New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 49 - ADMINISTRATION MANUAL
Subchapter 1 - GENERAL PROVISIONS
Section 10:49-1.3 - Definitions
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Adult mental health rehabilitation services provided in/by community residence programs" means community residential mental health services provided in/by any community residential program licensed by, and under contract with, the Division of Mental Health Services (DMHS), which provides services in accordance with N.J.A.C. 10:37A. These services include assessment and evaluation; individual service coordination; training in daily living skills; residential counseling; life support services and crisis intervention services.
"AFDC" means the former Aid to Families with Dependent Children program.
"AFDC-related Medicaid" means medical assistance provided to families who would otherwise qualify for AFDC or would be deemed to qualify for AFDC if the program would be deemed still in existence.
"American Indian/Alaska Native (AI/AN)" means a member of a Federally recognized Indian tribe, band, or group; an Eskimo or Aleut or other Alaska Native enrolled by the Secretary of the Interior pursuant to the Alaska Native Claims Settlement Act, 43 C.F.R. 1601 et seq.; or a person who is considered by the Secretary of the Interior as meeting the requirements of tribal membership in accordance with 42 C.F.R. 36a.16.
"Beneficiary or eligible beneficiary" means any person meeting the definition of recipient as defined below.
"Centers for Medicare and Medicaid Services (CMS)" means the agency of the Federal Department of Health and Human Services which is responsible for the administration of the Medicaid program in the United States.
"Commissioner of DHS" means the Commissioner of the Department of Human Services.
"Community residences for mentally ill adults" means any community residential program licensed by the Division of Mental Health Services in accordance with N.J.A.C. 10:37A. "Community residences for mentally ill adults" does not include supportive housing residences as defined at 10:37A-1.2 and 10:77A-1.2.
"Copayment" means a specified dollar amount required to be paid by or on behalf of the beneficiary in connection with benefits as specified in 10:49-9.1.
"County welfare agency (CWA)" means that agency of county government, which is charged with the responsibility for determining eligibility for public assistance programs including AFDC-Related Medicaid, Temporary Assistance to Needy Families (TANF), the Food Stamp program and Medicaid. Depending on the county, the CWA might be identified as the Board of Social Services, the Welfare Board, the Division of Welfare, or the Division of Social Services.
"Department" or "DHS" means the Department of Human Services. The Department of Human Services is the single State agency designated by 30:4D-3 in accordance with 42 CFR 412.30 for the administration of the New Jersey Medicaid/NJ FamilyCare program.
"Department of Children and Families" or "DCF" means the New Jersey Department of Children and Families, created by P.L. 2006, c. 47.
"DHSS" means the Department of Health and Senior Services.
"Division" or "DMAHS" means the Division of Medical Assistance and Health Services.
"DMHS" means the Division of Mental Health Services within the New Jersey Department of Human Services.
"Dual eligibles" means those Medicaid/NJ FamilyCare beneficiaries who are also eligible for Medicare benefits under Title XVIII of the Social Security Act.
"DYFS" means the Division of Youth and Family Services within the New Jersey Department of Children and Families.
"Fiscal agent" means an entity that processes and adjudicates provider claims on behalf of programs administered in whole or part by the Division.
"Managed care service administrator" means an entity in a non-risk based financial arrangement that contracts to provide a designated set of services for an administrative fee. Services provided may include, but are not limited to: medical management, claims processing, and provider network maintenance.
"Medicaid" means medical assistance provided to certain persons with low income and limited resources as authorized under Title XIX (Medicaid) of the Social Security Act.
"Medicaid Agent" means, under Reorganization Plan No. 001-1996, either DHSS or DMAHS, acting as administrators of the Medicaid program.
"Mental health rehabilitation services" means psychiatric and psychological services, including emotional and/or behavioral treatment, drug and alcohol dependency treatment, psychiatric treatment, psychotherapy and related nursing services.
"NJ FamilyCare" means the health insurance coverage program administered by DMAHS under the provisions of Title XIX and Title XXI of the Social Security Act.
"NJ FamilyCare-Plan A" means the State-operated program, which provides comprehensive, managed care coverage, including all benefits provided through the New Jersey Care . . . Special Medicaid Programs, to eligible 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, pregnant women eligible under the New Jersey Care . . . Special Medicaid Programs, pregnant women up to 200 percent of the Federal poverty level, AFDC-related children under age 21 and TANF/AFDC-RELATED Medicaid parents. In addition to covered managed care services, eligibles may access certain other services, which are paid fee-for-service.
"NJ FamilyCare-Plan B" means the State-operated program which provides comprehensive, managed care coverage to uninsured children through the age of 18 with family incomes above 133 percent and not in excess of 150 percent of the Federal poverty level. In addition to covered managed care services, eligibles may access mental health and substance abuse services and certain other services which are paid fee-for-service.
"NJ FamilyCare-Plan C" means the State-operated program which provides comprehensive, managed care coverage to uninsured children through the age of 18 with family incomes above 150 percent and not in excess of 200 percent of the Federal poverty level. In addition to covered managed care services, eligibles may access mental health and substance abuse services and certain other services which are paid fee-for-service. Eligibles are required to participate in cost-sharing in the form of monthly premiums and personal contributions to care for certain services.
"NJ FamilyCare-Plan D" means the State-operated program, which provides managed care coverage to uninsured children through the age of 18 with gross family incomes above 200 percent and not in excess of 350 percent of the Federal poverty level, parents/caretakers with income up to 200 percent of the Federal poverty level who applied on or before June 14, 2002, and as a result, were subsequently and continuously enrolled in the program, parents/caretakers with incomes less than or equal to 133 percent of the Federal poverty level who were enrolled in the program pursuant to P.L. 2005, c. 156, adults with incomes up to and including 250 percent of the Federal poverty level formerly covered by the Health Access Program and restricted alien parents formerly covered under NJ FamilyCare Plan H. In addition to covered managed care services, eligibles may access certain services including mental health and substance abuse services, with limitations, which are paid fee-for-service. Eligibles participate in cost-sharing in the form of monthly premiums and copayments for most services.
"NJ FamilyCare Plan D for adults" means the State-operated program which provides a benefit package through managed care organizations, supplemented by services provided on a fee-for-service basis, to specified parents/caretakers of children enrolled in NJ FamilyCare, in accordance with 10:49-5.7, 10:78-7.1 and this chapter.
"NJ FamilyCare Plan I" means the State-operated program which provides a Plan D benefit package on a fee-for-service basis to specified parents/caretakers of children enrolled in NJ FamilyCare, in accordance with 10:78-7.1 and this chapter.
"Prepaid health plan" means an entity that provides medical services to enrollees under a contract with DMAHS on the basis of prepaid capitation fees but which does not necessarily qualify as an HMO. For rules concerning prepaid health care services, see 10:49-1.1. For Medicaid Managed Care Program--New Jersey Care 2000, see N.J.A.C. 10:49-21.
"Program" means the New Jersey Medicaid program.
"Programs" means the New Jersey Medicaid program and the NJ FamilyCare program.
"Programs of Assertive Community Treatment (PACT)" means mental health rehabilitative services which are delivered in a self-contained treatment program, provided by a service delivery team and managed by a qualified program director, that merge clinical and rehabilitative expertise to provide mental health treatment, rehabilitation, and support services which are individualized and tailored to the unique needs and choices of the individual receiving the services.
"Provider" means any individual, partnership, association, corporation, institution, or any other public or private entity, agency, or business concern, meeting applicable requirements and standards for participation in the New Jersey Medicaid Program, other Special programs, and where applicable, holding a current valid license, and lawfully providing medical care, services, goods and supplies authorized under N.J.S.A. 30:4D-l et seq. and amendments thereto.
"Qualified applicant" means a person who is a resident of this State and is determined to need medical care and services as provided under the Medical Assistance and Health Services Act, 30:4D-1 et seq., and who meets one of the eligibility criteria set out therein.
"Recipient" means a qualified applicant receiving benefits under the Medical Assistance and Health Services Act, 30:4D-1 et seq.
"Temporary Assistance to Needy Families (TANF)" means that program administered by the Division of Family Development within the Department of Human Services in accordance with N.J.A.C. 10:90.
