Current through Register Vol. 56, No. 18, September 16, 2024
(a) Under NJ
FamilyCare-Plan C, personal contribution to care in the amounts indicated below
shall be collected by the provider for the services indicated below:
1. Outpatient hospital clinic services: $
5.00 personal contribution to care for outpatient visits. No personal
contribution to care shall be charged for well-child visits in accordance with
the schedule recommended by the American Academy of Pediatrics; lead screening
and treatment; age-appropriate immunizations; prenatal care; preventive
services; family planning services; or substance abuse treatment services.
Specific policies are set forth at
10:52-4.7.
2. $ 10.00 personal contribution to care for
each covered emergency room services visit which does not result in an
inpatient hospital stay.
3.
Physician services: $ 5.00 personal contribution to care per visit. No personal
contribution to care shall be charged for well-child visits in accordance with
the schedule recommended by the American Academy of Pediatrics; lead screening
and treatment; age-appropriate immunizations; prenatal care; preventive or for
family planning services, or substance abuse treatment services. Policies
specific to physician personal contribution to care services are set forth at
10:54-4.1.
4. Clinic services: $ 5.00 personal
contribution to care for clinic visits. No personal contribution to care shall
be charged for well-child visits in accordance with the schedule recommended by
the American Academy of Pediatrics; lead screening and treatment;
age-appropriate immunizations; prenatal care; preventive or for family planning
services, or substance abuse treatment services. Policies specific to clinic
personal contribution to care policies are set forth at
10:66-1.6.
5. Podiatric services: $ 5.00 personal
contribution to care for office visits. Specific policies regarding podiatric
personal contribution to care are set forth at
10:57-1.7.
6. Optometric services: $ 5.00 personal
contribution to care for professional vision care services. Specific policies
are set forth at
10:62-1.6.
7. Chiropractic services: $ 5.00 personal
contribution to care. Covered for spinal manipulation only.
8. Prescription drugs: $ 1.00 personal
contribution to care for generics and $ 5.00 for brand name drugs. Includes
insulin, needles and syringes. Specific policies regarding personal
contribution to care for prescription drugs are set forth at
10:51-1.12.
9. Psychological services: $ 5.00 personal
contribution to care. Specific policies for psychologists are set forth at
10:67-1.6.
10. Certified nurse-midwife services: $ 5.00
personal contribution to care. No personal contribution to care shall be
charged for prenatal care, preventive care, or for family planning services.
See 10:58-1.8 for specific policies
related to certified nurse-midwife services.
11. Advanced practice nurse: $ 5.00 personal
contribution to care. No personal contribution to care shall be charged for
well-child visits in accordance with the schedule recommended by the American
Academy of Pediatrics; lead screening and treatment; age-appropriate
immunizations; prenatal care; preventive or for family planning services, or
substance abuse treatment services. Special policies are set forth at
10:58A-1.6.
12. Dental services: $ 5.00 personal
contribution to care applies, unless the visit is for preventive dentistry
services. Specific policies are set forth at N.J.A.C. 10:57-1.7.
(b) Providers are required to
collect the personal contribution to care for the NJ FamilyCare-Plan C services
set forth in (a) above if the NJ FamilyCare Identification card indicates that
a personal contribution to care is required and the beneficiary does not have a
NJ FamilyCare letter which indicates that the beneficiary has reached his or
her cost share limit and no further personal contributions to care are required
until further notice. Personal contributions to care can not be
waived.
(c) Under NJ
FamilyCare-Plan D, copayments in the amounts indicated below shall be collected
by the provider for services as follows, if copayment is indicated on the
beneficiary's HMO card:
1. A $ 5.00 copayment
per visit shall be required for the following services:
i. Primary care provider office visit during
normal office hours;
(1) A $ 10.00 copayment
shall apply for services rendered during non-office hours and for home
visits.
(2) The $ 5.00 copayment
shall apply only to the first prenatal visit;
ii. Physician, specialist, podiatrist,
optometrist, certified nurse midwife, advanced practice nurse and psychologist
office visit;
(1) Optometrist office visit for
newborns covered under fee-for-service are not subject to the $ 5.00
copayment.
iii.
Outpatient rehabilitation services, including physical therapy, occupational
therapy and speech therapy;
iv.
Hospital outpatient department visits, laboratory and X-rays
services;
v. Routine eye
examinations;
vi. Prescription
drugs;
(1) If greater than a 34-day supply of
a prescription drug is dispensed, a $ 10.00 copayment shall apply;
and
vii. Outpatient
substance abuse services for detoxification;
2. A $ 25.00 copayment per visit shall be
required for outpatient mental health visits;
3. A $ 35.00 copayment per visit shall be
required for outpatient emergency services, including services provided in an
outpatient hospital department or an urgent care facility.
i. No copayment shall be required if the
beneficiary was referred to the emergency room by his or her primary care
provider for services that should have been rendered in the primary care
physician's office, or if the beneficiary is admitted into the
hospital;
4. A $ 10.00
copayment per visit shall be required for primary care providers, certified
nurse midwives, physician specialists, and advance practice nurses for
non-office hour visits and home visits; and
5. No copayment is required for well-child
visits in accordance with the recommended schedule of the American Academy of
Pediatrics, including lead screening and treatment, age appropriate
immunizations, prenatal care and preventive dental services.
(d) Personal contributions to care
under NJ FamilyCare-Plan C and copayments under NJ FamilyCare-Plan D shall be
effective upon date of enrollment.
1.
Exception: A personal contribution to care or copayment shall not apply to
services rendered to a newborn until the newborn is enrolled in a managed care
program.
(e) No personal
contribution to care under NJ FamilyCare-Plan C shall be charged for well-child
visits in accordance with the schedule recommended by the American Academy of
Pediatrics; lead screening and treatment; age-appropriate immunizations;
preventive dental services; prenatal care; for family planning services; or for
substance abuse treatment services.
(f) No copayment under NJ FamilyCare-Plan D
will be charged for well-child visits in accordance with the schedule
recommended by the American Academy of Pediatrics; nor for lead screening and
treatment; for age-appropriate immunizations; or for preventive dental
services.
(g) No cost sharing shall
be imposed on children who are American Indians/Alaska Natives. Proof of
Federally recognized AI/AN tribal status shall be provided in the form of a
tribal card or letter, in accordance with 42 C.F.R. 36a.16.
