New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 78 - NJ FAMILYCARE
Subchapter 7 - SERVICES UNDER NJ FAMILYCARE
Section 10:78-7.1 - Scope of services

Universal Citation: NJ Admin Code 10:78-7.1

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

(a) The NJ FamilyCare "Plan A" service package shall contain those services described at 10:49-5.2.

(b) The NJ FamilyCare "Plan D" benefit package shall contain those services described at 10:49-5.7. Those FamilyCare Plan D beneficiaries whose income is above 150 percent of the Federal poverty level shall be responsible for copayments for services received, in accordance with the provisions of this chapter.

1. No cost sharing shall be imposed on children who are American Indians or Alaska Natives as defined at 42 CFR 457.10. Proof of Federally recognized AI/AN tribal status shall be provided in the form of a tribal card or letter.

(c) Individuals who would be eligible for AFDC-related Medicaid or NJ FamilyCare and who are subject to the Federal immigration residency restriction shall receive services and shall be subject to any applicable premium contribution based on income eligibility, under the provisions of N.J.A.C. 10:69 or 10:79.

(d) Except as noted in N.J.A.C. 10:49-5.7, 5.8 and 5.10, NJ FamilyCare beneficiaries shall receive services through managed care organizations operating under a contract with the Department of Human Services. Single adults and couples without dependent children whose gross income is not more than 100 percent of the Federal poverty level will be enrolled in a managed care service administrator program. Effective July 1, 2002, adults without dependent children who are not eligible for WFNJ/GA and whose income is below 100 percent of the Federal poverty level shall receive the NJ FamilyCare Plan H service package described at 10:49-5.8.

(e) Copayments required of NJ FamilyCare beneficiaries shall be as described at 10:49-9.1. Premium payments required of NJ FamilyCare beneficiaries shall be as described at 10:49-9.2. Enrollment for these beneficiaries shall commence after their first premium payment has been received by the Statewide eligibility determination agency. No other NJ FamilyCare beneficiary will be responsible for a premium payment or a copayment.

1. No cost sharing shall be imposed on children who are American Indians or Alaska Natives as defined at 42 CFR 457.10. Proof of Federally recognized AI/AN tribal status shall be provided in the form of a tribal card or letter.

(f) Drugs used exclusively to treat AIDS and HIV shall not be included in the FamilyCare services packages, but shall be made available to FamilyCare beneficiaries through the ADDP program in accordance with N.J.A.C. 8:61-3.

(g) Effective July 1, 2002, for WFNJ/GA-eligible individuals, no managed care services will be provided. WFNJ/GA-eligible individuals will receive medical services in accordance with 10:49-24.3. Effective July 1, 2003, all substance abuse services for WFNJ/GA-eligible individuals will be administered through the Substance Abuse Initiative (SAI).

1. Effective June 15, 2002, hospital services for WFNJ/GA-eligible individuals shall be submitted for reimbursement through charity care.

(h) Childless adults with incomes below 100 percent of the Federal poverty level who are not eligible for WFNJ/GA and who are enrolled in NJ FamilyCare on June 30, 2002 shall receive the Plan H service package described at N.J.A.C. 10:49-5.8.

1. Effective June 15, 2002, hospital-based behavioral health services for childless adults with incomes below 100 percent of the Federal poverty level who are not eligible for WFNJ/GA shall be submitted for reimbursement through charity care.

(i) Contingent upon continuing approval by the Centers for Medicare & Medicaid Services of New Jersey's Health Insurance Flexibility and Accountability Act (HIFA) waiver, certain parents/caretakers of children enrolled in NJ FamilyCare who have earned incomes below 134 percent of the Federal poverty level shall receive the Plan D benefit package described at 10:49-5.7. Those parents/caretakers who are awaiting enrollment in a managed care organization or who meet the standards for exemption from the requirement for enrollment in managed care will receive the Plan D benefit package on a fee-for-service basis, which shall be called Plan I. Services available under Plan I are described at 10:49-5.10.

1. Parents who are eligible for NJ FamilyCare Plan A in accordance with N.J.A.C. 10:69, AFDC-Related Medicaid, shall continue to receive the Plan A benefit package.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.