New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES
Subchapter 3 - BENEFITS
Section 10:74-3.2 - Responsibilities of the contractor

Universal Citation: NJ Admin Code 10:74-3.2

Current through Register Vol. 56, No. 18, September 16, 2024

(a) The contractor shall make available emergency services, as defined in N.J.A.C. 10:74-1, on a 24-hour-a-day, seven-day-a-week basis.

(b) The contractor shall offer health education services as an integral part of its health care delivery system to its enrollees in order to assure appropriate use of health services and to promote the maintenance of health, including, but not limited to, instruction to beneficiaries regarding:

1. Their rights and responsibilities as members of managed care organizations; and

2. Appropriate measures to achieve/maintain wellness or prevent illness.

(c) The contractor shall provide EPSDT services for all Medicaid/NJ FamilyCare-Plan A enrollees under 21 years of age in accordance with the protocols approved by the Division as follows:

1. Initial and periodic treatments shall be provided. All further treatments indicated shall be provided in an appropriate and timely manner and shall be appropriately documented as specified by EPSDT requirements. The above shall be provided in accordance with EPSDT requirements as specified at 42 U.S.C. § 1396d(r) and 42 CFR 441.50 through 441.62. The above shall be provided for Medicaid/NJ FamilyCare-Plan A beneficiaries only. EPSDT treatment services shall be limited to services covered under the managed care contract for Medicaid/NJ FamilyCare Plans B, C, and D enrollees and services specified under the fee-for-service program.

2. The Division shall monitor the EPSDT services through periodic audits.

(d) The contractor shall comply with the managed care contract and provide or arrange to have provided all covered necessary health services in a manner that is prompt, appropriate and of a quality that conforms to generally acceptable professional standards as set forth in Section 1932 of the Federal Social Security Act, at 42 U.S.C. § 1396u-2, and all other applicable Federal and State laws, rules and regulations.

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