New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES
Subchapter 2 - CRITERIA FOR CONTRACTING WITH THE DEPARTMENT
Section 10:74-2.1 - Contract requirements
Universal Citation: NJ Admin Code 10:74-2.1
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The contractor shall:
1. Comply with the requirements of the
New Jersey Certificate of Authority statutes and rules ( P.L. 1973, c. 337,
26:2J-1 et seq., and N.J.A.C.
11:24);
2. Provide to the Division
of Medical Assistance and Health Services, Department of Human Services, a copy
of the approved Certificate of Authority and application document on
request;
3. Furnish the Department
with data, information and reports and maintain records as required by the
Department and other State or Federal agencies. Such reports shall include, but
are not limited to, enrollment data, encounter data, provider network data,
quality control and quality assurance, utilization review, financial statements
and service utilization;
4. Enroll
individuals and provide services without reference to race, sex, age, religion,
creed, color, national origin, ancestry, disability, or on the basis of health
status or need for health services, other than those services specifically
excluded from coverage as defined in the standard service package;
5. Assure that the provider network used for
private, commercial business be equally available to Medicaid/NJ FamilyCare
enrollees. Such provider network shall consist of hospitals, physicians,
dentists, laboratories, and all other providers of services covered under the
contract, and shall ensure that the providers meet, at a minimum, all standards
of practice and credentialing as required by Title XIX Medicaid and Title XXI
of the Social Security Act, and shall maintain a comprehensive network of
providers sufficient to meet the needs of the general population within the
counties in which the MCO has a certificate of authority to operate;
6. Instruct medical and dental providers
regarding MCO health services in respect to:
i. Appropriate medical and dental procedures
and treatment;
ii. Delivery of
culturally competent care;
iii.
Advances in medical science;
iv.
Responsibility to notify beneficiaries when they are due to receive certain
periodic services, for example, antenatal visits for pregnant women, and EPSDT
examinations for children;
v.
Advances in electronic health records; and
vi. Responsibility for assisting the MCO in
coordinating the care of enrollees;
7. Have a contract which has been approved by
CMS and the New Jersey Departments of Health and Senior Services and Banking
and Insurance;
8. Have the
organizational and administrative capabilities to carry out its duties and
responsibilities, which shall include, at a minimum, the following:
i. A full-time administrator to manage
day-to-day business activities of the contractor and to be the responsible
contract officer. (This does not require a full-time administrator to be
dedicated solely to the Medicaid/NJ FamilyCare contract.);
ii. Data reporting capabilities sufficient to
provide necessary reports and data as specified in the contract between the MCO
and Department, and to assure orderly and timely flow of information to the
Department. Such reports shall include, but are not limited to, enrollment
data, encounter data, provider network data, quality control, quality
assurance, utilization review and financial statements and service
utilization;
iii. Financial records
and books of accounts maintained in accordance with generally accepted
accounting principles which are sufficient to disclose fully the disposition of
all program funds received; and
iv.
An annual independent audit arranged for by the contractor and performed by a
certified public accountant;
9. Advise the Department of its
administrative organization and changes thereto, which shall include the
functions and responsibilities of each principal, an organizational chart and a
list of all personnel and providers used either directly by the contractor or
through subcontractual arrangements. For each principal and each provider not
previously reported, the following information shall be included:
i. Full name;
ii. Business address;
iii. Social Security number;
iv. IRS employer number;
v. Professional license number (when
applicable);
vi. Medical specialty
(when applicable);
vii.
Professional degree, if applicable; and
viii. Board eligibility/certification, if
applicable.
10. Comply
with eligibility requirements of the program, which shall include, but shall
not be limited to, enrolling only individuals who are covered under specified
Medicaid/NJ FamilyCare categories of assistance;
11. Identify and provide financial disclosure
of subcontractors with whom it has had business transactions in excess of $
25,000 per year, and any significant business transactions with such
subcontractors. Transactions that shall be reported include:
i. Any sale, exchange or leasing of
property;
ii. Any furnishing for
consideration of goods, services, or facilities (but not employee salaries);
and
iii. Any loans or extensions of
credit;
12. When
specifically requested, make available, in the form of a consolidated financial
statement, any information reported to the State, to the following:
i. The Secretary of the U.S. Department of
Health and Human Services;
ii. The
Office of the Inspector General;
iii. The Comptroller General;
iv. The Office of the State Comptroller,
Medicaid Fraud Division; and
v. The
enrollees of the MCO;
13. Shall comply and disclose to the Division
in accordance with 42 CFR 455.100-106 the required information concerning
ownership and control interest, related business transactions and persons
convicted of a crime, including the identity of each person with a controlling
interest and of any person(s) having ownership of five percent or
more;
14. Not employ or contract
with:
i. Any individual or entity excluded
from Medicaid or other Federal health care program participation under Sections
1128 (
42
U.S.C. §
1320a-7) or 1128A of the
Social Security Act (
42 U.S.C. §
1320a-7a) or under N.J.A.C. 10:49-11 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 (
42
U.S.C. §
1320a- 7(b)(8)) as being
controlled by a sanctioned individual;
ii. Any entity for the provision of such
services (directly or indirectly) through an excluded individual or
entity;
iii. Any individual or
entity discharged or suspended from doing business with the State of New
Jersey; or
iv. Any entity that has
a substantial contractual relationship (direct or indirect) with an individual
convicted of certain crimes as described in Section 1128(b)(8) of the Social
Security Act (
42
U.S.C. §
1320a- 7(b)(8)); and
15. Establish and implement
policies and procedures for identifying, investigating, and taking corrective
action against fraud and abuse on the provision of health services.
(b) The contractor shall also comply with 42 CFR Part 438, as amended and supplemented.
(c) The contractor shall also comply with Titles XIX and XXI of the Social Security Act.
(d) The contractor shall also comply with the Federal Patient Protection and Affordable Care Act ( Pub. L. 111-148), as amended by the Federal Health Care and Education Reconciliation Act of 2010 ( Pub. L. 111-152), collectively known as the Affordable Care Act, incorporated herein by reference, as amended and supplemented.
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