New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES
Subchapter 12 - REIMBURSEMENT
Section 10:74-12.1 - Contractor compensation

(a) Compensation to the contractor for MCO enrollees shall consist of monthly capitation payments for each enrollee. These payments shall be for a defined scope of services to be furnished to a defined number of enrollees, for providing the services contained in the Benefits Package as described in N.J.A.C. 10:74-3. Such payments shall be actuarially sound and in accordance with 42 CFR 438.6, incorporated herein by reference, as amended and supplemented. In addition, supplemental fee-for-service payments may be made to the contractor for certain services, which shall be specified by contract in a manner determined by the Division of Medical Assistance and Health Services. In addition, certain high-cost, low-utilized drugs and blood products costs as specified by contract will be reimbursed to the MCO at the lesser of their cost or the current Medicaid/NJ FamilyCare fee-for-service payment amount.

(b) The monthly capitation payments plus supplemental payments and certain reimbursed costs provided under the contract shall constitute full and complete payment to the contractor and full discharge of any and all responsibility by the Department for the costs of all services that the contractor provides pursuant to its contract.

(c) Payment shall not be made on behalf of an enrollee to providers of health care services other than to the contractor for the covered benefits as described in this chapter and rendered during the term of the contract.