New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES
Subchapter 1 - GENERAL PROVISIONS
Section 10:74-1.4 - Definitions
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:
"ABD" means those individuals who are determined to be categorically eligible for Medicaid because they are aged, blind or disabled. Eligibility shall be determined in accordance with N.J.A.C. 10:70, Medically Needy, 10:71, Medicaid Only, or 10:72, New Jersey Care . . . Special Medicaid Programs, as applicable.
"Administrative service(s)" means the obligations of the contractor as specified in its contract with the Department 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 administration, financial management, reporting, fraud and abuse investigations and encounter data reporting.
"Advanced practice nurse" means a person licensed to practice as a registered professional nurse who is certified by the New Jersey State Board of Nursing in accordance with N.J.A.C. 13:37-7 and 45:11-24 and 45 through 52, or similarly licensed and certified by a comparable agency of the state in which he or she practices.
"AFDC" means those families who are eligible for Medicaid using the Aid to Families with Dependent Children program rules in effect as of July 16, 1996.
"AFDC-related" refers to pregnant women and infants up to the age of one year who are eligible under the New Jersey Care . . . Special Medicaid Programs.
"AIDS Drug Distribution Program (ADDP)" means the Department of Health (DOH) program, which provides life-sustaining and life-prolonging medications to persons who are HIV-positive, or who are living with AIDS, and who meet residency and income criteria for program participation.
"Benefits package" means the services which the contractor has agreed to provide, arrange for, and be held fiscally responsible for, which are set forth in N.J.A.C. 10:74-3.
"Behavioral health services" refers to the treatment and amelioration of behavioral/mental health conditions, as well as efforts to prevent and intervene in substance use disorder.
"Capitation rate" means the fixed monthly amount that the contractor is paid by the Department for each enrollee to provide that enrollee with the services included in the benefits package described in N.J.A.C. 10:74-3.
"Care management" means 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 is driven by quality-based outcomes, such as: improved/maintained functional status, improved/maintained clinical status, enhanced quality of life, enrollee satisfaction, adherence to the care plan, improved enrollee safety, cost savings and enrollee autonomy. Care management functions include:
1. Early identification of enrollees who have or may have special needs;
2. Assessment of an enrollee's 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, behavioral and other support services where needed;
6. Monitoring;
7. Continuity of care; and
8. Follow-up and documentation.
"Centers for Medicare & Medicaid Services (CMS)" means the agency within the U.S. Department of Health and Human Services which has responsibility for administering the Medicaid and State Child Health Insurance programs in accordance with Titles XIX and XXI of the Social Security Act.
"Certificate of authority" means a license, issued by the New Jersey Department of Banking and Insurance granting authority to operate an HMO in New Jersey in compliance with 26:2J-3 and 4 and N.J.A.C. 11:24.
"Certified nurse-midwife (CNM)" means a registered professional nurse licensed in New Jersey who, by virtue of added knowledge and skill gained through an organized program of study and clinical experience, receives certification by the American College of Nurse-Midwives. A CNM shall be licensed by and registered with the New Jersey Board of Medical Examiners.
"Child Protection and Permanency" (CP&P) means the child protection and child welfare agency within the New Jersey Department of Children and Families (DCF), which is responsible for the care, custody, guardianship, maintenance, and protection of children and provides comprehensive social services to ensure the safety, permanency, and well-being of children and families.
" Cold-call marketing" means any unsolicited personal contact with a potential enrollee by an employee or agent of the contractor, directly or indirectly, for the purpose of influencing the individual to enroll with the contractor. Marketing by an employee is considered direct and marketing by an agent is considered indirect.
"Commissioner" means the Commissioner of the New Jersey Department of Human Services or a duly authorized representative.
"Complaint" means a protest by an enrollee, or by a provider on the enrollee's behalf, regarding the conduct of the contractor or any agent of the contractor, or regarding an act or failure to act by the contractor or any agent of the contractor, or regarding any other matter in which an enrollee feels aggrieved by the contractor, that is communicated to the contractor and resolved to the enrollee's satisfaction within five business days. In accordance with the managed care contract, a complaint not resolved within five business days shall be treated as a grievance.
"Comprehensive risk contract" means a risk contract that covers comprehensive services, that is, inpatient hospital services and any of the following services, or any three or more of the following:
1. Outpatient hospital services;
2. Rural health clinic services;
3. Federally qualified health center (FQHC) services;
4. Other laboratory and radiology services;
5. Nursing facility (NF) services;
6. Early and periodic screening, diagnostic and treatment (EPSDT) services;
7. Family planning services;
8. Physician services; or
9. Home health services.
"Comprehensive Waiver" means the New Jersey 1115 Comprehensive Waiver Demonstration that consolidated several previously existing Medicaid waivers for the purpose of:
1. Integrating primary care, acute care, behavioral health care, and long-term services and supports;
2. Providing a wide array of services to individuals with intellectual or developmental disabilities who are living at home with their families;
3. Increasing community-based services for children who are dually diagnosed with developmental disabilities and mental illness by providing case management and behavioral and individual supports; and
4. Expanding managed care to individuals in need of long-term services and supports, diverting more individuals from institutional placement through increased access to home and community-based services (HCBS).
"Contractor" means a managed care organization as defined in this section which contracts with the Department for the provision of comprehensive health services to enrollees on a prepayment basis, or for the provision of administrative services for a specified benefits package to specified enrollees on a non-risk, reimbursement basis.
"Contractor's plan" means all services and responsibilities undertaken by the contractor pursuant to this chapter concerning managed health care services for Medicaid/NJ FamilyCare beneficiaries.
"County welfare agency (CWA)," formerly known as "county board of social services (CBOSS)," means that agency of county government that is responsible for determining eligibility for certain Medicaid/NJ FamilyCare programs. CWA is the general term for the county agency; 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.
"CP&P clients" are children who are financially eligible for Medicaid/NJ FamilyCare and are placed in resource homes or other State-supported placements under the supervision of CP&P and children whom CP&P has placed in private adoption agencies until they are legally adopted or are in subsidized adoptions.
"Cultural competence" means acceptance of, and respect for, cultural differences, sensitivity to how these differences influence relationships with patients/clients and the ability to devise strategies to better meet culturally diverse patients' needs and address racial health disparities.
"Department" means the New Jersey Department of Human Services.
"Department of Banking and Insurance" means the New Jersey Department of Banking and Insurance.
"Department of Children and Families" means the New Jersey Department of Children and Families.
"Department of Health" (DOH) means the New Jersey Department of Health.
"Director" means the Director of the Division of Medical Assistance and Health Services or a duly authorized representative.
"Disenrollment" means the process of removal of an enrollee from the contractor's plan, not from the Medicaid/NJ FamilyCare programs.
"Division" means the Division of Medical Assistance and Health Services (DMAHS) of the Department of Human Services.
"Division of Developmental Disabilities (DDD)" means the 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.
"Dually eligible individual" means an individual who is eligible for both Medicare and Medicaid/ NJ FamilyCare.
"Effective date of enrollment" means the date on which a person can begin to receive services under the contractor's plan.
"Emergency medical condition" means 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 health and medicine, 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. 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.
"Emergency services" means those services that are furnished by a provider who is qualified to furnish such services and are needed to evaluate or stabilize an emergency medical condition.
"Enrollee" or "enrolled beneficiary" means an individual 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 specific contractor's plan, whether through the mandatory managed care coverage or on an individual, voluntary basis, and who meets specific Medicaid/NJ FamilyCare eligibility requirements for Plan enrollment agreed to by the Department and the contractor, at N.J.A.C. 10:74-6.
"Enrollment," for the mandatory managed health care program, means the process whereby specified Medicaid/NJ FamilyCare-Plan A beneficiaries are required to join an MCO to receive health services, unless otherwise exempted or excluded. All other NJ FamilyCare beneficiaries, except for certain newborns, are not exempt from mandatory enrollment.
"Enrollment" for the voluntary program means the process by which certain Medicaid/NJ FamilyCare-Plan A eligible individuals voluntarily enroll in an MCO for the provision of health services and by which such application is approved.
"Enrollment area" means the geographic area bound by county lines from which Medicaid/NJ FamilyCare eligible residents may enroll with an MCO, unless otherwise specified in the MCO contract with the Department.
"Enrollment lock-in period" means the period between the first day of the fourth month and the end of 12 months after the effective date of enrollment in the contractor's plan, during which time the enrollee shall have good cause in order to disenroll or transfer from the contractor's plan. The enrollment lock-in period is not construed as a guarantee of eligibility during the lock-in period. Lock-in provisions do not apply to clients of DDD or SSI, New Jersey Care Special Medicaid Program--Aged, Blind, Disabled, and CP&P enrollees.
"EPSDT" means the Early and Periodic Screening, Diagnosis and Treatment program mandated by Title XIX of the Social Security Act.
"Excluded services" means services covered under the fee-for-service Medicaid/NJ FamilyCare programs that are not included in the managed care benefit package.
"Federal Poverty Level (FPL)" means the income level designated by the United States Department of Health and Human Services in accordance with 42 U.S.C. §§ 9902(2).
"Federally qualified HMO" means an HMO that has been determined by CMS to be a qualified HMO in accordance with 42 U.S.C. § 300e- 9(c).
"Fee-for-service (FFS)" means the method used by the Division for reimbursement based on its payment for specific services covered by the Division, but not covered by the MCO, which are rendered to an enrollee.
"Good cause" means reasons for disenrollment or transfer that include, but are not limited to: failure of an MCO to provide services, including providing physical access to the enrollee in accordance with the MCO contract terms; failure of an MCO to respond to an enrollee's grievance within a required time period; or failure of an MCO to respond to an enrollee's grievance.
"Grievance" means a complaint or expression of dissatisfaction about any matter that is orally communicated or submitted in writing and that is not resolved within five business days of receipt.
"Grievance system" means the system that includes grievances and appeals at the contractor level and provides access to the Medicaid fair hearing process. (See 10:49-10.3)
"Health benefits coordinator (HBC)" means an entity under contract with the Department whose primary responsibility is to assist Medicaid/NJ FamilyCare-eligible enrollees in the selection of and enrollment in a managed care plan.
"Health care professional" means a physician, or other health care professional, if coverage for the professional's services is provided under the contractor's contract for the services. The term includes podiatrists, optometrists, chiropractors, psychologists, dentists, physician assistants, physical or occupational therapists and therapist assistants, speech-language pathologists, audiologists, registered or licensed practical nurses (including advanced practice nurses, certified registered nurse anesthetists, and certified nurse midwives), licensed certified social workers, registered respiratory therapists, and certified respiratory therapy technicians.
"Health education services" means instruction to beneficiaries about preventative health care and obtaining the health care they need within an MCO, to medical providers about providing appropriate care within the MCO structure, and to community organizations for assisting their beneficiaries to achieve better health outcomes.
"Health maintenance organization (HMO)" means a public or private organization, organized under State law, which:
1. Is a Federally qualified HMO (defined above); or
2. Meets the Division's definition of an HMO, which includes, at a minimum, the following requirements:
i. Is organized primarily for the purpose of providing access to health services;
ii. Makes the services it provides to its Medicaid/NJ FamilyCare enrollees as accessible to them (in terms of timeliness, amount, duration, and scope) as those services are to non-enrolled Medicaid/NJ FamilyCare eligible individuals within the area served by the HMO;
iii. Makes provision against the risk of insolvency, and assures that Medicaid/NJ FamilyCare enrollees will not be liable for the HMO's debts if it does become insolvent; and
iv. Has a Certificate of Authority as defined in this section, granted by the State of New Jersey to operate in all or selected counties of New Jersey.
"HHS" or "DHHS" means the United States Department of Health and Human Services.
"IPN" means Independent Practitioner Network, which is a type of network used in an MCO operation. Services are provided for enrollees in the individual offices of the contracting primary care providers (PCPs).
"Lower mode transportation" means curb-to-curb car or van transportation provided to Medicaid/NJ FamilyCare beneficiaries who are ambulatory and who do not require assistance or supervision to travel to and from their medical appointments.
"Managed care entity (MCE)" means a managed care organization described in Section 1903(m)(1)(A) of the Social Security Act ( 42 U.S.C. § 1396b(m)) , 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 ( 42 U.S.C. § 1396a(w)) , which has a comprehensive risk contract and meets the other requirements of section 1902(w).
"Managed care organization (MCO)" means an entity that has, or is seeking to qualify for, a comprehensive risk contract, and that is:
1. A Federally-qualified HMO that meets the advance directives requirements of 42 CFR Part 489, Subpart I incorporated herein by reference, as amended and supplemented; or
2. A public or private entity that meets the advance directives requirements of 42 CFR Part 489, Subpart I, incorporated herein by reference, as amended and supplemented, and is determined to meet the following conditions:
i. Makes the services it provides to its Medicaid/NJ FamilyCare enrollees equally accessible (in terms of timeliness, amount, duration, and scope) as those services that are provided to other Medicaid/NJ FamilyCare beneficiaries within the area served by the entity; and
ii. Meets the solvency standards of 42 CFR 438.116 incorporated herein by reference, as amended and supplemented.
"Managed care service administrator (MCSA)" 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.
"Managed long-term services and supports (MLTSS)" means services that are provided under the New Jersey 1115 Comprehensive Waiver through Medicaid/NJ FamilyCare MCO plans, the purpose of which is to support clients who meet nursing home level of care in the most appropriate setting to meet their specific needs, allowing them to remain at home in the community instead of living in a nursing facility.
1. Individuals qualify for MLTSS by meeting established Medicaid financial requirements and Medicaid clinical and age and/or disability requirements for nursing facility services contained at N.J.A.C. 10:69, 70, 71, or 72.
2. For children who meet the nursing home level of care, and who are applying for MLTSS, there is no deeming of parental income or resources in the determination of eligibility.
3. Once qualified to receive MLTSS, the individual must be enrolled with a managed care organization (MCO) in order to receive MLTSS services.
"Mandatory enrollment" means the process whereby an individual eligible for Medicaid/NJ FamilyCare is required to enroll in an MCO, unless otherwise exempt or excluded, to receive the services described in the standard benefits package as approved by the Department of Human Services pursuant to any necessary Federal waivers.
"Marketing" means any activity by, or means of communication from, the MCO, its employees, affiliated providers, subcontractors, or agents, or on behalf of the MCO by any person, firm, or corporation, by which information about the MCO's plan is made known to Medicaid/NJ FamilyCare eligible persons that can reasonably be interpreted as intended to influence the individual to enroll in the MCO's plan or either to not enroll in, or to disenroll from, another MCO's plan.
"Medicaid" refers to the program funded under Title XIX of the Social Security Act, administered by the Department, to provide covered health care services to eligible beneficiaries.
"Medicaid/NJ FamilyCare beneficiary" means an individual eligible to receive services under the New Jersey Medicaid fee-for-service program or any NJ FamilyCare plan in accordance with N. J.A.C. 10:69, 10:70, 10:71, 10:72, 10:78, or 10:79.
"Medically necessary services" means 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 to 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 treatment, the type of provider and the setting, are reflective of the level of services that can be safely provided, are 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 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 deemed not medically necessary. Medically necessary services provided are based on peer-reviewed publications, expert pediatric, psychiatric, and medical opinion, and medical/pediatric community acceptance. In the case of pediatric enrollees, this definition applies, 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/NJ FamilyCare 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.
"Medical screening" means an examination which is:
1. Provided on hospital property, and provided for that patient for whom it is requested or required;
2. Performed within the capabilities of the hospital's emergency room (including ancillary services routinely available to its emergency room);
3. Performed purposely 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 rules and by hospital bylaws.
"Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)" means the Federal law ( Pub. L. 110-343), which provides participants who already have benefits under mental health and substance use disorder (MH/SUD) coverage parity with benefits limitations under their medical/surgical coverage. Medicaid/NJ FamilyCare managed care organizations are subject to the MHPAEA statute.
"Multilingual" means, at a minimum, English and Spanish plus any other language that is spoken by 200 enrollees or five percent or more of the enrolled Medicaid/NJ FamilyCare population in the contractor's plan, whichever is greater.
"NJ FamilyCare Alternative Benefit Plan (ABP)" means the eligibility package that provides comprehensive, managed care coverage to parents of dependent children, and single or married adults without dependent children. The beneficiary must be between the ages 19 to 64 and have an income between the AFDC standard set forth at N.J.A.C. 10:69-10 and 138 percent of the Federal poverty level.
"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 FPL, to children under the age of one year and pregnant women eligible under the New Jersey Care . . . Special Medicaid Programs, to uninsured pregnant women with incomes up to 200 percent of the FPL and to beneficiaries who are in AFDC work-related extensions of eligibility. In addition to covered managed care services, Plan A enrollees may access certain other services which are paid fee-for-service by the State and not covered by MCOs, as specified in this chapter.
"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 FPL. In addition to covered managed care services, Plan B enrollees may access certain other services which are paid fee-for-service and not covered by MCOs, as specified in this chapter.
"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 FPL. In addition to covered managed care services, Plan C enrollees may access certain other services which are paid fee-for-service and not covered by MCOs, as specified in this chapter. Plan C enrollees, except American Indians and Alaska Natives (AI/AN), are required to participate in cost-sharing in the form of monthly premiums and personal contributions to care for certain services, as specified in this chapter.
"NJ FamilyCare-Plan D" means the State-operated program that provides managed care coverage to uninsured children below the age of 19 with family incomes above 200 percent and up to and including 350 percent of the FPL. In addition to covered managed care services, Plan D enrollees may access certain services that are paid fee-for-service and not covered by MCOs, as specified in this chapter. Plan D enrollees with incomes above 150 percent of the FPL, except American Indians and Alaska Natives (Al/AN) below the age of 19, participate in cost-sharing in the form of monthly premiums and copayments for services, as specified in this chapter.
"NJ FamilyCare beneficiary" means an individual eligible to receive services under the New Jersey FamilyCare program or NJ FamilyCare - Children's Program in accordance with N.J.A.C. 10:78 or 79.
"Network" means "provider network" as defined in this section.
" Non-covered Medicaid/NJ FamilyCare services" means all services not covered under the New Jersey State Plan for the Medicaid/NJ FamilyCare program.
"Non-participating provider" means a provider of service that does not have a contract or other arrangement in accordance with N.J.A.C. 11:24 with the contractor.
" Out-of-area services" means all services covered under the contractor's benefits package included under the terms of the Medicaid/NJ FamilyCare contract that are provided to enrollees outside the defined service area.
" Out-of-plan services" means Medicaid/NJ FamilyCare covered services that have not been included in the contractor's benefits package. These services are provided under a fee-for-service arrangement through the Division to Medicaid beneficiaries and certain NJ FamilyCare beneficiaries who have enrolled in an MCO.
"Participating provider" means a provider that has entered into a provider contract or other arrangement in accordance with N.J.A.C. 11:24 with the contractor to provider services.
"Personal contribution to care (PCC)" means the fixed monetary amount paid by Plan C enrollees for certain services/items received from MCO providers.
"Physician" means a doctor of medicine (M.D.) or osteopathy (D.O.) licensed to practice medicine and surgery by the New Jersey State Board of Medical Examiners, or similarly licensed by comparable agencies of the state in which he or she practices.
"Post stabilization care services" means covered services related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain the stabilized condition or to improve or resolve the enrollee's condition.
"Prevalent language" means a language other than English that is spoken by a significant number or percentage of potential enrollees and enrollees in the State.
"Primary care" means all health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, pediatrician, or by an advanced practice nurse, to the extent that the furnishing of those services by a nurse practitioner is legally authorized in the state in which the advanced practice nurse furnishes them.
"Primary care dentist (PCD)" means 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)" means 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, initiation of referrals to specialty providers described in this chapter and for maintaining the continuity of patient care. This definition includes general/family practitioners, pediatricians, internists and may include specialist physicians, physician assistants, CNMs or advanced practice nurses (APNs), provided that the practitioner is able and willing to carry out all PCP responsibilities in accordance with this chapter and with applicable licensure requirements.
"Provider" means any physician, hospital, facility or other health care professional who is licensed or otherwise authorized to provide healthcare services in the state or jurisdiction in which they are furnished.
"Provider network," within the context of managed care, means the servicing providers with whom an MCO has entered into a written agreement to perform a specified part of the MCO's obligations. These obligations are for the provision of professional medical and behavioral services or goods and ensuring coverage of all required services included in the benefits package. The provider network will include primary care and specialty physicians, dentists, other health care professionals and entities, hospitals, laboratories and medical suppliers.
"Referral services" means those health care services rendered by a health professional other than the primary care provider, and who are approved by the primary care provider, or by the contractor.
"Risk contract" means a contract under which the MCO assumes risk for the cost of the services covered under the contract, and under which the MCO may incur a loss if the cost of providing services exceeds the payments made by the Department to the MCO for services covered under the contract.
"Routine care" means 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, for example, a physician's office, or by the patient himself.
"Secretary" means the Secretary of the United States Department of Health and Human Services (DHHS).
"Service area" means the geographic area in which the contractor is obligated to provide covered services for its Medicaid/NJ FamilyCare enrollees under its contract.
"Supplemental Security Income (SSI)" means the 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" means a type of MCO operation in which MCO 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 MCO. In addition, the MCO may contract with external entities to supplement its own staff resources.
"Standard service package" means the list of services, and any limitations thereto, which are required to be provided by managed health care providers to Medicaid/NJ FamilyCare beneficiaries. These packages differ by program.
"Subcontract" means any written agreement between the contractor and a third party to perform a specified part of the contractor's obligations under the contract.
"Subcontractor" means any third party who has a written agreement with the contractor to perform a specified part of the contractor's obligations to the State, and is subject to the same terms, rights, and duties as the contractor. A subcontractor shall not subcontract any obligations contained in its written agreement with the contractor.
"Substantial contractual relationship" means any contractual relationship that provides for one or more of the following services:
1. The administration, management, or provision of medical services; or
2. The establishment of policies, or the provision of operational support, for the administration, management, or provision of medical services.
"Target population" means the population from which the initial number of enrollees, not to exceed any limit specified in the contract, will be drawn; that is, individuals eligible for Medicaid/NJ FamilyCare residing within the stated enrollment area and belonging to one of the categories of eligibility for Medicaid/NJ FamilyCare to be covered under the contract.
"Termination" means the loss of Medicaid/NJ FamilyCare eligibility and, therefore, automatic disenrollment of the beneficiary from the MCO.
" Third-party liability (TPL)" means another party or entity, such as an insurance company, which is, or may be, responsible to pay for all or a part of the health care costs of a Medicaid/ NJ FamilyCare-Plan A beneficiary.
"Urgent care" means treatment of a condition that is potentially harmful to a patient's health and for which his or her physician/CNP/CNS has determined it is medically necessary for the patient to receive medical treatment within 24 hours to prevent deterioration.
