Common use of Special Medicaid Programs Clause in Contracts

Special Medicaid Programs. to uninsured children below the age of 19 with family incomes above 133 percent and up to and including 150 per cent of the federal poverty level. In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service and not covered under this contract. 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 federal poverty level. Eligibles are required to participate in cost-sharing in the form of monthly premiums and a personal contribution to care for most services. In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service and not covered under this contract. NJ FAMILYCARE PLAN D--means the State-operated program which provides managed care coverage to uninsured: o Adults and couples without dependent children under the age of 19 with family incomes above 50% and up to and including 100 percent of the federal poverty level; o Adults and couples without dependent children under the age of 23 years with family incomes up to and including 250% of the federal poverty level; o Parents/caretakers with children below the age of 19 who do not qualify for AFDC Medicaid with family incomes up to and including 200 percent of the federal poverty level; o Parents/caretakers with children below the age of 23 years and children from the age of 19 through 22 years who a re full time students who do not qualify for AFDC Medicaid with family incomes up to and including 250% of the federal poverty level; and o Children below the age of 19 with family incomes between 201 percent and up to and including 350 percent of the federal poverty level. Eligibles with incomes above 150 percent of the federal poverty level are required to participate in cost sharing in the form of monthly premiums and copayments for most services. These groups are identified by Program Status Codes (PSCs) on the eligibility system as indicated below. For clarity, the codes related to Plan D non-cost sharing groups are also listed. Cost Sharing No Cost Sharing ------------ --------------- 493 497 494 763 495 300 498 700 301 701 In addition to covered managed care services, eligibles under these programs may access certain services which are paid fee-for-service and not covered under this contract.

Special Medicaid Programs. to uninsured children below the age of 19 with family incomes above 133 percent and up to and including 150 per cent of the federal poverty level. In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service and not covered under this contract. 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 federal poverty level. Eligibles are required to participate in cost-sharing in the form of monthly premiums and a personal contribution to care for most services. In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service and not covered under this contract. NJ FAMILYCARE PLAN D--means the State-operated program which provides managed care coverage to uninsured: o - Adults and couples without dependent children under the age of 19 with family incomes above 50% and up to and including 100 percent of the federal poverty level; o - Adults and couples without dependent children under the age of 23 years with family incomes up to and including 250% of the federal poverty level; o - Parents/caretakers with children below the age of 19 who do not qualify for AFDC Medicaid with family incomes up to and including 200 percent of the federal poverty level; o - Parents/caretakers with children below the age of 23 years and children from the age of 19 through 22 years who a re are full time students who do not qualify for AFDC Medicaid with family incomes up to and including 250% of the federal poverty level; and o - Children below the age of 19 with family incomes between 201 percent and up to and including 350 percent of the federal poverty level. Eligibles with incomes above 150 percent of the federal poverty level are required to participate in cost sharing in the form of monthly premiums and copayments for most services. These groups are identified by Program Status Codes (PSCs) on the eligibility system as indicated below. For clarity, the codes related to Plan D non-cost sharing groups are also listed. Cost Sharing No Cost Sharing ------------ --------------- 493 497 494 763 495 300 498 700 301 701 In addition to covered managed care services, eligibles under these programs may access certain services which are paid fee-for-service and not covered under this contract.

Special Medicaid Programs. to uninsured children below the age of 19 with family incomes above 133 percent and up to and including 150 per cent of the federal poverty level. In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service and not covered under this contract. 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 federal poverty level. Eligibles are required to participate in cost-sharing in the form of monthly premiums and a personal contribution to care for most services. Exception - Both Eskimos and Native American Indians under the age of 19 years old, identified by Race Code 3, shall not participate in cost sharing, and shall not be required to pay a personal contribution to care. In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service and not covered under this contract. NJ FAMILYCARE PLAN D--means the State-operated program which provides managed care coverage to uninsured: o Adults and couples without dependent children under the age of 19 with family incomes above 50% and up to and including 100 percent of the federal poverty level; o Adults and couples without dependent children under the age of 23 years with family incomes up to and including 250% of the federal poverty level; o - Parents/caretakers with caretakers[Reserved] -with children below the age of 19 who do not qualify for AFDC Medicaid with family incomes up to and including 200 [Reserved] 133 percent of the federal poverty level; o Parents/caretakers with children below the age of 23 years and children from the age of 19 through 22 years who a re full time students who do not qualify for AFDC Medicaid with family incomes up to and including 250% of the federal poverty level; and o [Reserved] - Children below the age of 19 with family incomes between 201 percent and up to and including 350 percent of the federal poverty level. Eligibles with incomes above 150 percent of the federal poverty level are required to participate in cost sharing in the form of monthly premiums and copayments for most servicesservices with the exception of both Eskimos and Native American Indians under the age of 19 years. These groups are identified by Program Status Codes (PSCs) or Race Code on the eligibility system as indicated below. For clarity, the codes Program Status Codes or Race Code, in the case of Eskimos and Native American Indians under the age of 19 years, related to Plan D non-cost sharing groups are also listed. PSC PSC Race Code Cost Sharing No Cost Sharing No Cost Sharing ------------ --------------- --------------- [Reserved] [Reserved] 3 493 497 380 494 763 [Reserved] 495 300 498 700 301 701 [Reserved] In addition to covered managed care services, eligibles under these programs may access certain services which are paid fee-for-service and not covered under this contract. [Reserved] NJ FAMILYCARE PLAN I--means the State-operated program that provides certain benefits on a fee-for-service basis through the DMAHS for Plan D parents/caretakers with a program status code of 380. N.J.S.A.--New Jersey Statutes Annotated. NON-COVERED CONTRACTOR SERVICES--services that are not covered in the contractor's benefits package included under the terms of this contract.

Special Medicaid Programs. to uninsured children below the age of 19 with family incomes above 133 percent and up to and including 150 per cent of the federal poverty level. In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service and not covered under this contract. 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 federal poverty level. Eligibles are required to participate in cost-sharing in the form of monthly premiums and a personal contribution to care for most services. Exception - Both Eskimos and Native American Indians under the age of 19 years old, identified by Race Code 3, shall not participate in cost sharing, and shall not be required to pay a personal contribution to care. In addition to covered managed care services, eligibles under this program may access certain other services which are paid fee-for-service and not covered under this contract. NJ FAMILYCARE PLAN D--means the State-operated program which provides managed care coverage to uninsured: o Adults and couples without dependent children under the age of 19 with family incomes above 50% and up to and including 100 percent of the federal poverty level; o Adults and couples without dependent children under the age of 23 years with family incomes up to and including 250% of the federal poverty level; o - Parents/caretakers with -with children below the age of 19 who do not qualify for AFDC Medicaid with family incomes up to and including 200 133 percent of the federal poverty level; o Parents/caretakers with children below the age of 23 years and children from the age of 19 through 22 years who a re full time students who do not qualify for AFDC Medicaid with family incomes up to and including 250% of the federal poverty level; and o AND - Children below the age of 19 with family incomes between 201 percent and up to and including 350 percent of the federal poverty level. Eligibles with incomes above 150 percent of the federal poverty level are required to participate in cost sharing in the form of monthly premiums and copayments for most servicesservices with the exception of both Eskimos and Native American Indians under the age of 19 years. These groups are identified by Program Status Codes (PSCs) or Race Code on the eligibility system as indicated below. For clarity, the codes Program Status Codes or Race Code, in the case of Eskimos and Native American Indians under the age of 19 years, related to Plan D non-cost sharing groups are also listed. PSC PSC Race Code Cost Sharing No Cost Sharing No Cost Sharing ------------ --------------- --------------- 493 497 380 3 494 763 495 300 498 700 301 701 In addition to covered managed care services, eligibles under these programs may access certain services which are paid fee-for-service and not covered under this contract. XX FAMILYCARE PLAN I--means the State-operated program that provides certain benefits on a fee-for-service basis through the DMAHS for Plan D parents/caretakers with a program status code of 380. N. J.S.A.--New Jersey Statutes Annotated, NON-COVERED CONTRACTOR SERVICES--services that are not covered in the contractor's benefits package included under the terms of this contract. NON-COVERED MEDICAID SERVICES--all services that are not covered by the New Jersey Medicaid State Plan. NON-PARTICIPATING PROVIDER--a provider of service that does not have a contract with the contractor. OIT--the New Jersey Office of Information Technology. OTHER HEALTH COVERAGE--private non-Medicaid individual or group health/dental insurance. It may be referred to as Third Party Liability (TPL) or includes Medicare. OUT OF AREA SERVICES--all services covered under the contractor's benefits package included under the terms of the Medicaid contract which are provided to enrollees outside the defined basic service area. OUTPATIENT CARE--treatment provided to an enrollee who is not admitted to an inpatient hospital or health care facility.