrollment until the
effective date of termination of enrollment or termination of
this contract, whichever occurs first.
I. Payment If Enrollment Begins after First Day of Month. When
DMAHS' capitation payment obligation is computed, if an
enrollee's coverage begins after the first day of a month,
DMAHS will pay the contractor a fractional capitation payment
that is proportionate to the part of the month during which
the contractor provides coverage. Payments are calculated and
made to the last day of a calendar month except as noted in
this Article.
J. Risk Assumption. The capitation rates shall not include any
amount for recoupment of any losses suffered by the contractor
for risks assumed under this contract or any prior contract
with the Department.
K. Hospitalizations. For any eligible person who applies for
participation in the contractor's plan, but who is
hospitalized prior to the time coverage under the plan becomes
effective, such coverage shall not commence until the date
after such person is discharged from the hospital and DMAHS
shall be liable for payment for the hospitalization, including
any charges for readmission within forty-eight (48) hours of
discharge for the same diagnosis. If an enrollee's
disenrollment or termination becomes effective during a
hospitalization, the contractor shall be liable for
hospitalization until the date such person is discharged from
the hospital, including any charges for readmission within
forty-eight (48) hours of discharge for the same diagnosis.
The contractor must notify DMAHS of these occurrences to
facilitate payment to appropriate providers.
L. Continuation of Benefits. The contractor shall continue
benefits for all enrollees for the duration of the contract
period for which capitation payments have been made, including
enrollees in an inpatient facility until discharge. The
contractor shall notify DMAHS of these occurrences.
VIII-21
8.9 CONTRACTOR ADVANCED PAYMENTS AND PIPS TO PROVIDERS
A. The contractor shall make advance payments to its
providers, capitation, FFS, or other financial
reimbursement arrangement, based on a provider's
historical billing or utilization of services if the
contractor's claims processing systems become
inoperational or experience any difficulty in making
timely payments. Under no circumstances shall the
contractor default on the claims payment timeliness
provisions of this contract. Advance payments shall
also be made when compliance with claims payment
timeliness is less than ninety (90) percent for two
(2) quarters. Such advance payments will continue
until the contractor is in full compliance with
timely payment provisions for two (2) successive
quarters.
B. Periodic Interim Payments (PIPs) to Hospitals. The
contractor shall provide periodic interim payments to
participating, PIP-qualifying hospitals.
1. Designation of PIP-Qualifying Hospitals.
Each quarter, DMAHS shall determine which
hospitals qualify for monthly PIPs.
VIII-22
2. When Contractor is Required to Make PIPs.
The contractor shall make PIPs to a
participating (network provider), qualifying
hospital when the average monthly payment
from the contractor to the hospital is at
least $100,000 for the most recent six-month
period excluding outliers. An outlier is
defined as a single admission for which the
payment to the hospital exceeds $100,000. It
should be noted that outlier claims paid are
included in the establishment of the monthly
PIPs and the reconciliation of the PIPs.
3. Methodologies to Establish Amount of PIPs.
a. The contractor may work out a
mutually agreeable arrangement with
the participating PIP-qualifying
hospitals for developing a
methodology for determining the
amount of the PIPs and reconciling
the PIP advances to paid claims. If
a mutually agreeable arrangement
cannot be reached, the contractor
shall make PIPs in accordance with
the methodology described in 3.b.
below.
b. Beginning August 1, 2000, the
contractor shall provide a
participating, PIP-qualifying
hospital with an initial 60-day PIP
(representing two 30-day cash
advances) which shall be reconciled
using a claims offset process, with
the first 30-day PIP reconciled to
claims adjudicated during the first
month following the initial PIP
(August), and the second 30-day PIP
reconciled to claims adjudicated
during the second month following
the initial PIP (September). In
September 2000 and all subsequent
months, the hospital shall receive
a 30-day PIP which shall be offset
against claims adjudicated at the
end of the following month. At
reconciliation, any excess claims
adjudicated above the PIP amount
shall result in an additional
payment to the hospital equal to
the value of any excess claims
above the PIP. If the value of
claims adjudicated is less than the
PIP, the shortage shall be offset
against the next PIP made to the
hospital. An example of how this
methodology shall work is as
follows:
VIII-23
EXAMPLE:
-----------------------------------------------------------------------------------------------
PIP Claims Reconciliation Net
Payment Adjudicated Adjustment Payment Balance
-----------------------------------------------------------------------------------------------
Aug 1 300,000 (A)
-----------------------------------------------------------------------------------------------
Aug 1 300,000 (B) 600,000
-----------------------------------------------------------------------------------------------
Aug 1-31 180,000 420,000
-----------------------------------------------------------------------------------------------
Sept 1 300,000 (C) (120,000) (A) 180,000 600,000
-----------------------------------------------------------------------------------------------
Sept 1-30 270,000 330,000
-----------------------------------------------------------------------------------------------
Oct 1 300,000 (D) (30,000) (B) 270,000 600,000
-----------------------------------------------------------------------------------------------
Oct 1-31 320,000 280,000
-----------------------------------------------------------------------------------------------
Nov 1 300,000 (E) 20,000 (C) 320,000 600,000
-----------------------------------------------------------------------------------------------
8.10 FEDERALLY QUALIFIED HEALTH CENTERS
A. Standards for Contractor FQHC Rates. The contractor shall not
reimburse FQHCs less than the level and amount of payment
which the contractor would make for a similar set of services
if the services were furnished by a non-FQHC. The contractor
may pay the FQHCs on a fee-for-service or capitated basis. The
contractor shall make payments for primary care equal to, or
greater than, the average amounts paid to other primary care
providers. Non-primary care services may be included if
mutually agreeable between the contractor and FQHC. For
non-primary care services, payments shall be equal to, or
greater than, the average amounts paid to other non-primary
care providers for equivalent services.
B. DMAHS Reimbursement to FQHCs. Under Title XIX, an FQHC shall
be paid reasonable cost reimbursement by DMAHS. At the end of
each fiscal year the contractor and the FQHC will complete
certain reporting requirements specified that will enable
DMAHS to determine reasonable costs and compare that to what
was actually paid by the contractor to the FQHC. DMAHS will
reimburse the FQHC for the difference (i.e., difference
between the determined reasonable cost per encounter and the
payments to the FQHC made by the contractor and DMAHS) if the
payments by the contractor to the FQHC are less than
reasonable costs. DMAHS will recoup payments from the FQHC in
excess of reasonable costs. FQHC providers must meet the
contractor's credentialing and program requirements.
C. Contractor Participation in Reconciliation Process. The
contractor shall participate in the reconciliation processes
if there is a dispute between what the contractor reported
(See Section A.7.20 of the Appendices (Table 18)) and what the
FQHC reported as valid encounters or payments. This
participation may include appearances in the Office of
Administrative Law, as well as meeting with DMAHS staff.
VIII-24
