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EXHIBIT 10.6
CONTRACT
BETWEEN
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
AND
______________________________, CONTRACTOR
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STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
AND
------------------------
CONTRACT TO PROVIDE SERVICES
This risk comprehensive contract is entered into this_______day of_________, and
is effective on the _______ day of __________ between the Department of Human
Services, which is in the executive branch of state government, the state agency
designated to administer the Medicaid program under Title XIX of the Social
Security Act, 42 U.S.C. 1396 et seq. pursuant to the New Jersey Medical
Assistance Act, N.J.S.A. 30:4D-1 et seq. and the State Child Health Insurance
Program under Title XXI of the Social Security Act, 42 U.S.C. 1397aa et seq.,
pursuant to the Children's Health Care Coverage Act, PL 1997, c.272 (also known
as "NJ KidCare"), pursuant to Family Care Health Coverage Act, P.L. 2000, c.71
(also known as "NJ FamilyCare") whose principal office is located at CN 712, in
the City of Trenton, New Jersey hereinafter referred to as the "Department" and
__________________________________________, a federally qualified/ state defined
health maintenance organization (HMO) which is a New Jersey, profit/non-profit
corporation, certified to operate as an HMO by the State of New Jersey
Department of Banking and Insurance and the State of New Jersey Department of
Health and Senior Services, and whose principal corporate office is located
at_______________ __________________, in the City of________________, County
of______________, New Jersey, hereinafter referred to as the "contractor".
WHEREAS, the contractor is engaged in the business of providing prepaid,
capitated comprehensive health care services pursuant to N.J.S.A. 26:2J-1 et
seq.; and
WHEREAS, the Department, as the state agency designated to administer a program
of medical assistance for eligible persons under Title XIX of the Social
Security Act (42 U.S.C. Sec. 1396, et seq., also known as "Medicaid"), for
eligible persons under the Family Care Health Coverage Act (P.L. 2000, c.71) and
for children under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa,
et seq., also known as "State Child Health Insurance Program"), is authorized
pursuant to the federal regulations at 42 C.F.R. 434 to provide such a program
through an HMO and is desirous of obtaining the contractor's services for the
benefit of persons eligible for Medicaid/NJ FamilyCare; and
WHEREAS, the Division of Medical Assistance and Health Services (DMAHS), is the
Division within the Department designated to administer the medical assistance
program, and the Department's functions as regards all Medicaid/NJ FamilyCare
program benefits provided through the contractor for Medicaid/NJ FamilyCare
eligibles enrolled in the contractor's plan.
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NOW THEREFORE, in consideration of the contracts and mutual covenants herein
contained, the Parties hereto agree as follows:
PREAMBLE
Governing Statutory and Regulatory Provisions: This contract and all renewals
and modifications are subject to the following laws and all amendments thereof:
Title XIX and Title XXI of the Social Security Act, 42 U.S.C. 1396 et. seq., 42
U.S.C. 1397aa et seq., the New Jersey Medical Assistance Act and the Medicaid,
and NJ KidCare and NJ FamilyCare State Plans approved by HCFA (N.J.S.A. 30:4D-1
et seq.; 30:4I-1 et seq.; 30:4J-1 et seq.); federal and state Medicaid and State
Child Health Insurance, and NJ FamilyCare regulations, other applicable federal
and state statutes, and all applicable local laws and ordinances.
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TABLE OF CONTENTS
ARTICLE ONE: DEFINITIONS
ARTICLE TWO: CONDITIONS PRECEDENT
ARTICLE THREE: MANAGED CARE MANAGEMENT INFORMATION SYSTEM
3.1 GENERAL OPERATIONAL REQUIREMENTS FOR THE MCMIS..................................................... III-1
3.1.1 ONLINE ACCESS.......................................................................... III-1
3.1.2 PROCESSING REQUIREMENTS................................................................ III-1
3.1.3 REPORTING AND DOCUMENTATION REQUIREMENTS............................................... III-3
3.1.4 OTHER REQUIREMENTS..................................................................... III-3
3.2 ENROLLEE SERVICES.................................................................................. III-4
3.2.1 CONTRACTOR ENROLLMENT DATA............................................................. III-4
3.2.2 ENROLLEE PROCESSING REQUIREMENTS....................................................... III-5
3.2.3 CONTRACTOR ENROLLMENT VERIFICATION..................................................... III-6
3.2.4 ENROLLEE COMPLAINT AND GRIEVANCE TRACKING SYSTEM....................................... III-7
3.2.5 ENROLLEE REPORTING..................................................................... III-7
3.3 PROVIDER SERVICES.................................................................................. III-7
3.3.1 PROVIDER INFORMATION AND PROCESSING REQUIREMENTS....................................... III-7
3.3.2 PROVIDER CREDENTIALING................................................................. III-8
3.3.3 PROVIDER/ENROLLEE LINKAGE.............................................................. III-8
3.3.4 PROVIDER MONITORING.................................................................... III-9
3.3.5 REPORTING REQUIREMENTS................................................................. III-9
3.4 CLAIMS/ENCOUNTER PROCESSING........................................................................ III-9
3.4.1 GENERAL REQUIREMENTS................................................................... III-9
3.4.2 COORDINATION OF BENEFITS............................................................... III-11
3.4.3 REPORTING REQUIREMENTS................................................................. III-11
3.5 PRIOR AUTHORIZATION, REFERRAL AND UTILIZATION MANAGEMENT........................................... III-12
3.5.1 FUNCTIONS AND CAPABILITIES............................................................. III-12
3.5.2 REPORTING REQUIREMENTS................................................................. III-13
3.6 FINANCIAL PROCESSING............................................................................... III-13
3.6.1 FUNCTIONS AND CAPABILITIES............................................................. III-13
3.6.2 REPORTING PRODUCTS..................................................................... III-14
3.7 QUALITY ASSURANCE.................................................................................. III-14
3.7.1 FUNCTIONS AND CAPABILITIES............................................................. III-14
3.7.2 REPORTING PRODUCTS..................................................................... III-16
3.8 MANAGEMENT AND ADMINISTRATIVE REPORTING............................................................ III-16
3.8.1 GENERAL REQUIREMENTS................................................................... III-16
3.8.2 QUERY CAPABILITIES..................................................................... III-17
3.8.3 REPORTING CAPABILITIES................................................................. III-17
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3.9 ENCOUNTER DATA REPORTING........................................................................... III-18
3.9.1 REQUIRED ENCOUNTER DATA ELEMENTS....................................................... III-18
3.9.2 SUBMISSION OF TEST ENCOUNTER DATA...................................................... III-19
3.9.3 SUBMISSION OF PRODUCTION ENCOUNTER DATA................................................ III-19
3.9.4 REMITTANCE ADVICE...................................................................... III-20
3.9.5 SUBCONTRACTS AND ENCOUNTER DATA REPORTING FUNCTION..................................... III-21
3.9.6 FUTURE ELECTRONIC ENCOUNTER SUBMISSION REQUIREMENTS.................................... III-21
ARTICLE FOUR: PROVISION OF HEALTH CARE SERVICES
4.1 COVERED SERVICES................................................................................... IV-1
4.1.1 GENERAL PROVISIONS AND CONTRACTOR RESPONSIBILITIES..................................... IV-1
4.1.2 BENEFIT PACKAGE........................................................................ IV-3
4.1.3 SERVICES REMAINING IN FEE-FOR-SERVICE PROGRAM AND MAY NECESSITATE CONTRACTOR
ASSISTANCE TO THE ENROLLEE TO ACCESS THE SERVICES...................................... IV-6
4.1.4 MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR................................... IV-8
4.1.5 INSTITUTIONAL FEE-FOR-SERVICE BENEFITS -- NO COORDINATION BY THE CONTRACTOR............ IV-9
4.1.6 BENEFIT PACKAGE FOR NJ FAMILYCARE PLAN D............................................... IV-9
4.1.7 SUPPLEMENTAL BENEFITS.................................................................. IV-14
4.1.8 CONTRACTOR AND DMAHS SERVICE EXCLUSIONS................................................ IV-14
4.2 SPECIAL PROGRAM REQUIREMENTS....................................................................... IV-15
4.2.1 EMERGENCY SERVICES..................................................................... IV-15
4.2.2 FAMILY PLANNING SERVICES AND SUPPLIES.................................................. IV-20
4.2.3 OBSTETRICAL SERVICES REQUIREMENTS/ISSUES............................................... IV-20
4.2.4 PRESCRIBED DRUGS AND PHARMACY SERVICES................................................. IV-20
4.2.5 LABORATORY SERVICES.................................................................... IV-23
4.2.6 EPSDT SCREENING SERVICES............................................................... IV-24
4.2.7 IMMUNIZATIONS.......................................................................... IV-29
4.2.8 CLINICAL TRIALS........................................................................ IV-30
4.2.9 HEALTH PROMOTION AND EDUCATION PROGRAMS................................................ IV-32
4.3 COORDINATION WITH ESSENTIAL COMMUNITY PROVIDERS.................................................... IV-33
4.3.1 GENERAL................................................................................ IV-33
4.3.2 HEAD START PROGRAMS.................................................................... IV-33
4.3.3 SCHOOL-BASED YOUTH SERVICES PROGRAMS................................................... IV-34
4.3.4 LOCAL HEALTH DEPARTMENTS............................................................... IV-36
4.3.5 WIC PROGRAM REQUIREMENTS/ISSUES........................................................ IV-36
4.3.6 COMMUNITY LINKAGES..................................................................... IV-36
4.4 COORDINATION WITH MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES....................................... IV-37
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4.5 ENROLLEES WITH SPECIAL NEEDS....................................................................... IV-39
4.5.1 INTRODUCTION........................................................................... IV-39
4.5.2 GENERAL REQUIREMENTS................................................................... IV-40
4.5.3 PROVIDER NETWORK REQUIREMENTS.......................................................... IV-45
4.5.4 CARE MANAGEMENT AND COORDINATION OF CARE FOR PERSONS WITH SPECIAL NEEDS................ IV-47
4.5.5 CHILDREN WITH SPECIAL HEALTH CARE NEEDS................................................ IV-48
4.5.6 CLIENTS OF THE DIVISION OF DEVELOPMENTAL DISABILITIES.................................. IV-50
4.5.7 PERSONS WITH HIV/AIDS.................................................................. IV-51
4.6 QUALITY MANAGEMENT SYSTEM.......................................................................... IV-52
4.6.1 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PLAN.................................... IV-53
4.6.2 QAPI ACTIVITIES........................................................................ IV-55
4.6.3 REFERRAL SYSTEMS....................................................................... IV-66
4.6.4 UTILIZATION MANAGEMENT................................................................. IV-67
4.6.5 CARE MANAGEMENT........................................................................ IV-73
4.7 MONITORING AND EVALUATION.......................................................................... IV-77
4.7.1 GENERAL PROVISIONS..................................................................... IV-77
4.7.2 EVALUATION AND REPORTING - CONTRACTOR RESPONSIBILITIES................................. IV-79
4.7.3 MONITORING AND EVALUATION - DEPARTMENT ACTIVITIES...................................... IV-81
4.7.4 INDEPENDENT EXTERNAL REVIEW ORGANIZATION REVIEWS....................................... IV-82
4.8 PROVIDER NETWORK................................................................................... IV-83
4.8.1 GENERAL PROVISIONS..................................................................... IV-83
4.8.2 PRIMARY CARE PROVIDER REQUIREMENTS..................................................... IV-85
4.8.3 PROVIDER NETWORK FILE REQUIREMENTS..................................................... IV-87
4.8.4 PROVIDER DIRECTORY REQUIREMENTS........................................................ IV-88
4.8.5 CREDENTIALING/RECREDENTIALING REQUIREMENTS/ISSUES...................................... IV-88
4.8.6 LABORATORY SERVICE PROVIDERS........................................................... IV-89
4.8.7 SPECIALTY PROVIDERS AND CENTERS........................................................ IV-90
4.8.8 PROVIDER NETWORK REQUIREMENTS.......................................................... IV-91
4.8.9 DENTAL PROVIDER NETWORK REQUIREMENTS................................................... IV-103
4.8.10 GOOD FAITH NEGOTIATIONS................................................................ IV-103
4.8.11 PROVIDER NETWORK ANALYSIS.............................................................. IV-103
4.9 PROVIDER CONTRACTS AND SUBCONTRACTS................................................................ IV-103
4.9.1 GENERAL PROVISIONS..................................................................... IV-103
4.9.2 CONTRACT SUBMISSION.................................................................... IV-106
4.9.3 PROVIDER CONTRACT AND SUBCONTRACT TERMINATION.......................................... IV-107
4.9.4 PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL COMMUNICATIONS........................ IV-108
4.9.5 ANTIDISCRIMINATION..................................................................... IV-109
4.10 EXPERT WITNESS REQUIREMENTS AND COURT OBLIGATIONS.................................................. IV-110
4.11 ADDITIONS, DELETIONS, AND/OR CHANGES............................................................... IV-111
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ARTICLE FIVE: ENROLLEE SERVICES
5.1 GEOGRAPHIC REGIONS................................................................................. V-1
5.2 AID CATEGORIES ELIGIBLE FOR CONTRACTOR ENROLLMENT.................................................. V-2
5.3 EXCLUSIONS AND EXEMPTIONS.......................................................................... V-2
5.3.1 ENROLLMENT EXCLUSIONS.................................................................. V-3
5.3.2 ENROLLMENT EXEMPTIONS.................................................................. V-5
5.4 ENROLLMENT OF MANAGED CARE ELIGIBLES............................................................... V-6
5.5 ENROLLMENT AND COVERAGE REQUIREMENTS............................................................... V-6
5.6 VERIFICATION OF ENROLLMENT......................................................................... V-10
5.7 MEMBER SERVICES UNIT............................................................................... V-11
5.8 ENROLLEE EDUCATION AND INFORMATION................................................................. V-12
5.8.1 GENERAL REQUIREMENTS................................................................... V-12
5.8.2 ENROLLEE NOTIFICATION/HANDBOOK......................................................... V-12
5.8.3 ANNUAL INFORMATION TO ENROLLEES........................................................ V-18
5.8.4 NOTIFICATION OF CHANGES IN SERVICES.................................................... V-18
5.8.5 ID CARD................................................................................ V-18
5.8.6 ORIENTATION AND WELCOME LETTER......................................................... V-19
5.9 PCP SELECTION AND ASSIGNMENT....................................................................... V-20
5.9.1 INITIAL SELECTION/ASSIGNMENT........................................................... V-20
5.9.2 PCP CHANGES............................................................................ V-21
5.10 DISENROLLMENT FROM CONTRACTOR'S PLAN............................................................... V-22
5.10.1 GENERAL PROVISIONS..................................................................... V-22
5.10.2 DISENROLLMENT FROM THE CONTRACTOR'S PLAN AT THE ENROLLEE'S REQUEST..................... V-23
5.10.3 DISENROLLMENT FROM THE CONTRACTOR'S PLAN AT THE CONTRACTOR'S REQUEST................... V-25
5.10.4 TERMINATION............................................................................ V-26
5.11 TELEPHONE ACCESS................................................................................... V-27
5.12 APPOINTMENT AVAILABILITY........................................................................... V-29
5.13 APPOINTMENT MONITORING PROCEDURES.................................................................. V-31
5.14 CULTURAL AND LINGUISTIC NEEDS...................................................................... V-32
5.15 ENROLLEE COMPLAINTS AND GRIEVANCES................................................................. V-34
5.15.1 GENERAL REQUIREMENTS................................................................... V-34
5.15.2 NOTIFICATION TO ENROLLEES OF GRIEVANCE PROCEDURE....................................... V-35
5.15.3 GRIEVANCE PROCEDURES................................................................... V-37
5.15.4 PROCESSING GRIEVANCES.................................................................. V-37
5.15.5 RECORDS MAINTENANCE.................................................................... V-38
5.16 MARKETING.......................................................................................... V-39
5.16.1 GENERAL PROVISIONS - CONTRACTOR'S RESPONSIBILITIES..................................... V-39
5.16.2 STANDARDS FOR MARKETING REPRESENTATIVES................................................ V-44
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ARTICLE SIX: PROVIDER INFORMATION
6.1 GENERAL....................................................................................... VI-1
6.2 PROVIDER PUBLICATIONS......................................................................... VI-1
6.3 PROVIDER EDUCATION AND TRAINING............................................................... VI-3
6.4 PROVIDER TELEPHONE ACCESS..................................................................... VI-3
6.5 PROVIDER GRIEVANCES AND APPEALS............................................................... VI-4
ARTICLE SEVEN: TERMS AND CONDITIONS (ENTIRE CONTRACT)
7.1 CONTRACT COMPONENTS........................................................................... VII-1
7.2 GENERAL PROVISIONS............................................................................ VII-1
7.3 STAFFING...................................................................................... VII-4
7.4 RELATIONSHIPS WITH DEBARRED OR SUSPENDED PERSONS PROHIBITED................................... VII-5
7.5 CONTRACTING OFFICER AND CONTRACTOR'S REPRESENTATIVE........................................... VII-7
7.6 AUTHORITY OF THE STATE........................................................................ VII-8
7.7 EQUAL OPPORTUNITY EMPLOYER.................................................................... VII-8
7.8 NONDISCRIMINATION REQUIREMENTS................................................................ VII-8
7.9 INSPECTION RIGHTS............................................................................. VII-10
7.10 NOTICES/CONTRACT COMMUNICATION................................................................ VII-11
7.11 TERM.......................................................................................... VII-11
7.11.1 CONTRACT DURATION AND EFFECTIVE DATE................................................... VII-11
7.11.2 AMENDMENT, EXTENSION, AND MODIFICATION................................................. VII-11
7.12 TERMINATION................................................................................... VII-13
7.13 CLOSEOUT REQUIREMENTS......................................................................... VII-15
7.14 MERGER/ACQUISITION REQUIREMENTS............................................................... VII-19
7.15 SANCTIONS..................................................................................... VII-23
7.16 LIQUIDATED DAMAGES PROVISIONS................................................................. VII-24
7.16.1 GENERAL PROVISIONS..................................................................... VII-24
7.16.2 MANAGED CARE OPERATIONS, TERMS AND CONDITIONS, AND PAYMENT PROVISIONS.................. VII-26
7.16.3 TIMELY REPORTING REQUIREMENTS.......................................................... VII-27
7.16.4 ACCURATE REPORTING REQUIREMENTS........................................................ VII-27
7.16.5 TIMELY PAYMENTS TO MEDICAL PROVIDERS................................................... VII-28
7.16.6 CONDITIONS FOR TERMINATION OF LIQUIDATED DAMAGES....................................... VII-29
7.16.7 EPSDT PERFORMANCE STANDARDS............................................................ VII-29
7.16.8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CIVIL MONEY PENALTIES.......................... VII-30
7.16.8.1 FEDERAL STATUTES..................................................................... VII-30
7.16.8.2 FEDERAL PENALTIES.................................................................... VII-31
7.17 STATE SANCTIONS............................................................................... VII-32
7.18 APPEAL PROCESS................................................................................ VII-32
7.19 ASSIGNMENTS................................................................................... VII-32
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7.20 CONTRACTOR CERTIFICATIONS......................................................................... VII-33
7.20.1 GENERAL PROVISIONS......................................................................... VII-33
7.20.2 CERTIFICATION SUBMISSIONS.................................................................. VII-33
7.20.3 ENVIRONMENTAL COMPLIANCE................................................................... VII-33
7.20.4 ENERGY CONSERVATION........................................................................ VII-33
7.20.5 INDEPENDENT CAPACITY OF CONTRACTOR......................................................... VII-34
7.20.6 NO THIRD PARTY BENEFICIARIES............................................................... VII-34
7.20.7 PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING........................................... VII-34
7.21 REQUIRED CERTIFICATE OF AUTHORITY................................................................. VII-35
7.22 SUBCONTRACTS...................................................................................... VII-35
7.23 SET-OFF FOR STATE TAXES AND CHILD SUPPORT......................................................... VII-35
7.24 CLAIMS............................................................................................ VII-35
7.25 MEDICARE RISK CONTRACTOR.......................................................................... VII-36
7.26 TRACKING AND REPORTING............................................................................ VII-36
7.27 FINANCIAL STATEMENTS.............................................................................. VII-38
7.27.1 AUDITED FINANCIAL STATEMENTS (GAAP BASIS).................................................. VII-38
7.27.2 FINANCIAL STATEMENTS (SAP)................................................................. VII-38
7.28 FEDERAL APPROVAL AND FUNDING...................................................................... VII-39
7.29 CONFLICT OF INTEREST.............................................................................. VII-39
7.30 RECORDS RETENTION................................................................................. VII-40
7.31 WAIVERS........................................................................................... VII-41
7.32 CHANGE BY THE CONTRACTOR.......................................................................... VII-41
7.33 INDEMNIFICATION................................................................................... VII-41
7.34 INVENTIONS........................................................................................ VII-43
7.35 USE OF CONCEPTS................................................................................... VII-43
7.36 PREVAILING WAGE................................................................................... VII-43
7.37 DISCLOSURE STATEMENT.............................................................................. VII-44
7.38 FRAUD AND ABUSE................................................................................... VII-46
7.38.1 ENROLLEES.................................................................................. VII-46
7.38.2 PROVIDERS.................................................................................. VII-46
7.38.3 NOTIFICATION TO DMAHS...................................................................... VII-48
7.39 EQUALITY OF ACCESS AND TREATMENT/DUE PROCESS...................................................... VII-48
7.40 CONFIDENTIALITY................................................................................... VII-48
7.41 SEVERABILITY...................................................................................... VII-50
7.42 CONTRACTING OFFICER AND CONTRACTOR'S REPRESENTATIVE............................................... VII-50
ARTICLE EIGHT: FINANCIAL PROVISIONS
8.1 GENERAL INFORMATION................................................................................ VIII-1
8.2 FINANCIAL REQUIREMENTS............................................................................. VIII-1
8.2.1 COMPLIANCE WITH CERTAIN CONDITIONS........................................................... VIII-1
8.2.2 SOLVENCY REQUIREMENTS........................................................................ VIII-1
8.2.3 GENERAL PROVISIONS AND CONTRACTOR COMPLIANCE................................................. VIII-2
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8.3 INSURANCE REQUIREMENTS............................................................................. VIII-3
8.3.1 INSURANCE CANCELLATION AND/OR CHANGES.................................................. VIII-3
8.3.2 STOP-LOSS INSURANCE.................................................................... VIII-3
8.4 MEDICAL COST RATIO................................................................................. VIII-4
8.4.1 MEDICAL COST RATIO STANDARD............................................................ VIII-4
8.4.2 EXEMPTIONS............................................................................. VIII-4
8.4.3 DAMAGES................................................................................ VIII-5
8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS............................................ VIII-5
8.5.1 REGIONS................................................................................ VIII-5
8.5.2 AFDC/TANF AND NJ FAMILYCARE, PLAN A CHILDREN........................................... VIII-6
8.5.3 NJ FAMILYCARE PLAN A PARENTS/CARETAKERS................................................ VIII-6
8.5.4 NJ FAMILYCARE PLAN A ADULTS WITHOUT DEPENDENT CHILDREN UNDER 19 YEARS OF AGE........... VIII-6
8.5.5 NJ FAMILYCARE PLANS B & C.............................................................. VIII-7
8.5.6 NJ FAMILYCARE PLAN D CHILDREN.......................................................... VIII-7
8.5.7 NJ FAMILYCARE PLAN D PARENTS/CARETAKERS................................................ VIII-7
8.5.8 NJ FAMILYCARE PLAN D ADULTS WITHOUT DEPENDENT CHILDREN UNDER 19 YEARS OF AGE........... VIII-7
8.5.9 PREMIUM GROUPS FOR DYFS AND AGING OUT XXXXXX CHILDREN.................................. VIII-8
8.5.10 ABD WITHOUT MEDICARE................................................................... VIII-8
8.5.11 ABD WITH MEDICARE...................................................................... VIII-8
8.5.12 CLIENTS OF DDD......................................................................... VIII-9
8.5.13 PREMIUM GROUPS FOR ENROLLEES WITH AIDS................................................. VIII-9
8.5.14 SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME............................................. VIII-10
8.5.15 PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS............................................. VIII-10
8.5.16 PAYMENT FOR HIV/AIDS DRUGS............................................................. VIII-10
8.5.17 EPSDT INCENTIVE PAYMENT................................................................ VIII-10
8.6 HEALTH BASED PAYMENT SYSTEM (HBPS) FOR THE ABD WITHOUT MEDICARE POPULATION......................... VIII-11
8.7 THIRD PARTY LIABILITY.............................................................................. VIII-13
8.8 COMPENSATION/CAPITATION CONTRACTUAL REQUIREMENTS................................................... VIII-19
8.9 CONTRACTOR ADVANCED PAYMENTS AND PIPS TO PROVIDERS................................................. VIII-21
8.10 FEDERALLY QUALIFIED HEALTH CENTERS................................................................. VIII-23
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ARTICLE ONE: DEFINITIONS
The following terms shall have the meaning stated, unless the context
clearly indicates otherwise.
ABUSE--means provider practices that are inconsistent with sound
fiscal, business, or medical practices, and result in an unnecessary
cost to the Medicaid/NJ FamilyCare program, or in reimbursement for
services that are not medically necessary or that fail to meet
professionally recognized standards for health care. It also includes
enrollee practices that result in unnecessary cost to the Medicaid/NJ
FamilyCare program. (See 42 C.F.R. Section 455.2)
ADDP--AIDS Drug Distribution Program, a Department of Health and Senior
Services-sponsored program which provides life-sustaining and
life-prolonging medications to persons who are HIV positive or who are
living with AIDS and meet certain residency and income criteria for
program participation.
ADJUDICATE--the point in the claims processing at which a final
decision is reached to pay or deny a claim.
ADMINISTRATIVE SERVICE(S)--the contractual obligations of the
contractor that include but may not be limited to utilization
management, credentialing providers, network management, quality
improvement, marketing, enrollment, member services, claims payment,
management information systems, financial management, and reporting.
ADVERSE EFFECT--medically necessary medical care has not been provided
and the failure to provide such necessary medical care has presented an
imminent danger to the health, safety, or well-being of the patient or
has placed the patient unnecessarily in a high-risk situation.
ADVERSE SELECTION--the enrollment with a contractor of a
disproportionate number of persons with high health care costs.
AFDC OR AFDC/TANF--Aid to Families with Dependent Children, established
by 42 U.S.C. Section 601 et seq., and N.J.S.A. 44:10-1 et seq., as a
joint federal/State cash assistance program administered by counties
under State supervision. For cash assistance, it is now called "TANF."
For Medicaid, the former AFDC rules still apply.
AFDC-RELATED--see "SPECIAL MEDICAID PROGRAMS" and "TANF"
AID CODES--the two-digit number which indicates the aid category under
which a person is eligible to receive Medicaid and NJ FamilyCare.
AMELIORATE--to improve, maintain, or stabilize a health outcome, or to
prevent or mitigate an adverse change in health outcome.
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ANTICIPATORY GUIDANCE--the education provided to parents or authorized
individuals during routine prenatal or pediatric visits to prevent or
reduce the risk to their fetuses or children developing a particular
health problem.
ASSIGNMENT--the process by which a Medicaid enrollee in a New Jersey
Care 2000+ contractor receives a Primary Care Provider (PCP).
AT-RISK--any service for which the provider agrees to accept
responsibility to provide or arrange for in exchange for the capitation
payment.
AUTHORIZED PERSON--in general means a person authorized to make medical
determinations for an enrollee, including, but not limited to,
enrollment and disenrollment decisions and choice of a PCP.
For individuals who are eligible through the Division of Youth and
Family Services (DYFS), the authorized person is authorized to make
medical determinations, including but not limited to enrollment,
disenrollment and choice of a PCP, on behalf of or in conjunction with
individuals eligible through DYFS. These persons may include a xxxxxx
home parent, an authorized health care professional employee of a group
home, an authorized health care professional employee of a residential
center or facility, a DYFS employee, a pre-adoptive or adoptive parent
receiving subsidy from DYFS, a natural or biological parent, or a legal
caretaker.
For individuals who are eligible through the Division of Developmental
Disabilities (DD), the authorized person may be one of the following:
A. The enrollee, if he or she is an adult and has the
capacity to make medical decisions;
B. The parent or guardian of the enrollee, if the
enrollee is a minor, or the individual or agency
having legal guardianship if the enrollee is an adult
who lacks the capacity to make medical decisions;
C. The Bureau of Guardianship Services (BGS); or
D. A person or agency who has been duly designated by a
power of attorney for medical decisions made on
behalf of an enrollee.
Throughout the contract, information regarding enrollee rights and
responsibilities can be taken to include authorized persons, whether
stated as such or not.
AUTOMATIC ASSIGNMENT--the enrollment of an eligible person, for whom
enrollment is mandatory, in a managed care plan chosen by the New
Jersey Department of Human Services pursuant to the provisions of
Article 5.4 of this contract.
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BASIC SERVICE AREA--the geographic area in which the contractor is
obligated to provide covered services for its Medicaid/NJ FamilyCare
enrollees under this contract.
BENEFICIARY--any person eligible to receive services in the New Jersey
Medicaid/NJ FamilyCare program.
BENEFITS PACKAGE--the health care services set forth in this contract,
for which the contractor has agreed to provide, arrange, and be held
fiscally responsible.
BILINGUAL--see "MULTILINGUAL"
BONUS--a payment the contractor makes to a physician or physician group
beyond any salary, fee-for-service payments, capitation, or returned
withholding amount.
CAPITATED SERVICE--any covered service for which the contractor
receives capitation payment.
CAPITATION--a contractual agreement through which a contractor agrees
to provide specified health care services to enrollees for a fixed
amount per month.
CAPITATION PAYMENTS--the amount prepaid monthly by DMAHS to the
contractor in exchange for the delivery of covered services to
enrollees based on a fixed Capitation Rate per enrollee,
notwithstanding (a) the actual number of enrollees who receive services
from the contractor, or (b) the amount of services provided to any
enrollee.
CAPITATION RATE--the fixed monthly amount that the contractor is
prepaid by the Department for each enrollee for which the contractor
provides the services included in the Benefits Package described in
this contract.
CARE MANAGEMENT--a set of enrollee-centered, goal-oriented, culturally
relevant, and logical steps to assure that an enrollee receives needed
services in a supportive, effective, efficient, timely, and
cost-effective manner. Care management emphasizes prevention,
continuity of care, and coordination of care, which advocates for, and
links enrollees to, services as necessary across providers and
settings. Care management functions include 1) early identification of
enrollees who have or may have special needs, 2) assessment of an
enrollees risk factors, 3) development of a plan of care, 4) referrals
and assistance to ensure timely access to providers, 5) coordination of
care actively linking the enrollee to providers, medical services,
residential, social, and other support services where needed, 6)
monitoring, 7) continuity of care, and 8) follow-up and documentation.
CERTIFICATE OF AUTHORITY--a license granted by the New Jersey
Department of Banking and Insurance and the New Jersey Department of
Health and Senior Services to operate an HMO in compliance with
N.J.S.A. 26:2J-1 et. seq.
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CHILDREN'S HEALTH CARE COVERAGE PROGRAM--means the program established
by the "Children's Health Care Coverage Act", P.L. 1997, c.272 as a
health insurance program for targeted, low-income children.
CHILDREN WITH SPECIAL HEALTH CARE NEEDS--those children who have or are
at increased risk for chronic physical, developmental, behavioral, or
emotional conditions and who also require health and related services
of a type and amount beyond that required by children generally.
CHRONIC ILLNESS--a disease or condition of long duration (repeated
inpatient hospitalizations, out of work or school at least three months
within a twelve-month period, or the necessity for continuous health
care on an ongoing basis), sometimes involving very slow progression
and long continuance. Onset is often gradual and the process may
include periods of acute exacerbation alternating with periods of
remission.
CLINICAL PEER--a physician or other health care professional who holds
a non-restricted license in New Jersey and is in the same or similar
specialty as typically manages the medical condition, procedure, or
treatment under review.
CNM OR CERTIFIED NURSE MIDWIFE--a registered professional nurse who is
legally authorized under State law to practice as a nurse-midwife, and
has completed a program of study and clinical experience for
nurse-midwives or equivalent.
CNP OR CERTIFIED NURSE PRACTITIONER--a registered professional nurse
who is licensed by the New Jersey Board of Nursing and meets the
advanced educational and clinical practice requirements beyond the two
to four years of basic nursing education required of all registered
nurses.
CNS OR CLINICAL NURSE SPECIALIST--a person licensed to practice as a
registered professional nurse who is licensed by the New Jersey State
Board of Nursing or similarly licensed and certified by a comparable
agency of the state in which he/she practices.
COLD CALL MARKETING--any unsolicited personal contact with a potential
enrollee by an employee or agent of the contractor for the purpose of
influencing the individual to enroll with the contractor. Marketing by
an employee of the contractor is considered direct; marketing by an
agent is considered indirect.
COMMISSIONER--the Commissioner of the New Jersey Department of Human
Services or a duly authorized representative.
COMPLAINT--a protest by an enrollee as to the conduct by the contractor
or any agent of the contractor, or an act or failure to act by the
contractor or any agent of the contractor, or any other matter in which
an enrollee feels aggrieved by the contractor, that is communicated to
the contractor and that could be resolved by the contractor within the
same day/24 hours of receipt.
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CONDITION--a disease, illness, injury, disorder, or biological or
psychological condition or status for which treatment is indicated.
CONTESTED CLAIM--a claim that is denied because the claim is an
ineligible claim, the claim submission is incomplete, the coding or
other required information to be submitted is incorrect, the amount
claimed is in dispute, or the claim requires special treatment.
CONTINUITY OF CARE--the plan of care for a particular enrollee that
should assure progress without unreasonable interruption.
CONTRACT--the written agreement between the State and the contractor,
and comprises the contract, any addenda, appendices, attachments, or
amendments thereto.
CONTRACTING OFFICER--the individual empowered to act and respond for
the State throughout the life of any contract entered into with the
State.
CONTRACTOR--the Health Maintenance Organization with a valid
Certificate of Authority in New Jersey that contracts hereunder with
the State for the provision of comprehensive health care services to
enrollees on a prepaid, capitated basis.
CONTRACTOR'S PLAN--all services and responsibilities undertaken by the
contractor pursuant to this contract.
CONTRACTOR'S REPRESENTATIVE--the individual legally empowered to bind
the contractor, using his/her signature block, including his/her title.
This individual will be considered the Contractor's Representative
during the life of any contract entered into with the State unless
amended in writing pursuant to Article 7.
COPAYMENT--the part of the cost-sharing requirement for NJ FamilyCare
Plan D enrollees in which a fixed monetary amount is paid for certain
services/items received from the contractor's providers.
COST AVOIDANCE--a method of paying claims in which the provider is not
reimbursed until the provider has demonstrated that all available
health insurance has been exhausted.
COVERED SERVICES--see "BENEFITS PACKAGE"
CREDENTIALING--the contractor's determination as to the qualifications
and ascribed privileges of a specific provider to render specific
health care services.
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CULTURAL COMPETENCY--a set of interpersonal skills that allow
individuals to increase their understanding, appreciation, acceptance
of and respect for cultural differences and similarities within, among
and between groups and the sensitivity to how these differences
influence relationships with enrollees. This requires a willingness and
ability to draw on community-based values, traditions and customs, to
devise strategies to better meet culturally diverse enrollee needs, and
to work with knowledgeable persons of and from the community in
developing focused interactions, communications, and other supports.
CWA OR COUNTY WELFARE AGENCY ALSO KNOWN AS COUNTY BOARD OF SOCIAL
SERVICES-- the agency within the county government that makes
determination of eligibility for Medicaid and financial assistance
programs.
DAYS--calendar days unless otherwise specified.
DBI--the New Jersey Department of Banking and Insurance in the
executive branch of New Jersey State government.
DEFAULT--see "AUTOMATIC ASSIGNMENT"
DELIVERABLE--a document/report/manual to be submitted to the Department
by the contractor pursuant to this contract.
DENTAL DIRECTOR--the contractor's Director of dental services, who is
required to be a Doctor of Dental Science or a Doctor of Medical
Dentistry and licensed by the New Jersey Board of Dentistry, designated
by the contractor to exercise general supervision over the provision of
dental services by the contractor.
DEPARTMENT--the Department of Human Services (DHS) in the executive
branch of New Jersey State government. The Department of Human Services
includes the Division of Medical Assistance and Health Services (DMAHS)
and the terms are used interchangeably. The Department also includes
Division of Youth and Family Services (DYFS), the Division of Family
Development (DFD), the Division of Mental Health Services (DMHS), and
the Division of Developmental Disabilities (DDD).
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DEVELOPMENTAL DISABILITY--a severe, chronic disability of a person
which is attributable to a mental or physical impairment or combination
of mental and physical impairments; is manifested before the person
attains age twenty-two (22); is likely to continue indefinitely;
results in substantial functional limitations in three or more of the
following areas of major life activity: self-care, receptive and
expressive language, learning, mobility, self-direction, capacity for
independent living and economic self-sufficiency; and reflects the
person's need for a combination and sequence of special,
interdisciplinary, or generic care, treatment, or other services which
are lifelong or of extended duration and are individually planned and
coordinated. Developmental disability includes but is not limited to
severe disabilities attributable to mental retardation, autism,
cerebral palsy, epilepsy, xxxxx bifida and other neurological
impairments where the above criteria are met.
DFD--the Division of Family Development, within the New Jersey
Department of Human Services that administers programs of financial and
administrative support for certain qualified individuals and families.
DIAGNOSTIC SERVICES--any medical procedures or supplies recommended by
a physician or other licensed practitioner of the healing arts, within
the scope of his or her practice under State law, to enable him or her
to identify the existence, nature, or extent of illness, injury, or
other health deviation in an enrollee.
DIRECTOR--the Director of the Division of Medical Assistance and Health
Services or a duly authorized representative.
DISABILITY--a physical or mental impairment that substantially limits
one or more of the major life activities for more than three months a
year.
DISABILITY IN ADULTS--for adults applying under New Jersey Care Special
Medicaid Programs and Title II (Social Security Disability Insurance
Program) and for adults applying under Title XVI (the Supplemental
Security Income [SSI] program), disability is defined as the inability
to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment(s) which can be
expected to result in death or which has lasted or can be expected to
last for a continuous period of not less than 12 months.
DISABILITY IN CHILDREN--a child under age 18 is considered disabled if
he or she has a medically determinable physical or mental impairment(s)
which results in marked and severe functional limitations that limit
the child's ability to function independently, appropriately, and
effectively in an age-appropriate manner, and can be expected to result
in death or which can be expected to last for 12 months or longer.
DISENROLLMENT--the removal of an enrollee from participation in the
contractor's plan, but not from the Medicaid program.
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DIVISION OF DEVELOPMENTAL DISABILITIES (DDD)--a Division within the New
Jersey Department of Human Services that provides evaluation,
functional and guardianship services to eligible persons. Services
include residential services, family support, contracted day programs,
work opportunities, social supervision, guardianship, and referral
services.
DIVISION OR DMAHS--the New Jersey Division of Medical Assistance and
Health Services within the Department of Human Services which
administers the contract on behalf of the Department.
DHHS OR HHS--United States Department of Health and Human Services of
the executive branch of the federal government, which administers the
Medicaid program through the Health Care Financing Administration
(HCFA).
DHSS--the New Jersey Department of Health and Senior Services in the
executive branch of New Jersey State government, one of the regulatory
agencies of the managed care industry. Its role and functions are
delineated throughout the contract.
DURABLE MEDICAL EQUIPMENT (DME)--equipment, including assistive
technology, which: a) can withstand repeated use; b) is used to service
a health or functional purpose; c) is ordered by a qualified
practitioner to address an illness, injury or disability; and d) is
appropriate for use in the home or work place/school.
DYFS--the Division of Youth and Family Services, within the New Jersey
Department of Human Services, whose responsibility is to ensure the
safety of children and to provide social services to children and their
families. DYFS enrolls into Medicaid financially eligible children
under its supervision who reside in DYFS-supported substitute living
arrangements such as xxxxxx care and certain subsidized adoption
placements.
DYFS RESIDENTIAL FACILITIES--include Residential Facilities, Teaching
Family Homes, Juvenile Family In-Crisis Shelters, Children's Shelters,
Transitional Living Homes, Treatment Homes Programs, Alternative Home
Care Program, and Group Homes.
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT)--a Title
XIX mandated program that covers screening and diagnostic services to
determine physical and mental defects in enrollees under the age of 21,
and health care, treatment, and other measures to correct or ameliorate
any defects and chronic conditions discovered, pursuant to Federal
Regulations found in Title XIX of the Social Security Act.
EFFECTIVE DATE OF CONTRACT--shall be October 1, 2000.
EFFECTIVE DATE OF DISENROLLMENT--the last day of the month in which the
enrollee may receive services under the contractor's plan.
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EFFECTIVE DATE OF ENROLLMENT--the date on which an enrollee can begin
to receive services under the contractor's plan pursuant to Article
Five of this contract.
ELDERLY PERSON--a person who is 65 years of age or older.
EMERGENCY MEDICAL CONDITION--a medical condition manifesting itself by
acute symptoms of sufficient severity, (including severe pain) such
that a prudent layperson, who possesses an average knowledge of
medicine and health, could reasonably expect the absence of immediate
medical attention to result in placing the health of the individual
(or, with respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy; serious impairment to bodily
functions; or serious dysfunction of any bodily organ or part.
EMERGENCY SERVICES--covered inpatient and outpatient services furnished
by any qualified provider that are necessary to evaluate or stabilize
an emergency medical condition.
ENCOUNTER--the basic unit of service used in accumulating utilization
data and/or a face-to-face contact between a patient and a health care
provider resulting in a service to the patient.
ENCOUNTER DATA--the record of the number and types of services rendered
to patients during a specific time period and defined in Article 3.9 of
this contract.
ENROLLEE--an individual who is eligible for Medicaid/NJ FamilyCare,
residing within the defined enrollment area, who elects or has had
elected on his or her behalf by an authorized person, in writing, to
participate in the contractor's plan and who meets specific Medicaid/NJ
FamilyCare eligibility requirements for plan enrollment agreed to by
the Department and the contractor. Enrollees include individuals in the
AFDC/TANF, AFDC/TANF-Related Pregnant Women and Children, SSI-Aged,
Blind and Disabled, DYFS, NJ FamilyCare, and Division of Developmental
Disabilities/Community Care Waiver (DDD/CCW) populations. See also
"Authorized Person."
ENROLLEE WITH SPECIAL NEEDS--for adults, special needs includes
complex/chronic medical conditions requiring specialized health care
services, including persons with physical, mental/substance abuse,
and/or developmental disabilities, including such persons who are
homeless. Children with special health care needs are those who have or
are at increased risk for a chronic physical, developmental,
behavioral, or emotional conditions and who also require health and
related services of a type or amount beyond that required by children
generally.
ENROLLMENT--the process by which an individual eligible for Medicaid
voluntarily or mandatorily applies to utilize the contractor's plan in
lieu of standard Medicaid benefits, and such application is approved by
DMAHS.
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ENROLLMENT AREA--the geographic area bound by county lines from which
Medicaid/NJ FamilyCare eligible residents may enroll with the
contractor unless otherwise specified in the contract.
ENROLLMENT LOCK-IN PERIOD--the period between the first day of the
fourth (4th) month and the end of twelve (12) months after the
effective date of enrollment in the contractor's plan, during which the
enrollee must have good cause to disenroll or transfer from the
contractor's plan. This is not to be construed as a guarantee of
eligibility during the lock-in period. Lock-in provisions will not
apply to clients of DDD or SSI, New Jersey Care Special Medicaid
Program - Aged, Blind, Disabled, and DYFS enrollees.
ENROLLMENT PERIOD--the twelve (12) month period commencing on the
effective date of enrollment.
EPSDT--see "EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT"
EQUITABLE ACCESS--the concept that enrollees are given equal
opportunity and consideration for needed services without exclusionary
practices of providers or system design because of gender, age, race,
ethnicity, sexual orientation, health status, or disability.
EXCLUDED SERVICES--those services covered under the fee-for-service
Medicaid program that are not included in the contractor benefits
package.
EXTERNAL REVIEW ORGANIZATION (ERO)--an outside independent accredited
review organization under contract with the Department for the purposes
of conducting annual contractor operation assessments and quality of
care reviews for contractors.
FAIR HEARING--the appeal process available to all Medicaid Eligibles
pursuant to N.J.S.A. 30:4D-7 and administered pursuant to N.J.A.C.
10:49-10.1 et seq.
FEDERAL FINANCIAL PARTICIPATION--the funding contribution that the
federal government makes to the New Jersey Medicaid and NJ FamilyCare
programs.
FEDERALLY QUALIFIED HEALTH CENTER (FQHC)--an entity that provides
outpatient health programs pursuant to 42 U.S.C. Section 201 et seq.
FEDERALLY QUALIFIED HMO--an HMO that has been found by the Secretary of
the federal Department of Health and Human Services to provide "basic"
and "supplemental" health services to its enrollees in accordance with
the Health Maintenance Organization Act of 1973, as amended (Title XIII
of the Public Health Service Act, 42 U.S.C. Section 300e), and to meet
the other requirements of that Act relating to fiscal assurance
mechanisms, continuing education for staff, and membership
representation on the HMO's board of directors.
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FEE-FOR-SERVICE OR FFS--a method for reimbursement based on payment for
specific services rendered to an enrollee.
FRAUD--an intentional deception or misrepresentation made by a person
with the knowledge that the deception could result in some unauthorized
benefit to him/herself or some other person. It includes any act that
constitutes fraud under applicable federal or State law. (See 42 C.F.R.
Section 455.2)
FULL TIME EQUIVALENT--the number of personnel with the same job title
and responsibilities who, in the aggregate, perform work equivalent to
a singular individual working a 40-hour work week.
GA--means General Assistance, established by N.J.S.A. 10:90-1 et seq.,
as a State cash assistance program administered by counties and
municipalities under State supervision.
GAAP--Generally Accepted Accounting Principles.
GOOD CAUSE--reasons for disenrollment or transfer that include failure
of the contractor to provide services including physical access to the
enrollee in accordance with contract terms, enrollee has filed a
grievance and has not received a response within the specified time
period or enrollee has filed a grievance and has not received
satisfaction. See Article 5.10.2 for more detail.
GOVERNING BODY--a managed care organization's Board of Directors or,
where the Board's participation with quality improvement issues is not
direct, a designated committee of the senior management of the managed
care organization.
GRIEVANCE--means any complaint that is submitted in writing, or that is
orally communicated and could not be resolved within the same day of
receipt.
GROUP MODEL--a type of HMO operation similar to a group practice except
that the group model must meet the following criteria: (a) the group is
a separate legal entity, (i.e. administrative entity) apart from the
HMO; (b) the group is usually a corporation or partnership; (c) members
of the group must pool their income; (d) members of the group must
share medical equipment, as well as technical and administrative staff;
(e) members of the group must devote at least 50 percent of their time
to the group; and (f) members of the group must have "substantial
responsibility" for delivery of health services to HMO members, within
four years of qualification. After that period, the group may request
additional time or a waiver in accordance with federal regulations at
42 C.F.R. Section 110.104(2), Subpart A.
HCFA--the Health Care Financing Administration within the U.S.
Department of Health and Human Services.
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HEALTH BENEFITS COORDINATOR (HBC)--the external organization under
contract with the Department whose primary responsibility is to assist
Medicaid eligible individuals in contractor selection and enrollment.
HEALTH CARE PROFESSIONAL--a physician or other health care professional
if coverage for the professional's services is provided under the
contractor's contract for the services. It includes podiatrists,
optometrists, chiropractors, psychologists, dentists, physician
assistants, physical or occupational therapists and therapy assistants,
speech-language pathologists, audiologists, registered or licensed
practical nurses (including nurse practitioners, clinical nurse
specialists, certified registered nurses, registered nurse
anesthetists, and certified nurse midwives), licensed certified social
workers, registered respiratory therapists, and certified respiratory
therapy technicians.
HEALTH CARE SERVICES--are all preventive and therapeutic medical,
dental, surgical, ancillary (medical and non-medical) and supplemental
benefits provided to enrollees to diagnose, treat, and maintain the
optimal well-being of enrollees provided by physicians, other health
care professionals, institutional, and ancillary service providers.
HEALTH INSURANCE--private insurance available through an individual or
group plan that covers health services. It is also referred to as Third
Party Liability.
HEALTH MAINTENANCE ORGANIZATION (HMO)--any entity which contracts with
providers and furnishes at least basic comprehensive health care
services on a prepaid basis to enrollees in a designated geographic
area pursuant to N.J.S.A. 26:2J-1 et seq., and with regard to this
contract is either:
A. A Federally Qualified HMO; or
B. Meets the State Plan's definition of an HMO which
includes, at a minimum, the following requirements:
1. It is organized primarily for the purpose of
providing health care services;
2. It makes the services it provides to its
Medicaid enrollees as accessible to them (in
terms of timeliness, amount, duration, and
scope) as the services are to non-enrolled
Medicaid eligible individuals within the
area served by the HMO;
3. It makes provision, satisfactory to the
Division and Departments of Banking and
Insurance and Health and Senior Services,
against the risk of insolvency, and assures
that Medicaid enrollees will not be liable
for any of the HMO's debts if it does become
insolvent; and
4. It has a Certificate of Authority granted by
the State of New Jersey to operate in all or
selected counties in New Jersey.
HEDIS--Health Plan Employer Data and Information Set.
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INDICATORS--the objective and measurable means, based on current
knowledge and clinical experience, used to monitor and evaluate each
important aspect of care and service identified.
INDIVIDUAL HEALTH CARE PLAN (IHCP)--a multi-disciplinary plan of care
for enrollees with special needs who qualify for a higher level of care
management based on a Complex Needs Assessment. IHCPs specify short-
and long-term goals, identify needed medical services and relevant
social/support services, specialized transportation and communication,
appropriate outcomes, and barriers to effective outcomes, and
timelines. The IHCP is implemented and monitored by the care manager.
INQUIRY--means a request for information by an enrollee, or a verbal
request by an enrollee for action by the contractor that is so clearly
contrary to the Medicaid Managed Care Program or the contractor's
operating procedures that it may be construed as a factual
misunderstanding, provided that the issue can be immediately explained
and resolved by the contractor. Inquiries need not be treated or
reported as complaints or grievances.
INSOLVENT--unable to meet or discharge financial liabilities pursuant
to N.J.S.A. 17B:32-33.
INSTITUTIONALIZED--residing in a nursing facility, psychiatric
hospital, or intermediate care facility/mental retardation (ICF/MR);
this does not include admission in an acute care or rehabilitation
hospital setting.
IPN OR INDEPENDENT PRACTITIONER NETWORK--one type of HMO operation
where member services are normally provided in the individual offices
of the contracting physicians.
LIMITED-ENGLISH-PROFICIENT POPULATIONS--individuals with a primary
language other than English who must communicate in that language if
the individual is to have an equal opportunity to participate
effectively in and benefit from any aid, service or benefit provided by
the health provider.
MAINTENANCE SERVICES--include physical services provided to allow
people to maintain their current level of functioning. Does not include
habilitative and rehabilitative services.
MANAGED CARE--a comprehensive approach to the provision of health care
which combines clinical preventive, restorative, and emergency services
and administrative procedures within an integrated, coordinated system
to provide timely access to primary care and other medically necessary
health care services in a cost effective manner.
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MANAGED CARE ENTITY--a managed care organization described in Section
1903(m)(1)(A) of the Social Security Act, including Health Maintenance
Organizations (HMOs), organizations with Section 1876 or
Medicare+Choice contracts, provider sponsored organizations, or any
other public or private organization meeting the requirements of
Section 1902(w) of the Social Security Act, which has a risk
comprehensive contract and meets the other requirements of that
Section.
MANDATORY--the requirement that certain DMAHS beneficiaries, delineated
in Article 5, must select, or be assigned to a contractor in order to
receive Medicaid services.
MANDATORY ENROLLMENT--the process whereby an individual eligible for
Medicaid/NJ FamilyCare is required to enroll in a contractor, unless
otherwise exempted or excluded, to receive the services described in
the standard benefits package as approved by the Department of Human
Services through necessary federal waivers.
MARKETING--any activity by the contractor, its employees or agents, or
on behalf of the contractor by any person, firm or corporation by which
information about the contractor's plan is made known to Medicaid or NJ
FamilyCare Eligible Persons for enrollment purposes.
MAXIMUM PATIENT CAPACITY--the estimated maximum number of active
patients that could be assigned to a specific provider within mandated
access-related requirements.
MCMIS--managed care management information system, an automated
information system designed and maintained to integrate information
across the enterprise. The State recommends that the system include,
but not necessarily be limited to, the following functions:
- Enrollee Services
- Provider Services
- Claims and Encounter Processing
- Prior Authorization, Referral and Utilization
Management
- Financial Processing
- Quality Assurance
- Management and Administrative Reporting
- Encounter Data Reporting to the State
MEDICAID--the joint federal/State program of medical assistance
established by Title XIX of the Social Security Act, 42 U.S.C. Section
1396 et seq., which in New Jersey is administered by DMAHS in DHS
pursuant to N.J.S.A. 30:4D-1 et seq.
MEDICAID ELIGIBLE--an individual eligible to receive services under the
New Jersey Medicaid program.
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MEDICAID EXPANSION--means the expansion of the New Jersey
Care...Special Medicaid Programs, incorporates NJ FamilyCare Plan A,
that will extend coverage to uninsured children below the age of 19
years with family incomes up to and including 133 percent of the
federal poverty level. (See NJ FamilyCare Plan A)
MEDICAID RECIPIENT OR MEDICAID BENEFICIARY--an individual eligible for
Medicaid who has applied for and been granted Medicaid benefits by
DMAHS, generally through a CWA or Social Security District Office.
MEDICAL COMMUNICATION--any communication made by a health care provider
with a patient of the health care provider (or, where applicable, an
authorized person) with respect to:
A. The patient's health status, medical care, or
treatment options;
B. Any utilization review requirements that may affect
treatment options for the patient; or
C. Any financial incentives that may affect the
treatment of the patient.
The term "medical communication" does not include a communication by a
health care provider with a patient of the health care provider (or,
where applicable, an authorized person) if the communication involves a
knowing or willful misrepresentation by such provider.
MEDICAL DIRECTOR--the licensed physician, in the State of New Jersey,
i.e. Medical Doctor (MD) or Doctor of Osteopathy (DO), designated by
the contractor to exercise general supervision over the provision of
health service benefits by the contractor.
MEDICAL GROUP--a partnership, association, corporation, or other group
which is chiefly composed of health professionals licensed to practice
medicine or osteopathy, and other licensed health professionals who are
necessary for the provision of health services for whom the group is
responsible.
MEDICALLY DETERMINABLE IMPAIRMENT--an impairment that results from
anatomical, physiological, or psychological abnormalities which can be
shown by medically acceptable clinical and laboratory diagnostic
techniques. A physical or mental impairment must be established by
medical evidences consisting of signs, symptoms, and laboratory
findings -- not only the individual's statement of symptoms.
MEDICAL RECORDS--the complete, comprehensive records, accessible at the
site of the enrollee's participating primary care physician or
provider, that document all medical services received by the enrollee,
including inpatient, ambulatory, ancillary, and emergency care,
prepared in accordance with all applicable DHS rules and regulations,
and signed by the medical professional rendering the services.
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MEDICAL SCREENING--an examination 1) provided on hospital property, and
provided for that patient for whom it is requested or required, and 2)
performed within the capabilities of the hospital's emergency room (ER)
(including ancillary services routinely available to its ER), and 3)
the purpose of which is to determine if the patient has an emergency
medical condition, and 4) performed by a physician (M.D. or D.O.)
and/or by a nurse practitioner, or physician assistant as permitted by
State statutes and regulations and hospital bylaws.
MEDICALLY NECESSARY SERVICES--services or supplies necessary to
prevent, diagnose, correct, prevent the worsening of, alleviate,
ameliorate, or cure a physical or mental illness or condition; to
maintain health; to prevent the onset of an illness, condition, or
disability; to prevent or treat a condition that endangers life or
causes suffering or pain or results in illness or infirmity; to prevent
the deterioration of a condition; to promote the development or
maintenance of maximal functioning capacity in performing daily
activities, taking into account both the functional capacity of the
individual and those functional capacities that are appropriate for
individuals of the same age; to prevent or treat a condition that
threatens to cause or aggravate a handicap or cause physical deformity
or malfunction, and there is no other equally effective, more
conservative or substantially less costly course of treatment available
or suitable for the enrollee. The services provided, as well as the
type of provider and setting, must be reflective of the level of
services that can be safely provided, must be consistent with the
diagnosis of the condition and appropriate to the specific medical
needs of the enrollee and not solely for the convenience of the
enrollee or provider of service and in accordance with standards of
good medical practice and generally recognized by the medical
scientific community as effective. Course of treatment may include mere
observation or, where appropriate, no treatment at all. Experimental
services or services generally regarded by the medical profession as
unacceptable treatment are not medically necessary for purposes of this
contract.
Medically necessary services provided must be based on peer-reviewed
publications, expert pediatric, psychiatric, and medical opinion, and
medical/pediatric community acceptance.
In the case of pediatric enrollees, this definition shall apply with
the additional criteria that the services, including those found to be
needed by a child as a result of a comprehensive screening visit or an
inter-periodic encounter whether or not they are ordinarily covered
services for all other Medicaid enrollees, are appropriate for the age
and health status of the individual and that the service will aid the
overall physical and mental growth and development of the individual
and the service will assist in achieving or maintaining functional
capacity.
MEDICALLY NEEDY (MN) PERSON OR FAMILY--a person or family receiving
services under the Medically Needy Program.
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MEDICARE--the program authorized by Title XVIII of the Social Security
Act to provide payment for health services to federally defined
populations.
MEDICARE+CHOICE ORGANIZATION--an entity that contracts with HCFA to
offer a Medicare+Choice plan pursuant to 42 U.S.C. Section 1395w-27.
MEMBER--an enrolled participant in the contractor's plan; also means
enrollee.
MINORITY POPULATIONS--Asian/Pacific Islanders, African-American/Black,
Hispanic/Latino, and American Indians/Alaska Natives.
MIS--management information system.
MULTILINGUAL--at a minimum, English and Spanish and any other language
which is spoken by 200 enrollees or five percent of the enrolled
Medicaid population of the contractor's plan, whichever is greater.
NCQA--the National Committee for Quality Assurance.
NEWBORN--an infant born to a mother enrolled in a contractor at the
time of birth.
NEW JERSEY STATE PLAN OR STATE PLAN--the DHS/DMAHS document, filed with
and approved by HCFA, that describes the New Jersey Medicaid program.
N.J.A.C.--New Jersey Administrative Code.
NJ FAMILYCARE PLAN A--means the State-operated program which provides
comprehensive managed care coverage to:
- Uninsured children below the age of 19 with family incomes up
to and including 133 percent of the federal poverty level;
- Children under the age of one year and pregnant women eligible
under the New Jersey Care...Special Medicaid Programs;
- Pregnant women up to 200 percent of the federal poverty level;
- AFDC eligibles with incomes up to and including 133 percent
of the federal poverty level;
- Parents/caretaker relatives with children below the age of 19
years who do not qualify for AFDC Medicaid and have family
incomes up to and including 133 percent of the federal poverty
level;
- Uninsured single adults/couples without dependent children
with family incomes up to and including 50 percent of the
federal poverty level; and
- General Assistance eligibles.
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.
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NJ FAMILYCARE PLAN B--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 133 percent and
up to and including 150 percent 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:
- 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;
- 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; 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 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
498
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.
N.J.S.A.--New Jersey Statutes Annotated.
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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.
OUTCOMES--the results of the health care process, involving either the
enrollee or provider of care, and may be measured at any specified
point in time. Outcomes can be medical, dental, behavioral, economic,
or societal in nature.
OUTPATIENT CARE--treatment provided to an enrollee who is not admitted
to an inpatient hospital or health care facility.
P FACTOR (P7)--the grade of service for the telephone system. The digit
following the P (e.g., 7) indicates the number of calls per hundred
that are or can be blocked from the system. In this sample, P7 means
seven (7) calls in a hundred may be blocked, so the system is designed
to meet this criterion. Typically, the grade of service is designed to
meet the peak busy hour, the busiest hour of the busiest day of the
year.
PARTICIPATING PROVIDER--a provider that has entered into a provider
contract with the contractor to provide services.
PARTIES--the DMAHS, on behalf of the DHS, and the contractor.
PATIENT--an individual who is receiving needed professional services
that are directed by a licensed practitioner of the healing arts toward
the maintenance, improvement, or protection of health, or lessening of
illness, disability, or pain.
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PAYMENTS--any amounts the contractor pays physicians or physician
groups or subcontractors for services they furnished directly, plus
amounts paid for administration and amounts paid (in whole or in part)
based on use and costs of referral services (such as withhold amounts,
bonuses based on referral levels, and any other compensation to the
physician or physician groups or subcontractor to influence the use of
referral services). Bonuses and other compensation that are not based
on referral levels (such as bonuses based solely on quality of care
furnished, patient satisfaction, and participation on committees) are
not considered payments for purposes of the requirements pertaining to
physician incentive plans.
PEER REVIEW--a mechanism in quality assurance and utilization review
where care delivered by a physician, dentist, or nurse is reviewed by a
panel of practitioners of the same specialty to determine levels of
appropriateness, effectiveness, quality, and efficiency.
PERSONAL CONTRIBUTION TO CARE (PCC)--means the portion of the
cost-sharing requirement for NJ FamilyCare Plan C enrollees in which a
fixed monetary amount is paid for certain services/items received from
contractor providers.
PERSONAL INJURY (PI)--a program designed to recover the cost of medical
services from an action involving the tort liability of a third party.
PHYSICIAN GROUP--a partnership, association, corporation, individual
practice association, or other group that distributes income from the
practice among members. An individual practice association is a
physician group only if it is composed of individual physicians and has
no subcontracts with physician groups.
PHYSICIAN INCENTIVE PLAN--any compensation arrangement between a
contractor and a physician or physician group that may directly or
indirectly have the effect of reducing or limiting services furnished
to Medicaid beneficiaries enrolled in the organization.
POST-STABILIZATION SERVICES--services subsequent to an emergency that a
treating physician views as medically necessary after an emergency
medical condition has been stabilized.
PREPAID HEALTH PLAN--an entity that provides medical services to
enrollees under a contract with the DHS and on the basis of prepaid
capitation fees, but does not necessarily qualify as an MCE.
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PREVENTIVE SERVICES--services provided by a physician or other licensed
practitioner of the healing arts within the scope of his or her
practice under State law to:
A. Prevent disease, disability, and other health
conditions or their progression;
B. Treat potential secondary conditions before they
happen or at an early remediable stage;
C. Prolong life; and
D. Promote physical and mental health and efficiency
PRIMARY CARE DENTIST (PCD)--a licensed dentist who is the health care
provider responsible for supervising, coordinating, and providing
initial and primary dental care to patients; for initiating referrals
for specialty care; and for maintaining the continuity of patient care.
PRIMARY CARE PROVIDER (PCP)--a licensed medical doctor (MD) or doctor
of osteopathy (DO) or certain other licensed medical practitioner who,
within the scope of practice and in accordance with State
certification/licensure requirements, standards, and practices, is
responsible for providing all required primary care services to
enrollees, including periodic examinations, preventive health care and
counseling, immunizations, diagnosis and treatment of illness or
injury, coordination of overall medical care, record maintenance, and
initiation of referrals to specialty providers described in this
contract and the Benefits Package, and for maintaining continuity of
patient care. A PCP shall include general/family practitioners,
pediatricians, internists, and may include specialist physicians,
physician assistants, CNMs or CNPs/CNSs, provided that the practitioner
is able and willing to carry out all PCP responsibilities in accordance
with these contract provisions and licensure requirements.
PRIOR AUTHORIZATION (ALSO KNOWN AS "PRE-AUTHORIZATION" OR "APPROVAL")--
authorization granted in advance of the rendering of a service after
appropriate medical/dental review.
PROVIDER--means any physician, hospital, facility, or other health care
professional who is licensed or otherwise authorized to provide health
care services in the state or jurisdiction in which they are furnished.
PROVIDER CAPITATION--a set dollar payment per patient per unit of time
(usually per month) that the contractor pays a provider to cover a
specified set of services and administrative costs without regard to
the actual number of services.
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PROVIDER CONTRACT--any written contract between the contractor and a
provider that requires the provider to perform specific parts of the
contractor's obligations for the provision of health care services
under this contract.
QAPI--Quality Assessment and Performance Improvement.
QARI--Quality Assurance Reform Initiative.
QIP--Quality Improvement Project.
QISMC--Quality Improvement System for Managed Care.
QUALIFIED INDIVIDUAL WITH A DISABILITY--an individual with a disability
who, with or without reasonable modifications to rules, policies, or
practices, the removal of architectural, communication, or
transportation barriers, or the provision of auxiliary aids and
services, meets the essential eligibility requirements for the receipt
of services or the participation in programs or activities provided by
a public entity (42 U.S.C. Section 12131).
REASSIGNMENT--the process by which an enrollee's entitlement to receive
services from a particular Primary Care Practitioner/Dentist is
terminated and switched to another PCP/PCD.
REFERRAL SERVICES--those health care services provided by a health
professional other than the primary care practitioner and which are
ordered and approved by the primary care practitioner or the
contractor.
Exception A: An enrollee shall not be required to obtain a
referral or be otherwise restricted in the choice of the
family planning provider from whom the enrollee may receive
family planning services.
Exception B: An enrollee may access services at a Federally
Qualified Health Center (FQHC) in a specific enrollment area
without the need for a referral when neither the contractor
nor any other contractor has a contract with the Federally
Qualified Health Center in that enrollment area and the cost
of such services will be paid by the Medicaid fee-for-service
program.
REINSURANCE--an agreement whereby the reinsurer, for a consideration,
agrees to indemnify the contractor, or other provider, against all or
part of the loss which the latter may sustain under the enrollee
contracts which it has issued.
RISK OR UNDERWRITING RISK--the possibility that a contractor may incur
a loss because the cost of providing services may exceed the payments
made by the Department to the contractor for services covered under the
contract.
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RISK COMPREHENSIVE CONTRACT--for purposes of this contract, a risk
contract for furnishing comprehensive health care services, i.e.,
inpatient hospital services and any three of the following services or
groups of services:
A. Outpatient hospital services and rural health
clinical services;
B. Other laboratory and diagnostic and therapeutic
radiologic services;
C. Skilled nursing facility services, EPSDT, and family
planning;
D. Physician services; and
E. Home health services.
RISK THRESHOLD--the maximum liability, if the liability is based on
referral services, to which a physician or physician group may be
exposed under a physician incentive plan without being at substantial
financial risk.
ROUTINE CARE--treatment of a condition which would have no adverse
effects if not treated within 24 hours or could be treated in a less
acute setting (e.g., physician's office) or by the patient.
SAFETY-NET PROVIDERS OR ESSENTIAL COMMUNITY PROVIDERS--public-funded or
government-sponsored clinics and health centers which provide
specialty/specialized services which serve any individual in need of
health care whether or not covered by health insurance and may include
medical/dental education institutions, hospital-based programs,
clinics, and health centers.
SAP--Statutory Accounting Principles.
SCOPE OF SERVICES--those specific health care services for which a
provider has been credentialed, by the plan, to provide to enrollees.
SCREENING SERVICES--any encounter with a health professional practicing
within the scope of his or her profession as well as the use of
standardized tests given under medical direction in the examination of
a designated population to detect the existence of one or more
particular diseases or health deviations or to identify for more
definitive studies individuals suspected of having certain diseases.
SECRETARY--the Secretary of the United States Department of Health and
Human Services.
SEMI--Special Education Medicaid Initiative, a federal Medicaid program
that allows for reimbursement to local education agencies for certain
special education related services (e.g., physical therapy,
occupational therapy, and speech therapy).
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SERVICE AREA--the geographic area or region comprised of those counties
as designated in the contract.
SERVICE LOCATION/SERVICE SITE--any location at which an enrollee
obtains any health care service provided by the contractor under the
terms of the contract.
SHORT TERM--a period of 30 calendar days or less.
SIGNING DATE--the date on which the parties sign this contract. In no
event shall the signing date be later than 5 P.M. Eastern Standard Time
on March 17, 2000.
SPECIAL MEDICAID PROGRAMS--programs for: (a) AFDC/TANF-related family
members who do not qualify for cash assistance, and (b) SSI-related
aged, blind and disabled individuals whose incomes or resources exceed
the SSI Standard.
For AFDC/TANF, they are:
Medicaid Special: covers children ages 19 to 21 using AFDC
standards; New Jersey Care: covers pregnant women and children
up to age 1 with incomes at or below 185 percent of the
federal poverty level (FPL); children up to age 6 at 133
percent of FPL; and children up to age 13 (the age range
increases annually, pursuant to federal law until children up
to age 18 are covered) at 100 percent of FPL.
For SSI-related, they are:
Community Medicaid Only-provides full Medicaid benefits for
aged, blind and disabled individuals who meet the SSI age and
disability criteria, but do not receive cash assistance,
including former SSI recipients who receive Medicaid
continuation;
New Jersey Care-provides full Medicaid benefits for all
SSI-related Aged, Blind, and Disabled individuals with income
below 100 percent of the federal poverty level and resources
at or below 200 percent of the SSI resource standard.
SSI--the Supplemental Security Income program, which provides cash
assistance and full Medicaid benefits for individuals who meet the
definition of aged, blind, or disabled, and who meet the SSI financial
needs criteria.
STAFF MODEL--a type of HMO operation in which HMO employees are
responsible for both administrative and medical functions of the plan.
Health professionals, including physicians, are reimbursed on a salary
or fee-for-service basis. These employees are subject to all policies
and procedures of the HMO. In addition, the HMO may contract with
external entities to supplement its own staff resources (e.g., referral
services of specialists).
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STANDARD SERVICE PACKAGE--see "COVERED SERVICES" and "BENEFITS PACKAGE"
STATE--the State of New Jersey.
STATE PLAN--see "NEW JERSEY STATE PLAN"
STOP-LOSS--the dollar amount threshold above which the contractor
insures the financial coverage for the cost of care for an enrollee
through the use of an insurance underwritten policy.
SUBCONTRACT--any written contract between the contractor and a third
party to perform a specified part of the contractor's obligations under
this contract.
SUBCONTRACTOR--any third party who has a written contract with the
contractor to perform a specified part of the contractor's obligations
under this contract.
SUBCONTRACTOR PAYMENTS--any amounts the contractor pays a provider or
subcontractor for services they furnish directly, plus amounts paid for
administration and amounts paid (in whole or in part) based on use and
costs of referral services (such as withhold amounts, bonuses based on
referral levels, and any other compensation to the physician or
physician group to influence the use of referral services). Bonuses and
other compensation that are not based on referral levels (such as
bonuses based solely on quality of care furnished, patient
satisfaction, and participation on committees) are not considered
payments for purposes of physician incentive plans.
SUBSTANTIAL CONTRACTUAL RELATIONSHIP--any contractual relationship that
provides for one or more of the following services: 1) the
administration, management, or provision of medical services; and 2)
the establishment of policies, or the provision of operational support,
for the administration, management, or provision of medical services.
TANF--Temporary Assistance for Needy Families, which replaced the
federal AFDC program.
TARGET POPULATION--the population of individuals eligible for
Medicaid/NJ FamilyCare residing within the stated enrollment area and
belonging to one of the categories of eligibility found in Article Five
from which the contractor may enroll, not to exceed any limit specified
in the contract.
TDD--Telecommunication Device for the Deaf.
TT--Tech Telephone.
TERMINAL ILLNESS--a condition in which it is recognized that there will
be no recovery, the patient is nearing the "terminus" of life and
restorative treatment is no longer effective.
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THIRD PARTY--any person, institution, corporation, insurance company,
public, private or governmental entity who is or may be liable in
contract, tort, or otherwise by law or equity to pay all or part of the
medical cost of injury, disease or disability of an applicant for or
recipient of medical assistance payable under the New Jersey Medical
Assistance and Health Services Act N.J.S.A. 30:4D-1 et seq.
THIRD PARTY LIABILITY--the liability of any individual or entity,
including public or private insurance plans or programs, with a legal
or contractual responsibility to provide or pay for medical/dental
services. Third Party is defined in N.J.S.A. 30:4D-3m.
TRADITIONAL PROVIDERS--those providers who have historically delivered
medically necessary health care services to Medicaid enrollees and have
maintained a substantial Medicaid portion in their practices.
TRANSFER--an enrollee's change from enrollment in one contractor's plan
to enrollment of said enrollee in a different contractor's plan.
UNCONTESTED CLAIM--a claim that can be processed without obtaining
additional information from the provider of the service or third party.
URGENT CARE--treatment of a condition that is potentially harmful to a
patient's health and for which his/her physician determined it is
medically necessary for the patient to receive medical treatment within
24 hours to prevent deterioration.
UTILIZATION--the rate patterns of service usage or types of service
occurring within a specified time.
UTILIZATION REVIEW--procedures used to monitor or evaluate the clinical
necessity, appropriateness, efficacy, or efficiency of health care
services, procedures or settings, and includes ambulatory review,
prospective review, concurrent review, second opinions, care
management, discharge planning, or retrospective review.
VOLUNTARY ENROLLMENT--the process by which a Medicaid eligible
individual voluntarily enrolls in a contractor.
WIC--A special supplemental food program for Women, Infants, and
Children.
WITHHOLD--a percentage of payments or set dollar amounts that a
contractor deducts from a practitioner's service fee, capitation, or
salary payment, and that may or may not be returned to the physician,
depending on specific predetermined factors.
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ARTICLE TWO: CONDITIONS PRECEDENT
A. This contract shall be with qualified, established HMOs
operating in New Jersey through a Certificate of Authority for
Medicaid lines of business approved by the New Jersey
Department of Banking and Insurance and Department of Health
and Senior Services. The contractor shall receive all
necessary authorizations and approvals of governmental or
regulatory authorities to operate in the service/enrollment
areas as of the effective date of operations.
B. The contractor shall ensure continuity of care and full access
to primary, specialty, and ancillary care as required under
this contract and access to full administrative programs and
support services offered by the contractor for all its lines
of business and/or otherwise required under this contract.
C. The contractor shall, by the effective date, have received all
necessary authorizations and approvals of governmental or
regulatory authorities including an approved Certificate of
Authority (COA) to operate in all counties in a geographic
region as defined in Article 5.1 or shall have an approved (by
DMAHS) county phase-in plan defined in Section H. This Article
does not and is not intended to require the contractor to
obtain COAs in all three geographic regions.
D. Documentation. Subsequent to the signing date by the
contractor but prior to contract execution by the Department,
the Department shall review and approve the materials listed
in Section B.2.2 of the Appendices.
E. Readiness Review. The Department will, prior to the signing
date, conduct a readiness review of the areas set forth in
Section B.2.3 of the Appendices to generally assess the
contractor's readiness to begin operations and issue a letter
to the contractor that conveys its findings and any changes
required before contracting with the Department.
F. This contract, as well as any attachments or appendices hereto
shall only be effective, notwithstanding any provisions in
such contract to the contrary, upon the receipt of federal
approval and approval as to form by the Office of the Attorney
General for the State of New Jersey.
G. The contractor shall remain in compliance with the following
conditions which shall satisfy the Departments of Banking and
Insurance, Health and Senior Services, and Human Services
prior to this contract becoming effective:
1. The contractor shall maintain an approved certificate
of authority to operate as a health maintenance
organization in New Jersey from the Department of
Banking and Insurance and the Department of Health
and Senior Services for the Medicaid population.
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2. The contractor shall comply with and remain in
compliance with minimum net worth and fiscal solvency
and reporting requirements of the Department of
Banking and Insurance, the Department of Human
Services, the federal government, and this contract.
3. The contractor shall provide written certification of
new written contracts for all providers other than
FQHCs and shall provide copies of fully executed
contracts for new contracts with FQHCs on a quarterly
basis.
4. If insolvency protection arrangements change, the
contractor shall notify the DMAHS sixty (60) days
before such change takes effect and provide written
copy of DOBI approval.
H. County Expansion Phase-In Plan. If the contractor does not
have an approved COA for each of the counties in a designated
region, the contractor shall submit to DMAHS a county
expansion phase-in plan for review and approval by DMAHS prior
to the execution of this contract. The plan shall include
detailed information of:
- The region and names of the counties
targeted for expansion;
- Anticipated dates of the submission of the
COA modification to DOBI and DHSS (with
copies to DMAHS);
- Anticipated date of approval of the COA;
- Anticipated date for full operations in the
region;
- Anticipated date for initial beneficiary
enrollment in each county
The phase-in plan shall indicate that full expansion into a
region shall be completed by June 30, 2001. The contractor
shall maintain full coverage for each county in each region in
which the contractor operates for the duration of this
contract.
I. No court order, administrative decision, or action by any
other instrumentality of the United States Government or the
State of New Jersey or any other state is outstanding which
prevents implementation of this contract.
J. Net Worth
1. The contractor shall maintain a minimum net worth in
accordance with N.J.A.C. Title 8:38-11 et seq.
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2. The Department shall have the right to conduct
targeted financial audits of the contractor's
Medicaid line of business. The contractor shall
provide the Department with financial data, as
requested by the Department, within a timeframe
specified by the Department.
K. The contractor shall comply with the following financial
operations requirements:
1. A contractor shall establish and maintain:
a. An office in New Jersey, and
b. Premium and claims accounts in a bank with a
principal office in New Jersey.
2. The contractor shall have a fiscally sound operation
as demonstrated by:
a. Maintenance of a minimum net worth in
accordance with DOBI requirements (total
line of business) and the requirements
outlined in G and J above and Article 8.2.
b. Maintenance of a net operating surplus for
Medicaid line of business. If the contractor
fails to earn a net operating surplus during
the most recent calendar year or does not
maintain minimum net worth requirements on a
quarterly basis, it shall submit a plan of
action to DMAHS within the time frame
specified by the Department. The plan is
subject to the approval of DMAHS. It shall
demonstrate how and when minimum net worth
will be replenished and present marketing
and financial projections. These shall be
supported by suitable back-up material. The
discussion shall include possible alternate
funding sources, including invoking of
corporate parental guarantee. The plan will
include:
i. A detailed marketing plan with
enrollment projections for the next
two years.
ii. A projected balance sheet for the
next two years.
iii. A projected statement of revenues
and expenses on an accrual basis
for the next two years.
iv. A statement of cash flow projected
for the next two years.
v. A description of how to maintain
capital requirements and replenish
net worth.
vi. Sources and timing of capital shall
be specifically identified.
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3. The contractor may be required to obtain prior to
this contract and maintain "Stop-Loss" insurance,
pursuant to provisions in Article 8.3.2.
4. The contractor shall obtain prior to this contract
and maintain for the duration of this contract, any
extension thereof or for any period of liability
exposure, protection against insolvency pursuant to
provisions in G above and Article 8.2.
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ARTICLE THREE: MANAGED CARE MANAGEMENT INFORMATION SYSTEM
The contractor's MCMIS shall provide certain minimum functional capabilities as
described in this contract. The contractor shall have sophisticated information
systems capabilities that cannot only support the specific requirements of this
contract, but also respond to future program requirements. The DHS shall provide
the contractor with what the DHS, in its sole discretion, believes is sufficient
lead time to make system changes.
The various components of the contractor's MCMIS shall be sufficiently
integrated to effectively and efficiently support the requirements of this
contract. The contractor's MCMIS shall also be a collection point and repository
for all data required under this contract and shall provide comprehensive
information retrieval capabilities. Contractors with multiple systems and/or
subcontracted health care services shall integrate the data, at a minimum, to
provide for combined reporting and, as required, to support the required
processing functions.
3.1 GENERAL OPERATIONAL REQUIREMENTS FOR THE MCMIS
The following requirements apply to the contractor's MCMIS. Any
reference to "systems" in this Article shall mean contractor's MCMIS
unless otherwise specified. If the contractor subcontracts any MCMIS
functions, then these requirements apply to the subcontractor's
systems. For example, if the contractor contracts with a dental network
to provide services and pay claims/collect encounters, then these
requirements shall apply to the dental network's systems. However, if
the contractor contracts with a dental network only to provide dental
services, then these requirements do not apply.
3.1.1 ONLINE ACCESS
The system(s) shall provide online access for contractor use to all
major files and data elements within the MIS including enrollee
demographic and enrollment information, provider demographic and
enrollment data, processed claims and encounters, prior approvals,
referrals, reference files, and payment and financial transactions.
3.1.2 PROCESSING REQUIREMENTS
A. Timely Processing. The contractor shall provide for timely
updates and edits for all transactions on a schedule that
allows the contractor to meet the State's performance
requirements. In general, the State expects the following
schedule:
1. Enrollee and provider file updates to be daily
2. Reference file updates to be at least weekly or as
needed
3. Prior authorizations and referral updates to be daily
4. Claims and encounters to be processed (entered and
edited) daily
5. Claim payments to be at a minimum biweekly
6. Capitation payments to be monthly
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Specific update schedule requirements are identified in the
remaining subarticles of this Article.
B. Error Tracking and Audit Trails. The update and edit processes
for each transaction shall provide for the monitoring of
errors incurred by type of error and frequency. The system
shall maintain information indicating the errors failed, the
person making the corrections, when the correction was made,
and if the error was overridden on all critical transactions
(e.g., terminating enrollment or denying a claim). The major
update processes shall maintain sufficient audit trails to
allow reconstruction of the processing events.
C. Comprehensive Edits and Audits. The contractor's system shall
provide for a comprehensive set of automated edits and audits
that will ensure the data are valid, the benefits are covered
and appropriate, the payments are accurate and timely, other
insurance is maximized, and all of the requirements of this
contract are met.
D. System Controls and Balancing. The contractor's system shall
provide adequate control totals for balancing and ensuring
that all inputs are accounted for. The contractor shall have
operational procedures for balancing and validating all
outputs and processes. Quality checkpoints should be as
automated as possible.
E. Multimedia Input Capability. The system shall support a
variety of input media formats including hardcopy, diskette,
tape, clearing house, direct entry, electronic transmission or
other means, as defined by all federal and State laws and
regulations. The contractor may use any clearing house(s)
and/or alternatively provide for electronic submissions
directly from the provider to the contractor. These
requirements apply to claims/encounter and prior authorization
(PA), referral, and UM subsystems. Provider/vendor data must
be routed through the contractor when submitting
data/information to the State.
F. Backup/Restore and Archiving. The contractor shall provide for
periodic backup of all key processing and transaction files
such that there will be a minimum of interruption in the event
of a disaster. Unless otherwise agreed by the State, key
processes must be restored as follows:
1. Enrollment verification - twenty-four (24) hours
2. Enrollment update process - twenty-four (24) hours
3. Prior authorization/referral processing - twenty-four
(24) hours
4. Claims/encounter processing - seventy-two (72) hours
5. Encounter submissions to State - one (1) week
6. Other functions - two (2) weeks
The contractor shall demonstrate its restore capabilities at
least once a year. The contractor shall also provide for
permanent archiving of all major files for a period
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of no less than seven (7) years. The contractor's
backup/recover plan must be approved by State.
3.1.3 REPORTING AND DOCUMENTATION REQUIREMENTS
A. Regular Reporting. The contractor's system shall provide
sufficient reports to meet the requirements of this contract
as well as to support the efficient and effective operation of
its business functions. The required reports, including time
frames and format requirements, are in Section A of the
Appendices.
B. Ad Hoc Reporting. The contractor shall have the capability to
support ad hoc reporting requests, in addition to those listed
in this contract, both from its own organization and from the
State in a reasonable time frame. The time frame for
submission of the report will be determined by DMAHS with
input from the contractor based on the nature of the report.
DMAHS shall at its option request six (6) to eight (8) reports
per year, hardcopy or electronic reports and/or file extracts.
This does not preclude or prevent DMAHS from requiring, or the
contractor from providing, additional reports that are
required by State or federal governmental entities or any
court of competent jurisdiction.
C. System Documentation. The contractor shall update
documentation on its system(s) within 30 days of
implementation of the changes. The contractor's documentation
must include a system introduction, program overviews,
operating environment, external interfaces, and data element
dictionary. For each of the functional components, the
documentation should include where applicable program
narratives, processing flow diagrams, forms, screens, reports,
files, detailed logic such as claims pricing algorithms and
system edits. The documentation should also include job
descriptions and operations instructions. The contractor shall
have available current documentation on-site for State audit
as requested.
3.1.4 OTHER REQUIREMENTS
A. Future Changes. The system shall be easily modifiable to
accommodate future system changes/enhancements to claims
processing or other related systems at the same time as
changes take place in the State's MMIS. In addition, the
system shall be able to accommodate all future requirements
based upon federal and State statutes, policies and
regulations. Unless otherwise agreed by the State, the
contractor shall be responsible for the costs of these
changes.
B. Year 2000. The MCMIS shall meet the Office of Information
Technology (OIT) standards for Year 2000 compliance unless
otherwise approved by the Department. The OIT standards may be
accessed on the Internet at
xxxx://xxx.xxxxx.xx.xx/xxxxxxxx/xxxxxxxx/xxx0000x.xxx.
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3.2 ENROLLEE SERVICES
The MCMIS shall support all of the enrollee services as specified in
Article 5 of this contract. The system shall:
A. Capture and maintain contractor enrollment data
electronically.
B. Provide information so that the contractor can send plan
materials and information to enrollees.
C. Capture electronically the Primary Care Provider (PCP)
selections by enrollees.
D. Provide contractor enrollment and Medicaid information to
providers.
E. Maintain an enrollee complaint and grievance tracking system
for Medicaid and NJ FamilyCare enrollees.
F. Produce the required enrollee data reports.
The enrollee module(s) shall interface with all other required modules
and permit the access, search, and retrieval of enrollee data by key
fields, including date-sensitive information.
3.2.1 CONTRACTOR ENROLLMENT DATA
A. Enrollee Data. The contractor shall maintain a complete
history of enrollee information, including contractor
enrollment, primary care provider assignment, third party
liability coverage, and Medicare coverage. In addition, the
contractor shall capture demographic information relating to
the enrollee (age, sex, county, etc.), information related to
family linkages, information relating to benefit and service
limitations, and information related to health care for
enrollees with special needs.
B. Updates. The contractor shall accept and process a weekly
enrollment and eligibility file (the managed care register
files; See Section B.3.2 of the Appendices) within 48 hours of
receipt from the Department. The system shall provide reports
that identify all errors encountered, count all transactions
processed, and provide for a complete audit trail of the
update processes. The MCMIS shall accommodate the following
specific Medicaid/NJ FamilyCare requirements.
1. The contractor shall be able to access and identify
all enrollees by their Medicaid/NJ FamilyCare
Identification Number. This number shall be readily
cross-referenced to the contractor's enrollee number
and the enrollee's social security number. For DYFS
cases, it is important that the
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contractor's system be able to distinguish the DYFS
enrolled children from other cases and that mailings
to the DYFS enrolled children not be consolidated
based on the first 10 digits of the Medicaid ID
number because the family members may not be residing
together.
2. The system shall be able to link family members for
on-line inquiry access and for consolidated mailings
based on the first ten-digits of the Medicaid ID
number.
3. The system shall be able to identify newborns from
the date of birth, submit the proper eligibility form
to the State, and link the newborn record to the NJ
FamilyCare/Medicaid eligibility and enrollment data
when these data are received back from the State.
4. The system shall capture and maintain all of the data
elements provided by the Department on the weekly
update files.
5. The system shall allow for day-specific enrollment
into the contractor.
3.2.2 ENROLLEE PROCESSING REQUIREMENTS
The contractor's system shall support the enrollee processing
requirements of this contract. The system shall be modified/enhanced as
required to meet the contract requirements in an efficient manner and
ensure that each requirement is consistently and accurately
administered by the contractor. Materials shall be sent to the enrollee
or authorized representative, as applicable.
A. Enrollee Notification. The contractor shall issue contractor
plan materials and information to all new enrollees prior to
the effective date of enrollment or within seven (7) calendar
days following the receipt of weekly enrollment file specified
above, or, in case of retroactive enrollment, issue the
materials by the 1stof the subsequent month or within seven
(7) calendar days following receipt of the weekly enrollment
file. The specifications for the contractor plan materials and
information are listed in Article 5.8.
B. ID Cards. The contractor shall issue an Identification Card to
all new enrollees within ten (10) calendar days following
receipt of the weekly enrollment file specified above but no
later than seven (7) calendar days after the effective date of
enrollment.
The specifications for Identification Cards are in Article
5.8.5. The system shall produce ID cards that include the
information required in that Article. The contractor shall
also be able to produce replacement cards on request.
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C. PCP Selection. The contractor shall provide the enrollee with
the opportunity to select a PCP. If no selection is made by
the enrollee, the contractor shall assign the PCP for the
enrollee according to the timeframes specified in Article 5.9.
If the enrollee selects a PCP, the contractor shall process
the selection. The contractor is responsible for monitoring
the PCP capacity and limitations prior to assignment of an
enrollee to a PCP. The contractor shall notify the enrollee
accordingly if a selected PCP is not available.
The contractor shall notify the PCP of newly assigned
enrollees or any other enrollee roster changes that affect the
PCP monthly by the second working day of the month.
D. Other Enrollee Processing. The contractor's enrollee
processing shall also support the following:
1. Notification of State of any enrollee demographic
changes including date of death, change of address,
newborns, and commercial enrollment.
2. Generation of correspondence to enrollees based on
variable criteria, including PCP and demographic
information.
3.2.3 CONTRACTOR ENROLLMENT VERIFICATION
A. Electronic Verification System. The contractor shall provide a
system that supports the electronic verification of contractor
enrollment to network providers via the telephone 24 hours a
day and 365 days a year or on a schedule approved by the
State. This capability should require the enrollee's
contractor Identification Number, the Medicaid/NJ FamilyCare
Identification Number, or the Social Security Number. The
system should provide information on the enrollee's current
PCP as well as the enrollment information.
B. Telephone Enrollment Inquiry. The contractor shall provide
telephone operator personnel (both member services and
provider services) to verify contractor enrollment during
normal business hours. The contractor's telephone operator
personnel should have the capability to electronically verify
contractor enrollment based on a variety of fields, including
contractor Identification Number, Medicaid/NJ FamilyCare
Identification Number, Social Security Number, Enrollee Name,
Date of Birth, etc.
The contractor shall ensure that a recorded message is
available to providers when enrollment capability is
unavailable for any reason.
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3.2.4 ENROLLEE COMPLAINT AND GRIEVANCE TRACKING SYSTEM
The contractor shall develop an electronic system to capture and track
the content and resolution of enrollee complaints or grievances.
A. Data Requirements. The system shall capture, at a minimum, the
enrollee, the reason of the complaint or grievance, the date
the complaint or grievance was reported, the operator who
talked to the enrollee, the explanation of the resolution, the
date the complaint or grievance was resolved, the person who
resolved the complaint or grievance, referrals to other
departments, and comments including general information and/or
observations. See Article 5.15.
B. Processing and Reporting. The contractor shall identify trends
in complaint and grievance reasons and responsiveness to the
complaints or grievances. The system shall provide detail
reports to be used in tracking individual complaints and
grievances. The system shall also produce summary reports that
include statistics indicating the number of complaints and
grievances, the types, the dispositions, and the average time
for dispositioning, broken out by category of eligibility. See
Article 5.15.
3.2.5 ENROLLEE REPORTING
The contractor shall produce all of the reports according to the
timeframes and specifications outlined in Section A of the Appendices.
The contractor shall provide the State with a monthly file of enrollees
(See Section A.3.1 of the Appendices). The State's fiscal agent will
reconcile this file with the State's Recipient File. The contractor
shall provide for reconciling any differences and taking the
appropriate corrective action.
3.3 PROVIDER SERVICES
The contractor's system shall collect, process, and maintain current
and historical data on program providers. This information shall be
accessible to all parts of the MCMIS for editing and reporting.
3.3.1 PROVIDER INFORMATION AND PROCESSING REQUIREMENTS
A. Provider Data. The contractor shall maintain individual and
group provider network information with basic demographics,
EIN or tax identification number, professional credentials,
license and/or certification numbers and dates, sites, risk
arrangements (i.e., individual and group risk pools), services
provided, payment methodology and/or reimbursement schedules,
group/individual provider relationships, facility linkages,
number of grievances and/or complaints.
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For PCPs, the contractor shall maintain identification as
traditional or safety net provider, specialties, enrollees
with beginning and ending effective dates, capacity, emergency
arrangements or contact, other limitations or restrictions,
languages spoken, address, office hours, disability access.
See Article 5.
The contractor shall maintain provider history files and
provide for easy data retrieval. The system should maintain
audit trails of key updates.
Providers should be identified with a unique number. The
contractor shall be able to cross-reference its provider
number with the provider's EIN or tax number, the provider's
license number, UPIN, Medicaid provider number, and Medicare
provider number where applicable.
B. Updates. The contractor shall apply updates to the provider
file daily.
C. Complaint Tracking System. The system shall provide for the
capabilities to track and report provider complaints as
specified in Article 6.5. The contractor shall provide detail
reports identifying open complaints and summary statistics by
provider on the types of complaints, resolution, and average
time for resolution.
3.3.2 PROVIDER CREDENTIALING
A. Credentialing. The contractor shall credential and
re-credential each network provider as specified in Article
4.6.1. The system should provide a tracking and reporting
system to support this process.
B. Review. The contractor shall be able to flag providers for
review based on problems identified during credentialing,
information received from the State, information received from
HCFA, complaints, and in-house utilization review results.
Flagging providers should cause all claims to deny as
appropriate.
3.3.3 PROVIDER/ENROLLEE LINKAGE
A. Enrollee Rosters. The contractor shall generate electronic
and/or hard copy enrollee rosters to its PCPs each month by
the second business day of the month. The rosters shall
indicate all enrollees that are assigned to the PCP and should
provide the provider with basic demographic and enrollment
information related to the enrollee.
B. Provider Capacity. The contractor's system shall support the
provider network requirements described in Article 4.8.
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3.3.4 PROVIDER MONITORING
The contractor's system shall support monitoring and tracking of
provider/enrollee complaints, grievances and appeals from receipt to
disposition. The system shall be able to produce provider reports for
quality of medical and dental care analysis, flag and identify
providers with restrictive conditions (e.g., fraud monitoring), and
identify the confidentiality level of information (i.e., to manage who
has access to the information).
3.3.5 REPORTING REQUIREMENTS
The contractor shall produce all of the reports identified in Section A
of the Appendices. In addition, the system shall provide ongoing and
periodic reports to monitor provider activity, support provider
contracting, and provide administrative and management information as
required for the contractor to effectively operate.
3.4 CLAIMS/ENCOUNTER PROCESSING
The system shall capture and adjudicate all claims and encounters
submitted by providers. The major functions of this module(s) include
enrollee enrollment verification, provider enrollment verification,
claims and encounter edits, benefit determination, pricing, medical
review and claims adjudication, and claims payment. Once claims and
encounters are processed, the system shall maintain the
claims/encounter history file that supports the State's encounter
reporting requirements as well as all of the utilization management and
quality assurance functions and other reporting requirements of the
contractor.
3.4.1 GENERAL REQUIREMENTS
The contractor should have an automated claims and encounter processing
system that will support the requirements of this contract and ensure
the accurate and timely processing of claims and encounters. The
contractor should offer its providers an electronic payment option.
A. Input Processing. The contractor should support both hardcopy
and electronic submission of claims and encounters for all
claim types (hospital, medical, dental, pharmacy, etc.). The
contractor should also support hardcopy and electronic
submission of referral and authorization documents, claim
inquiry forms, and adjustment claims and encounters. Providers
shall be afforded a choice between an electronic or a hardcopy
submission. Electronic submissions include diskette, tape,
clearinghouse, electronic transmission, and direct entry. The
contractor must process all standard electronic formats
recognized by the State. The contractor may use any
clearinghouse(s) and/or alternatively provide for electronic
submission directly from providers to the contractor.
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The system shall maintain the receipt date for each document
(claim, encounter, referral, authorization, and adjustment)
and track the processing time from date of receipt to final
disposition.
B. Edits and Audits. The system shall perform sufficient edits to
ensure the accurate payment of claims and ensure the accuracy
and completeness of encounters that are submitted. Edits
should include, but not be limited to, verification of member
enrollment, verification of provider eligibility, field edits,
claim/encounter cross- check and consistency edits, validation
of code values, duplicate checks, authorization checks, checks
for service limitations, checks for service inconsistencies,
medical review, and utilization management. Pharmacy claim
edits shall include prospective drug utilization review
(ProDUR) checks.
The contractor shall comply with New Jersey law and
regulations to process records in error. (Note: Uncontested
payments to providers and uncontested portions of contested
claims should not be withheld pending final adjudication.)
C. Benefit and Reference Files. The system shall provide
file-driven processing for benefit determination, validation
of code values, pricing (multiple methods and schedules), and
other functions as appropriate. Files should include code
descriptions, edit criteria, and effective dates. The system
shall support the State's procedure and diagnosis coding
schemes and other codes that shall be submitted on the
hardcopy and electronic reports and files.
The system shall provide for an automated update to the
National Drug Code file including all product, packaging,
prescription, and pricing information.
The system shall provide online access to reference file
information. The system should maintain a history of the
pricing schedules and other significant reference data.
D. Claims/Encounter History Files. The contractor shall maintain
two (2) years active history of adjudicated claims and
encounter data for verifying duplicates, checking service
limitations, and supporting historical reporting. For drug
claims, the contractor may maintain nine (9) months of active
history of adjudicated claims/encounter data if it has the
ability to restore such information back to two (2) years and
provide for permanent archiving in accordance with Article
3.1.2F. Provisions should be made to maintain permanent
history by service date for those services identified as
"once-in-a-lifetime" (e.g., hysterectomy). The system should
readily provide access to all types of claims and encounters
(hospital, medical, dental, pharmacy, etc.) for combined
reporting of claims and encounters. Archive requirements are
described in Article 3.1.2F.
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3.4.2 COORDINATION OF BENEFITS
The contractor shall exhaust all other sources of payment prior to
remitting payment for a Medicaid enrollee.
A. Other Coverage Information. The contractor shall maintain
other coverage information for each enrollee. The contractor
shall verify the other coverage information provided by the
State pursuant to Article 8.13 and develop a system to include
additional other coverage information when it becomes
available. The contractor shall provide a periodic file of
updates to other coverage back to the State as specified in
Article 8.7.
B. Cost Avoidance. As provided in Article 8.13, except in certain
cases, the contractor shall attempt to avoid payment in all
cases where there is other insurance.
The system should have edits to identify potential other
coverage situations and flag the claims accordingly. The edits
should include looking for accident indicators, other coverage
information from the claims, other coverage information on
file for the enrollee, and potential accident/injury
diagnoses.
C. Postpayment Recoupments. Where other insurance is discovered
after the fact, for the exceptions identified in 8.13, and for
encounters, recoveries shall be initiated on a postpayment
basis.
D. Personal Injury Cases. These cases should be referred to the
Department for recovery.
E. Medicare. The contractor's system shall provide for
coordinating benefits on enrollees that are also covered by
Medicare. See Article 8.13.
F. Reporting and Tracking. The contractor's system shall identify
and track potential collections. The system should produce
reports indicating open receivables, closed receivables,
amounts collected, and amounts written off.
3.4.3 REPORTING REQUIREMENTS
A. General. The contractor's operational reports shall be
created, maintained and made available for audit by State
personnel and will include, but will not be limited to, the
following:
1. Claims Processing Statistics
2. Inventory and Claims Aging Statistics
3. Error Reports
4. Contested Claims and Encounters
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5. Aged Claims and Encounters
6. Checks and EOB(s)
7. Lag Factors and IBNR
B. The contractor shall produce reports according to the
timeframes and specification outlined in Section A of the
Appendices.
3.5 PRIOR AUTHORIZATION, REFERRAL AND UTILIZATION MANAGEMENT
The prior authorization/referral and utilization management functions
shall be an integrated component of the MCMIS. It shall allow for
effective management of delivery of care. It shall provide a
sophisticated environment for managing the monitoring of both inpatient
and outpatient care on a proactive basis.
3.5.1 FUNCTIONS AND CAPABILITIES
A. Prior Authorizations. The contractor shall provide an
automated system that includes the following:
1. Enrollee eligibility, utilization, and case
management information.
2. Edits to ensure enrollee is eligible, provider is
eligible, and service is covered.
3. Predefined treatment criteria to aid in adjudicating
the requests.
4. Notification to provider of approval or denial.
5. Notification to enrollees of any denials or cutbacks
of service.
6. Interface with claims processing system for editing.
B. Referrals. The contractor shall provide an automated system
that includes the following:
1. Ability for providers to enter referral information
directly, fax information to the contractor, or call
in on dedicated phone lines.
2. Interface with claims processing system for editing.
C. Utilization Management. The contractor should provide an
automated system that includes the following:
1. Provides case tracking, notifies the case worker of
outstanding actions.
2. Provide case history of all activity.
3. Provide online access to cases by enrollee and
provider numbers.
4. Includes an automated correspondence generator for
letters to clients and network providers.
5. Reports for case analysis, concurrent review, and
case follow up including hospital admissions,
discharges, and census reports.
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D. Fraud and Abuse. The contractor shall have a system that
supports the requirements in Article 7.40 to identify
potential and/or actual instances of fraud, abuse,
underutilization and/or overutilization and shall meet the
reporting requirements in Section A of the Appendices.
3.5.2 REPORTING REQUIREMENTS
The contractor's system shall support the reporting requirements as
described in Section A of the Appendices.
3.6 FINANCIAL PROCESSING
The contractor's system shall provide for financial processing to
support the requirements of the contract and the contractor's
operations.
3.6.1 FUNCTIONS AND CAPABILITIES
A. General. The system shall provide the necessary data for all
accounting functions including claims payment, capitation
payment, capitation reconciliation, recoupments, recoveries,
accounts receivable, accounts payable, general ledger, and
bank reconciliation. The financial module shall provide the
contractor's management with information to demonstrate the
contractor is meeting, exceeding or falling short of its
fiscal and level of risk goals. It shall interface with other
relevant modules. The information shall provide management
with the necessary tools to monitor financial performance,
make prompt payments on financial obligations, monitor
accounts receivables, and keep accurate and complete financial
records.
Reports should:
1. Provide information useful in making business and
economic decisions.
2. Provide information that will allow the Department to
monitor the future cash flow of the contractor
resulting from this contract.
3. Provide information relative to an enterprise's
economic resources, the claims on those resources,
and the effects of transactions, events and
circumstances that change resources and claims to
resources.
4. Generate data to evaluate the contractor's operations
(i.e., indicators of risk, efficiency,
capitalization, and profitability).
5. Provide support for detailed actuarial analysis of
the operations performed under the contract resulting
from this contract.
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6. Provide other information that is useful in
evaluating important past events or predicting
meaningful future events.
B. Specific Functions. The contractor's system shall provide for
integration of the financial system with the claims and
encounter system. At a minimum the system shall:
1. Update the specific claim records in the claims
history if payments are voided or refunded.
2. Update the specific claims records in the claims
history if amounts are recovered.
3. Update capitation history if payments are voided or
refunded.
4. Provide for liens and withholds of payments to
providers.
5. Provide for reissuing lost or stolen checks.
6. Provide for automatic recoupment if a claim is
adjusted and results in a negative payment.
3.6.2 REPORTING PRODUCTS
Report descriptions and criteria required by the State for the
financial portion of the system are set forth in Section A of the
Appendices.
3.7 QUALITY ASSURANCE
The contractor's system shall produce reports for analysis that focus
on the review and assessment of quality of care given, the detection of
over- and under-utilization, the development of user-defined criteria
and standards of care, and the monitoring of corrective actions.
3.7.1 FUNCTIONS AND CAPABILITIES
A. General. The system shall provide data to assist in the
definition and establishment of contractor performance
measurement standards, norms and service criteria.
1. The system shall provide reports to monitor and
identify deviations of patterns of treatment from
established standards or norms and established
baselines. These reports shall profile utilization of
providers and enrollees and compare them against
experience and norms for comparable individuals.
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2. The system should provide cost utilization reports by
provider and service in various arrays.
3. It should maintain data for medical and dental
assessments and evaluations.
4. It should collect, integrate, analyze, and report
data necessary to implement the Quality Assessment
and Performance Improvement (QAPI) program.
5. It should collect data on enrollee and provider
characteristics and on services furnished to
enrollees, as needed to guide the selection of
performance improvement project topics and to meet
the data collection requirements for such projects.
6. It should collect data in standardized formats to the
extent feasible and appropriate. The contractor must
review and ensure that data received from providers
are accurate, timely, and complete.
7. Reports should facilitate at a minimum monthly
tracking and trending of enrollee care issues to
monitor and assess contractor and provider
performance and services provided to enrollees.
8. Reports should monitor xxxxxxxx for evidence of a
pattern of inappropriate xxxxxxxx, services, and
assess potential mispayments as a result of such
practices.
9. Reports should support tracking utilization control
function(s) and monitoring activities for out-of-area
and emergency services.
B. Specific Capabilities. The system should:
1. Include a database for utilization, referrals,
tracking function for utilization controls, and
consultant services.
2. Accommodate and apply standard norms/criteria and
medical and dental policy standards for quality of
care and utilization review.
3. Include all types of claims and encounters data along
with service authorizations and referrals.
4. Include pharmacy utilization data from MH/SA
providers.
5. Interface, as applicable, with external utilization
and quality assurance/measurement software programs.
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6. Include tracking of coordination requirements with
MH/SA providers.
7. Include ability to protect patient confidentiality
through the use of masked identifiers and other
safeguards as necessary.
C. Measurement Functions. The system should include:
1. Ability to track review committee(s) functions when
case requires next review and/or follow-up.
2. Track access, use and coordination of services.
3. Provide patient satisfaction data through use of
enrollee surveys, grievance, complaint/appeals
processes, etc.
4. Generate HEDIS reports in the version specified by
the State.
3.7.2 REPORTING PRODUCTS
The system shall support the reporting requirements and other functions
described in Article 4 and Section A of the Appendices.
3.8 MANAGEMENT AND ADMINISTRATIVE REPORTING
The MCMIS shall have a comprehensive reporting capability to support
the reporting requirements of this contract and the management needs
for all of the contractor operations.
3.8.1 GENERAL REQUIREMENTS
A. Purpose. The reports should provide information to determine
and review fiscal viability, to evaluate the appropriateness
of care rendered, and to identify reporting/billing problems
and provider practices that are at variance with the norm, and
measure overall performance.
B. General Capabilities. MCMIS reporting capabilities shall
include the capabilities to access relatively small amounts of
data very quickly as well as to generate comprehensive reports
using multiple years of historical claims and encounter data.
The contractor shall provide a management and administrative
reporting system that allows full access to all of the
information utilized in the MCMIS. The contractor shall
provide a solution that makes all data contained in any
subcontractor's MIS available to authorized users through the
use of the various software that provides the capabilities
detailed in the following Articles.
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C. Regular Reports. The system shall generate a comprehensive set
of management and administrative management reports that
facilitate the oversight, evaluation, and management of this
program as well as the contractor's other operations.
The system should provide the capability for pre-defined,
parameter driven report/trend alerts. The system shall have
the capability to select important and specific parameters of
utilization, and have specified users alerted when these
parameters are being exceeded. For example, the State may want
to monitor the use of a specific drug as treatment for a
specific condition.
D. The contractor shall acquire the capability to receive and
transmit data in a secure manner electronically to and from
the State's data centers, which are operated by OIT. The
standard data transfer software that OIT utilizes for
electronic data exchange is Connect: Direct. Both mainframe
and PC versions are available. A dedicated line is preferred,
but at a minimum connectivity software can be used for the
connection.
3.8.2 QUERY CAPABILITIES
The contractor's MCMIS should have a sophisticated, query tool with
access to all major files for the users.
A. General. The system should provide a user-friendly, online
query language to construct database queries to data available
across all of the database(s), down to raw data elements. It
should provide options to select query output to be displayed
on-line, in a formatted hard-copy report, or downloaded to
disk for PC-based analysis.
B. Unduplicated Counts. The system should provide the capability
to execute queries that perform unduplicated counts (e.g.,
unduplicated count of original beneficiary ID number),
duplicated counts (e.g., total number of services provided for
a given aid category), or a combination of unduplicated and
duplicated counts.
3.8.3 REPORTING CAPABILITIES
The contractor should provide reporting tools with its MCMIS that
facilitate ad hoc, user, and special reporting. The MCMIS should
provide flexible report formatting/editing capabilities that meet the
contractor's business requirements and support the Department's
information needs. For example, it should provide the ability to
import, export and manipulate data files from spreadsheet, word
processing and database management tools as well as the database(s) and
should provide the capability to indicate header information, date and
run time, and page numbers on reports. The system should provide
multiple pre-defined report types and formats that are easily selected
by users.
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3.9 ENCOUNTER DATA REPORTING
The contractor shall collect, process, format, and submit electronic
encounter data for all services delivered for which the contractor is
responsible. The contractor shall capture all required encounter data
elements using coding structures recognized by the Department. The
contractor shall process the encounter data, integrating any manual or
automated systems to validate the adjudicated encounter data. The
contractor shall interface with any systems or modules within its
organization to obtain the required encounter data elements. The
contractor shall submit the encounter data to the Department's fiscal
agent electronically, via diskette, tape, or electronic transmission,
according to specifications in the Electronic Media Claims (EMC) Manual
found in Section B.3.3 of the Appendices. The encounter data processing
system shall have a data quality assurance plan to include timely data
capture, accurate and complete encounter records, and internal data
quality audit procedures. If DMAHS determines that changes are
required, the contractor shall be given advance notice and time to make
the change according to the extent and nature of the required change.
3.9.1 REQUIRED ENCOUNTER DATA ELEMENTS
A. All Types of Claims. The contractor shall capture all required
encounter data elements for each of the eight claim types:
Inpatient, Outpatient, Professional, Home Health,
Transportation, Vision, Dental, and Pharmacy.
B. Data Elements. The required data elements are provided in
Section A.7.11 and Section B.3.3 of the Appendices. Note that
New Jersey-specific Medicaid codes are required in some
fields. Providers shall be identified using the provider's EIN
or tax identification number. Inpatient hospital claims and
encounters shall be combined into a single stay when the
enrollee's dates of services are consecutive.
C. Contractor Encounter. The contractor shall submit encounter
data for claims and encounters received by the contractor. The
contractor shall identify a capitated arrangement versus a
"fee-for-service" arrangement for each of its network
providers. For noncapitated arrangements, the contractor shall
report the actual payment made to the provider for each
encounter. For capitated arrangements, the contractor may
report a zero payment for each encounter. However, a monthly
"Capitation Summary Record" shall be required for each
provider type, beneficiary capitation category, and service
month combination. The specifications for the submission of
monthly capitation summary records is further detailed in the
EMC Manual, found in Section B.3.3 of the Appendices.
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3.9.2 SUBMISSION OF TEST ENCOUNTER DATA
A. Submitter ID. The contractor shall make application in order
to obtain a Submitter Identification Number, according to the
instructions listed in the EMC Manual found in Section B.3.3
of the Appendices.
B. Test Requirement. The contractor shall be required to pass a
testing phase for each of the eight encounter claim types
before production encounter data will be accepted. The
contractor shall pass the testing phase for all encounter
claim type submissions within twelve (12) calendar weeks from
the award date of the contract. Contractors with prior
contracting experience with DHS who have successfully passed
test phases and have successfully submitted approved
production data may be exempted at DHS's option.
The contractor shall submit the test encounter data to the
Department's fiscal agent electronically, via diskette, tape,
or electronic transmission, according to the specifications of
the Electronic Media Claims (EMC) Manual found in Section
B.3.3 of the Appendices.
The contractor shall be responsible for passing a two-phased
test for each encounter claim type. The first phase requires
that each submitted file follows the prescribed format, that
header and trailer records are present and correctly located
within the file, and that the key fields are present. The
second phase requires that the required data elements are
present and properly valued.
Following each submission, an error report will be forwarded
to the contractor identifying the file and record location of
each error encountered for both testing phases. The contractor
shall analyze the report, complete the necessary corrections,
and re-submit the encounter data test file(s).
The contractor shall utilize production encounter data,
systems, tables, and programs when processing encounter test
files. The contractor shall submit error- free production data
once testing has been approved for all of the encounter claims
types.
3.9.3 SUBMISSION OF PRODUCTION ENCOUNTER DATA
A. Adjudicated Claims and Encounters. The contractor shall submit
all adjudicated encounter data for all services provided for
which the contractor is responsible. Adjudicated encounter
data are defined as data from claims and encounters that the
contractor has processed as paid or denied. The contractor is
not responsible for submitting contested claims or encounters
until final adjudication has been determined.
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B. Schedule. Encounter data shall be submitted per the schedule
established by the Department. Each submission shall include
encounter data that were adjudicated in the prior period and
any adjustments for encounter data previously submitted.
C. Two-Phase Process. Similar to testing, the contractor shall be
responsible for passing a two-phased test for all production
encounter data submitted. The first phase requires each
submitted file follow the prescribed format, that header and
trailer records are present and correctly located within the
file, and that the key fields are present. The second phase
requires that the required data elements are present and
properly valued.
D. Phase One Errors. If all or part of a production encounter
file(s) rejects during phase one, an error report will be
forwarded to the contractor identifying the file and record
location of each error encountered. The contractor shall
analyze the report, complete the necessary corrections, and
re-submit the "rejected" encounter production data within
forty-five (45) calendar days from the date the contractor
receives the notice of error(s).
E. The contractor shall not be permitted to provide services
under this contract nor shall the contractor receive
capitation payment until it has passed the testing and
production submission of encounter data.
3.9.4 REMITTANCE ADVICE
A. Remittance Advice File Processing Report. The Department's
fiscal agent shall produce a Remittance Advice File on a
monthly basis that itemizes all processed encounters. The
contractor shall be responsible for the acceptance and
processing of a Remittance Advice (RA) File according to the
specifications listed in the EMC Manual found in Section B.3.3
of the Appendices. The Remittance Advice File is produced on
magnetic tape and contains all submitted encounter data that
passed phase one testing. The disposition (paid or denied)
shall be reported for each encounter along with the "phase
two" errors for those claims that New Jersey Medicaid denied.
B. Reconciliation. The contractor shall be responsible for
matching the encounters on the Remittance Advice File against
the contractor's data files(s). The contractor shall correct
any encounters that denied improperly and/or any other
discrepancies noted on the file. Corrections shall be
resubmitted within thirty (30) calendar days from the date the
contractor receives the Remittance Advice File.
All corrections to "denied" encounter data, as reported on the
Remittance Advice File, shall be resubmitted as "full record"
adjustments, according to the requirements listed in the EMC
Manual found in Section B.3.3 of the Appendices.
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3.9.5 SUBCONTRACTS AND ENCOUNTER DATA REPORTING FUNCTION
A. Interfaces. All encounter data shall be submitted to the
Department directly by the contractor. DMAHS shall not accept
any encounter data submissions or correspondence directly from
any subcontractors, and DMAHS shall not forward any electronic
media, reports or correspondence directly to a subcontractor.
The contractor shall be required to receive all electronic
files and hardcopy material from the Department, or its
appointed fiscal agent, and distribute them within its
organization or to its subcontractors appropriately.
B. Communication. The contractor and its subcontractors shall be
represented at all DMAHS meetings scheduled to discuss any
issue related to the encounter function requirements.
3.9.6 FUTURE ELECTRONIC ENCOUNTER SUBMISSION REQUIREMENTS
At the present time, the Health Care Financing Administration (HCFA) is
pursuing a standardization of all electronic health care information,
including encounter data. The contractor shall be responsible for
completing and paying for any modifications required to submit
encounter data electronically, according to the same specifications and
timeframes outlined by HCFA for the New Jersey MMIS.
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ARTICLE FOUR: PROVISION OF HEALTH CARE SERVICES
4.1 COVERED SERVICES
For enrollees who are eligible through Title XIX or the NJ FamilyCare
program the contractor shall provide or arrange to have provided
comprehensive, preventive, and diagnostic and therapeutic, health care
services to enrollees that include all services that Medicaid
beneficiaries are entitled to receive under Medicaid, subject to any
limitations and/or excluded services as specified in this Article.
Provision of these services shall be equal in amount, duration, and
scope as established by the Medicaid program, in accordance with
medical necessity and without any predetermined limits, unless
specifically stated, and as set forth in 42 C.F.R. Part 440; 42 C.F.R.
Part 434; the Medicaid State Plan; the Medicaid Provider Manuals: The
New Jersey Administrative Code, Title 10, Department of Human Services
Division of Medical Assistance and Health Services; Medicaid/NJ
FamilyCare Alerts; Medicaid/NJ FamilyCare Newsletters; and all
applicable federal and State statutes, rules, and regulations.
4.1.1 GENERAL PROVISIONS AND CONTRACTOR RESPONSIBILITIES
A. With the exception of certain emergency services described in
Article 4.2.1 of this contract, all care covered by the
contractor pursuant to the benefits package must be provided,
arranged, or authorized by the contractor or a participating
provider.
B. The contractor and its providers shall furnish all covered
services required to maintain or improve health in a manner
that maximizes coordination and integration of services, and
in accordance with professionally recognized standards of
quality and shall ensure that the care is appropriately
documented to encompass all health care services for which
payment is made.
C. For beneficiaries eligible solely through the NJ FamilyCare
Plan A the contractor shall provide the same managed care
services and products provided to enrollees who are eligible
through Title XIX. For beneficiaries eligible solely through
the NJ FamilyCare Plans B and C the contractor shall provide
the same managed care services and products provided to
enrollees who are eligible through Title XIX with the
exception of limitations on EPSDT coverage as indicated in
Articles 4.1.2A.3 and 4.2.6A.2. NJ FamilyCare Plan D and other
plans have a different service package specified in Article
4.1.6.
D. Out-of-Area Coverage. The contractor shall provide or arrange
for out-of-area coverage of contracted benefits in emergency
situations and non-emergency situations when travel back to
the service area is not possible, is impractical, or when
medically necessary services could only be provided elsewhere.
The contractor shall not be responsible for out-of-state
coverage for routine care if the enrollee resides out-of-state
for more than 30 days. For full time students
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attending school and residing out of the country, the
contractor shall not be responsible for health care benefits
while the individual is in school.
E. Existing Plans of Care. The contractor shall honor and pay for
plans of care for new enrollees, including prescriptions,
durable medical equipment, medical supplies, prosthetic and
orthotic appliances, and any other on-going services initiated
prior to enrollment with the contractor. Services shall be
continued until the enrollee is evaluated by his/her primary
care physician and a new plan of care is established with the
contractor.
The contractor shall use its best efforts to contact the new
enrollee or, where applicable, authorized person and/or
contractor care manager. However, if after documented,
reasonable outreach (i.e., mailers, certified mail, use of
MEDM system provided by the State, contact with the Medicaid
District Office (MDO), DDD, or DYFS to confirm addresses
and/or to request assistance in locating the enrollee) the
enrollee fails to respond within 20 working days of certified
mail, the contractor may cease paying for the pre-existing
service until the enrollee or, where applicable, authorized
person, contacts the contractor for re-evaluation.
F. Routine Physicals. The contractor shall provide for routine
physical examinations required for employment, school, camp or
other entities/programs that require such examinations as a
condition of employment or participation.
G. Non-Participating Providers. The contractor shall pay for
services furnished by non-participating providers to whom an
enrollee was referred, even if erroneously referred, by
his/her PCP or network specialist. Under no circumstances
shall the enrollee bear the cost of such services when
referral errors by the contractor or its providers occur. It
is the sole responsibility of the contractor to provide
regular updates on complete network information to all its
providers as well as appropriate policies and procedures for
provider referrals.
H. The contractor shall have policies and procedures on the use
of enrollee self-referred services.
I. The contractor shall have policies and procedures on how it
will provide for genetic testing and counseling.
J. Second Opinions. The contractor shall have a Second Opinion
program that can be utilized at the enrollee's option for
diagnosis and treatment of serious medical conditions, such as
cancer and for elective surgical procedures. The program shall
include at a minimum: hernia repair (simple) for adults (18
years or older), hysterectomy (elective procedures), spinal
fusion (except for children under 18 years of age with a
diagnosis of scoliosis or xxxxx bifida), and laminectomy
(except for children under 18 years of age with a diagnosis of
scoliosis). The plan shall be incorporated into the
contractor's medical procedures. The exceptions
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noted do not require second surgical opinion before surgery
can be performed. The Second Opinion program shall be
incorporated into the contractor's medical procedures and
submitted to DMAHS for review and approval.
K. Unless otherwise required by this contract, the contractor
shall make no distinctions with regard to the provision of
services to Medicaid and NJ FamilyCare enrollees and the
provision of services provided to the contractor's
non-Medicaid/NJ FamilyCare enrollees.
L. DMAHS may intercede on an enrollee's behalf when DMAHS deems
it appropriate for the provision of medically necessary
services and to assist enrollees with the contractor's
operations and procedures which may cause undue hardship for
the enrollee. In the event of a difference in interpretation
of contractually required service provision between the
Department and the contractor, the Department's interpretation
shall prevail until a formal decision is reached, if
necessary.
M. A New Jersey Care 2000+ enrollee who seeks self-initiated care
from a non-participating provider without referral/
authorization shall be held responsible for the cost of care.
The enrollee shall be fully informed of the requirement to
seek care when it is available within the network and the
consequences of obtaining unauthorized out-of-network care for
covered services.
N. Protection of Enrollee -- Provider Communications. Health care
professionals may not be prohibited from advising their
patients about their health status or medical care or
treatment, regardless of whether this care is covered as a
benefit under the contract.
O. Medical or Dental Procedures. For procedures that may be
considered either medical or dental such as surgical
procedures for fractured jaw or removal of cysts, the
contractor shall establish written policies and procedures
clearly and definitively delineated for all providers and
administrative staff, indicating that either a physician
specialist or oral surgeon may perform the procedure and when,
where, and how authorization, if needed, shall be promptly
obtained.
4.1.2 BENEFIT PACKAGE
A. The following categories of services shall be provided by the
contractor for all Medicaid and NJ FamilyCare Plans A, B, and
C enrollees, except where indicated. See Section B.4.1 of the
Appendices for complete definitions of the covered services.
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1. Primary and Specialty Care by physicians and, within
the scope of practice and in accordance with State
certification/licensure requirements, standards and
practices, by Certified Nurse Midwives, Certified
Nurse Practitioners, Clinical Nurse Specialists, and
Physician Assistants
2. Preventive Health Care and Counseling and Health
Promotion
3. Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) Program Services
For NJ FamilyCare Plans B and C participants,
coverage includes early and periodic screening and
diagnosis medical examinations, dental, vision,
hearing, and lead screening services. It includes
only those treatment services identified through the
examination that are available under the contractor's
benefit package or specified services under the FFS
program.
4. Emergency Medical Care
5. Inpatient Hospital Services including acute care
hospitals, rehabilitation hospitals, and special
hospitals
6. Outpatient Hospital Services
7. Laboratory Services [Except routine testing related
to administration of Clozapine and the other
psychotropic drugs listed in Article 4.1.4B for
non-DDD clients.]
8. Radiology Services -- diagnostic and therapeutic
9. Prescription Drugs (legend and non-legend covered by
the Medicaid program) -- For payment method for
Protease Inhibitors and blood clotting factors VIII
and IX, and coverage of certain other anti-
retrovirals under NJ FamilyCare, see Article 8.
10. Family Planning Services and Supplies
11. Audiology
12. Inpatient Rehabilitation Services
13. Podiatrist Services
14. Chiropractor Services
15. Optometrist Services
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00. Optical Appliances
17. Hearing Aid Services
18. Home Health Agency Services -- Not a
contractor-covered benefit for the non-dually
eligible ABD population.
19. Hospice Agency Services
20. Durable Medical Equipment (DME)/Assistive Technology
Devices in accordance with existing Medicaid
regulations
21. Medical Supplies
22. Prosthetics and Orthotics including certified shoe
provider
23. Dental Services
24. Organ Transplants
25. Transportation Services for any contractor-covered
service or non-contractor covered service including
ambulance, mobile intensive care units (MICUs) and
invalid coach (including lift equipped vehicles)
26. Post-acute Care
27. Mental Health/Substance Abuse Services for enrollees
who are clients of the Division of Developmental
Disabilities
B. Conditions Altering Mental Status. Those diagnoses which are
categorized as altering the mental status of an individual but
are of organic origin shall be part of the contractor's
medical, financial and care management responsibilities for
all categories of enrollees. These include the diagnoses in
the following ICD-9-CM Series:
1. 290.0 Senile dementia, simple type
2. 290.1 Presenile dementia
3. 290.3 Senile dementia with acute confusional state
4. 290.4 Arteriosclerotic dementia uncomplicated
5. 290.8 Other
6. 290.9 Unspecified
7. 291.1 Korsakov's psychosis, alcoholic
8. 291.2 Other alcoholic dementia
9. 292.82 Drug induced dementia
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10. 292.9 Unspecified drug induced mental disorders
11. 293.0 Acute delirium
12. 293.1 Subacute delirium
13. 294.0 Amnestic syndrome
14. 294.1 Dementia in conditions classified elsewhere
15. 294.8 Other specified organic brain syndromes
(chronic)
16. 294.9 Unspecified organic brain syndrome (chronic)
17. 305.1 Non-dependent abuse of drugs - tobacco
18. 310.0 Frontal lobe syndrome
19. 310.2 Postconcussion syndrome
20. 310.8 Other specified nonpsychotic mental disorder
following organic brain damage
21. 310.9 Unspecified nonpsychotic mental disorder
following organic brain damage
In addition, the contractor shall retain responsibility for
delivering all covered Medicaid mental health/substance abuse
services to enrollees who are clients of the Division of
Developmental Disabilities (referred to as "clients of DDD").
Articles Four and Five contain further information regarding
clients of DDD.
4.1.3 SERVICES REMAINING IN FEE-FOR-SERVICE PROGRAM AND MAY NECESSITATE
CONTRACTOR ASSISTANCE TO THE ENROLLEE TO ACCESS THE SERVICES
A. The following services provided by the New Jersey Medicaid
program under its State plan shall remain in the
fee-for-service program but may require medical orders by the
contractor's PCPs/providers. These services shall not be
included in the contractor's capitation.
1. Personal Care Assistant Services (not covered for NJ
FamilyCare Plans B and C)
2. Medical Day Care (not covered for NJ FamilyCare Plans
B and C)
3. Outpatient Rehab - Physical therapy, occupational
therapy, and speech pathology services (For NJ
FamilyCare Plans B & C enrollees, limited to 60 days
per therapy per year)
4. Abortions and related services including surgical
procedure, cervical dilation, insertion of cervical
dilator, anesthesia including para cervical block,
history and physical examination on day of surgery;
lab tests including PT, PTT, OB Panel (includes
hemogram, platelet count, hepatitis B surface
antigen, rubella antibody, VDRL, blood typing ABO and
Rh, CBC and differential), pregnancy test, urinalysis
and urine drug
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screen, glucose and electrolytes; routine
venapuncture; ultrasound, pathological examination of
aborted fetus; Rhogam and its administration.
5. Transportation - lower mode (not covered for NJ
FamilyCare Plans B and C)
6. Sex Abuse Examinations
7. Services Provided by New Jersey MH/SA and DYFS
Residential Treatment Facilities or Group Homes. For
enrollees living in residential facilities or group
homes where ongoing care is provided, contractor
shall cooperate with the medical, nursing, or
administrative staff person designated by the
facility to ensure that the enrollees have timely and
appropriate access to contractor providers as needed
and to coordinate care between those providers and
the facility's employed or contracted providers of
health services. Medical care required by these
residents remains the contractor's responsibility
providing the contractor's provider network and
facilities are utilized.
8. Family Planning Services and Supplies when furnished
by a non-participating provider
9. Home health agency services for the non-dually
eligible ABD population
B. Dental Services. For those dental services specified below
that are initiated by a Medicaid non-New Jersey Care 2000+
provider prior to first time New Jersey Care 2000+ enrollment,
an exemption from contractor-covered services based on the
initial managed care enrollment date will be provided and the
services paid by Medicaid FFS. The exemption shall only apply
to those beneficiaries who have initially received these
services during the 60 or 120 day period immediately prior to
the initial New Jersey Care 2000+ enrollment date.
1. Procedure Codes to be paid by Medicaid FFS up to 60
days after first time New Jersey Care 2000+
enrollment:
02710 02792 03430
02720 02950 05110
02721 02952 05120
02722 02954 05211
02750 03310 05211-52
02751 03320 05212
02752 03330 05212-52
02790 03410-22 05213
02791 03411 05214
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2. Procedure Codes to be paid by Medicaid FFS up to 120
days from date of last preliminary extractions after
patient enrolls in New Jersey Care 2000+ (applies to
tooth codes 5 - 12 and 21 - 28 only):
05130
05130-22
05140
05140-22
3. Extraction Procedure Codes to be paid by Medicaid FFS
up to 120 days from last date of preliminary
extractions after first time New Jersey Care 2000+
enrollment in conjunction with the following codes
(05130, 05130- 22, 05140, 05140-22):
07110
07130
07210
4.1.4 MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR
A. Mental Health/Substance Abuse. The following mental
health/substance abuse services (except for the conditions
listed in 4.1.2.B) will be managed by the State or its agent
for non-DDD enrollees, including all NJ FamilyCare enrollees.
(The contractor will retain responsibility for furnishing
mental health/substance abuse services, excluding the cost of
the drugs listed below, to Medicaid enrollees who are clients
of the Division of Developmental Disabilities).
- Substance Abuse Services--diagnosis, treatment, and
detoxification
- Costs for Methadone and its administration
- Mental Health Services
B. Drugs. The following drugs will be paid fee-for-service by the
Medicaid program for all DMAHS enrollees:
- Clozapine
- Risperidone
- Olanzapine
- Quetiapine
- Methadone - cost and its administration. Except as
provided in Article 4.4, the contractor will remain
responsible for the medical care of enrollees
requiring substance abuse treatment
- Generically-equivalent drug products of the drugs
listed in this section.
C. Up to twelve (12) inpatient hospital days required for social
necessity
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D. DDD/CCW waiver services: individual supports (which includes
personal care and training), habilitation, case management,
respite, and Personal Emergency Response Systems (PERS).
4.1.5 INSTITUTIONAL FEE-FOR-SERVICE BENEFITS - NO COORDINATION BY THE
CONTRACTOR
The following institutional services shall remain in the
fee-for-service program without requiring coordination by the
contractor. In addition, Medicaid beneficiaries participating in a
waiver (except the Division of Developmental Disabilities Community
Care Waiver) or demonstration program or admitted for long term care
treatment in one of the following shall be disenrolled from the
contractor's plan on the date of admission to institutionalized care.
A. Nursing Facility care (if the admission is only for inpatient
rehabilitation/postacute care services and is less than 30
days, the enrollee will not be disenrolled).
B. Inpatient psychiatric services (except for RTCs) for
individuals under age 21 and 65 and over - Services that are
provided:
1. Under the direction of a physician;
2. In a facility or program accredited by the Joint
Commission on Accreditation of Health Care
Organizations; and
3. Meet the federal and State requirements.
C. Intermediate Care Facility/Mental Retardation Services - Items
and services furnished in an intermediate care facility for
the mentally retarded.
D. Waiver (except Division of Developmental Disabilities
Community Care Waiver) and demonstration program services.
4.1.6 BENEFIT PACKAGE FOR NJ FAMILYCARE PLAN D
A. Services Included In The Contractor's Benefits Package for NJ
FamilyCare Plan D. The following services shall be provided
and case managed by the contractor:
1. Primary Care
a. All physicians services, primary and
specialty
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b. In accordance with state
certification/licensure requirements,
standards, and practices, primary care
providers shall also include access to
certified nurse midwifes, certified nurse
practitioners, clinical nurse specialists,
and physician assistants
c. Services rendered at independent clinics
that provide ambulatory services
d. Federally Qualified Health Center primary
care services
2. Emergency room services
3. Family Planning Services, including medical history
and physical examinations (including pelvic and
breast), diagnostic and laboratory tests, drugs and
biologicals, medical supplies and devices,
counseling, continuing medical supervision,
continuity of care and genetic counseling
Services provided primarily for the diagnosis and
treatment of infertility, including sterilization
reversals, and related office (medical and clinic)
visits, drugs, laboratory services, radiological and
diagnostic services and surgical procedures are not
covered by the NJ FamilyCare program. Obtaining
family planning services from providers outside the
contractor's provider network is not available to NJ
FamilyCare Plan D enrollees.
4. Home Health Care Services -- Limited to skilled
nursing for a home bound beneficiary which is
provided or supervised by a registered nurse, and
home health aide when the purpose of the treatment is
skilled care; and medical social services which are
necessary for the treatment of the beneficiary's
medical condition
5. Hospice Services
6. Inpatient Hospital Services, including general
hospitals, special hospitals, and rehabilitation
hospitals. The contractor shall not be responsible
when the primary admitting diagnosis is mental health
or substance abuse related.
7. Outpatient Hospital Services, including outpatient
surgery
8. Laboratory Services -- All laboratory testing sites
providing services under this contract must have
either a Clinical Laboratory Improvement Act (CLIA)
certificate of waiver or a certificate of
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registration along with a CLIA identification number.
Those providers with certificates of waiver shall
provide only the types of tests permitted under the
terms of their waiver. Laboratories with certificates
of registration may perform a full range of
laboratory services.
9. Radiology Services -- Diagnostic and therapeutic
10. Optometrist Services, including one routine eye
examination per year
11. Optical appliances -- Limited to one pair of glasses
(or contact lenses) per 24 month period or as
medically necessary
12. Organ transplant services which are non-experimental
or non- investigational
13. Prescription drugs, excluding over-the-counter drugs
Exception: See Article 8 regarding Protease
Inhibitors and other antiretrovirals.
14. Dental Services -- Limited to preventive dental
services for children under the age of 12 years,
including oral examinations, oral prophylaxis, and
topical application of fluorides
15. Podiatrist Services -- Excludes routine hygienic care
of the feet, including the treatment of corns and
calluses, the trimming of nails, and other hygienic
care such as cleaning or soaking feet, in the absence
of a pathological condition
16. Prosthetic appliances -- Limited to the initial
provision of a prosthetic device that temporarily or
permanently replaces all or part of an external body
part lost or impaired as a result of disease, injury,
or congenital defect. Repair and replacement services
are covered when due to congenital growth.
17. Private duty nursing -- Only when authorized by the
contractor
18. Transportation Services -- Limited to ambulance for
medical emergency only
19. Well child care including immunizations, lead
screening and treatments
20. Maternity and related newborn care
21. Diabetic supplies and equipment
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B. Services Available To NJ FamilyCare Plan D Under
Fee-For-Service. The following services are available to NJ
FamilyCare Plan D enrollees under fee-for-service:
1. Abortion services
2. Skilled nursing facility services
3. Outpatient Rehabilitation Services -- Physical
therapy, Occupational therapy, and Speech therapy for
non-chronic conditions and acute illnesses and
injuries. Limited to treatment for a 60-day
consecutive period per incident of illness or injury
beginning with the first day of treatment per
contract year. Speech therapy services rendered for
treatment of delays in speech development, unless
resulting from disease, injury or congenital defects
are not covered
4. Inpatient hospital services for mental health,
including psychiatric hospitals, limited to 35 days
per year
5. Outpatient benefits for short-term, outpatient
evaluative and crisis intervention, or home health
mental health services, limited to 20 visits per year
a. When authorized by the Division of Medical
Assistance and Health Services, one (1)
mental health inpatient day may be exchanged
for up to four (4) home health visits or
four (4) outpatient services, including
partial care. This is limited to an exchange
of up to a maximum of 10 inpatient days for
a maximum of 40 additional outpatient
visits.
b. When authorized by the Division of Medical
Assistance and Health Services, one (1)
mental health inpatient day may be exchanged
for two (2) days of treatment in partial
hospitalization up to the maximum number of
covered inpatient days.
6. Inpatient and outpatient services for substance abuse
are limited to detoxification.
C. Exclusions. The following services not covered for NJ
FamilyCare Plan D participants either by the contractor or the
Department include, but are not limited to:
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0. Non-medically necessary services.
2. Intermediate Care Facilities/Mental Retardation
3. Private duty nursing unless authorized by the
contractor
4. Personal Care Assistant Services
5. Medical Day Care Services
6. Chiropractic Services
7. Dental services except preventive dentistry for
children under age 12
8. Orthotic devices
9. Targeted Case Management for the chronically ill
10. Residential treatment center psychiatric programs
11. Religious non-medical institutions care and services
12. Durable Medical Equipment
13. Early and Periodic Screening, Diagnosis and Treatment
(EPSDT) services (except for well child care,
including immunizations and lead screening and
treatments)
14. Transportation Services, including non-emergency
ambulance, invalid coach, and lower mode
transportation
15. Hearing Aid Services
16. Blood and Blood Plasma, except administration of
blood, processing of blood, processing fees and fees
related to autologous blood donations are covered.
17. Cosmetic Services
18. Custodial Care
19. Special Remedial and Educational Services
20. Experimental and Investigational Services
21. Medical Supplies (except diabetic supplies)
22. Infertility Services
23. Rehabilitative Services for Substance Abuse
24. Weight reduction programs or dietary supplements,
except surgical operations, procedures or treatment
of obesity when approved by the contractor
25. Acupuncture and acupuncture therapy, except when
performed as a form of anesthesia in connection with
covered surgery
26. Temporomandibular joint disorder treatment, including
treatment performed by prosthesis placed directly in
the teeth
27. Recreational therapy
28. Sleep therapy
29. Court-ordered services
30. Thermograms and thermography
31. Biofeedback
32. Radial keratotomy
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4.1.7 SUPPLEMENTAL BENEFITS
Any service, activity or product not covered under the State Plan may
be provided by the contractor only through written approval by the
Department and the cost of which shall be borne solely by the
contractor.
4.1.8 CONTRACTOR AND DMAHS SERVICE EXCLUSIONS
Neither the contractor nor DMAHS shall be responsible for the
following:
A. All services not medically necessary, provided, approved or
arranged by a contractor's physician or other provider (within
his/her scope of practice) except emergency services.
B. Cosmetic surgery except when medically necessary and approved.
C. Experimental organ transplants.
D. Services provided primarily for the diagnosis and treatment of
infertility, including sterilization reversals, and related
office (medical or clinic), drugs, laboratory services,
radiological and diagnostic services and surgical procedures.
E. Rest cures, personal comfort and convenience items, services
and supplies not directly related to the care of the patient,
including but not limited to, guest meals and accommodations,
telephone charges, travel expenses other than those services
not in Article 4.1 of this contract, take home supplies and
similar cost. Costs incurred by an accompanying parent(s) for
an out-of-state medical intervention are covered under EPSDT
by the contractor.
F. Services involving the use of equipment in facilities, the
purchase, rental or construction of which has not been
approved by applicable laws of the State of New Jersey and
regulations issued pursuant thereto.
G. All claims arising directly from services provided by or in
institutions owned or operated by the federal government such
as Veterans Administration hospitals.
H. Services provided in an inpatient psychiatric institution,
that is not an acute care hospital, to individuals under 65
years of age and over 21 years of age.
I. Services provided to all persons without charge. Services and
items provided without charge through programs of other public
or voluntary agencies (for example, New Jersey State
Department of Health and Senior Services, New Jersey Heart
Association, First Aid Rescue Squads, and so forth) shall be
utilized to the fullest extent possible.
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J. Services or items furnished for any sickness or injury
occurring while the covered person is on active duty in the
military.
K. Services provided outside the United States and territories.
L. Services or items furnished for any condition or accidental
injury arising out of and in the course of employment for
which any benefits are available under the provisions of any
workers' compensation law, temporary disability benefits law,
occupational disease law, or similar legislation, whether or
not the Medicaid beneficiary claims or receives benefits
thereunder, and whether or not any recovery is obtained from a
third-party for resulting damages.
M. That part of any benefit which is covered or payable under any
health, accident, or other insurance policy (including any
benefits payable under the New Jersey no-fault automobile
insurance laws), any other private or governmental health
benefit system, or through any similar third-party liability,
which also includes the provision of the Unsatisfied Claim and
Judgment Fund.
N. Any services or items furnished for which the provider does
not normally charge.
O. Services furnished by an immediate relative or member of the
Medicaid beneficiary's household.
P. Services billed for which the corresponding health care
records do not adequately and legibly reflect the requirements
of the procedure described or procedure code utilized by the
billing provider.
Q. Services or items reimbursed based upon submission of a cost
study when there are no acceptable records or other evidence
to substantiate either the costs allegedly incurred or
beneficiary income available to offset those costs. In the
absence of financial records, a provider may substantiate
costs or available income by means of other evidence
acceptable to the Division.
4.2 SPECIAL PROGRAM REQUIREMENTS
4.2.1 EMERGENCY SERVICES
A. For purposes of this contract, "emergency" means an onset of a
medical or behavioral condition, the onset of which is sudden,
that manifests itself by symptoms of sufficient severity,
including severe pain, that a prudent layperson, who possesses
an average knowledge of medicine and health, could reasonably
expect the absence of immediate medical attention to result
in:
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1. Placing the health of the person or others in serious
jeopardy;
2. Serious impairment to such person's bodily functions;
3. Serious dysfunction of any bodily organ or part of
such person; or
4. Serious disfigurement of such person.
With respect to a pregnant woman who is having contractions,
an emergency exists where there is inadequate time to effect a
safe transfer to another hospital before delivery or the
transfer may pose a threat to the health or safety of the
woman or the unborn child.
B. The contractor shall be responsible for emergency services,
both within and outside the contractor's enrollment area, as
required by an enrollee in the case of an emergency. Emergency
services shall also include:
1. Medical examination at an Emergency Room which is
required by N.J.A.C. 10:122D-2.5(b) when a xxxxxx
home placement of a child occurs after business
hours.
2. Examinations at an Emergency Room for suspected
physical/child abuse and/or neglect.
3. Post-Stabilization of Care. The contractor shall
comply with 42 C.F.R. * 422.100(b)(iv). The
contractor must cover post-stabilization services
without requiring authorization and regardless of
whether the enrollee obtains the services within or
outside the contractor's network if:
a. The services were pre-approved by the
contractor or its providers; or
b. The services were not pre-approved by the
contractor because the contractor did not
respond to the provider of
post-stabilization care services' request
for pre-approval within one (1) hour after
being requested to approve such care; or
c. The contractor could not be contacted for
pre-approval.
C. Access Standards. The contractor shall ensure that all covered
services, that are required on an emergency basis are
available to all its enrollees, twenty-four (24) hours per
day, seven (7) days per week, either in the contractor's own
provider network or through arrangements approved by DMAHS.
The contractor shall maintain twenty-four (24) hours per day,
seven (7) days per week on-call telephone coverage, including
Telecommunication Device for the Deaf (TDD)/Tech Telephone
(TT) systems, to advise enrollees of procedures for
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emergency and urgent care and explain procedures for obtaining
non-emergent/non-urgent care during regular business hours
within the enrollment area as well as outside the enrollment
area.
D. Non-Participating Providers. The contractor shall be
responsible for developing and advising its enrollees and
where applicable, authorized persons of procedures for
obtaining emergency services, including emergency dental
services, when it is not medically feasible for enrollees to
receive emergency services from or through a participating
provider, or when the time required to reach the participating
provider would mean risk of permanent damage to the enrollee's
health. The contractor shall bear the cost of providing
emergency service through non-participating providers.
E. Emergency Care Prior Authorization. Prior authorization shall
not be required for emergency services. This applies to
out-of-network as well as to in-network providers.
F. Medical Screenings/Urgent Care. Prior authorization shall not
be required for medical screenings or in urgent care
situations at the hospital emergency room. The hospital
emergency room physician may determine the necessity for
contacting the PCP or the contractor for information about an
enrollee who presents with an urgent condition.
G. The contractor shall pay for all medical screening services
rendered to its enrollees by hospitals and emergency room
physicians. The amount and method of reimbursement for medical
screenings shall be subject to negotiation between the
contractor and the hospital and directly with non-hospital
salaried emergency room physicians and shall include
reimbursement for urgent care and non-urgent care rates.
Non-participating hospitals may be reimbursed for hospital
costs at Medicaid rates or other mutually agreeable rates for
medical screening services. Additional fees for additional
services may be included at the discretion of the contractor
and the hospital.
1. The contractor shall not retroactively deny a claim
for an emergency medical screening exam because the
condition, which appeared to be an emergency medical
condition under the prudent layperson standard, was
subsequently determined to be non-emergency in
nature.
H. The contractor shall be liable for payment for the following
emergency services provided to an enrollee:
1. If the screening examination leads to a clinical
determination by the examining physician that an
actual emergency medical condition exists, the
contractor shall pay for both the services involved
in the screening exam and the services required to
stabilize the patient.
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2. All emergency services which are medically necessary
until the clinical emergency is stabilized. This
includes all treatment that is necessary to assure,
within reasonable medical probability, that no
material deterioration of the patient's condition is
likely to result from, or occur during, discharge of
the patient or transfer of the patient to another
facility.
If there is a disagreement between a hospital and the
contractor concerning whether the patient is stable
enough for discharge or transfer, or whether the
medical benefits of an unstabilized transfer outweigh
the risks, the judgment of the attending physician(s)
actually caring for the enrollee at the treating
facility prevails and is binding on the contractor.
The contractor may establish arrangements with
hospitals whereby the contractor may send one of its
physicians with appropriate ER privileges to assume
the attending physician's responsibilities to
stabilize, treat, or transfer the patient.
3. If the screening examination leads to a clinical
determination by the examining physician that an
actual emergency medical condition does not exist,
but the enrollee had acute symptoms of sufficient
severity at the time of presentation to warrant
emergency attention under the prudent layperson
standard, the contractor shall pay for all services
related to the screening examination.
4. The enrollee's PCP or other contractor representative
instructs the enrollee to seek emergency care
in-network or out-of-network, whether or not the
patient meets the prudent layperson definition.
I. The contractor may utilize a common list of symptom-based
presenting complaints that will reasonably substantiate that
an emergent/urgent medical condition existed. Some examples
include but are not limited to:
1. Severe pain of any kind.
2. Altered mental status, sustained or transient, for
any reason.
3. Abrupt change in neurological status, sustained or
transient, for any reason.
4. Complications of pregnancy.
5. Chest pain.
6. Acute allergic reactions.
7. Shortness of breath.
8. Abdominal pain.
9. Multiple episodes of vomiting or diarrhea, any age.
10. Fever greater than 102.5 degrees F in any age group.
11. Fever greater than 100.4 degrees F in infants three
months or younger.
12. Injuries with active bleeding.
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00. Injuries with functional loss of any body part.
14. All patients arriving at the hospital by ambulance
after an injury with any body part immobilized.
15. All patients arriving at the hospital by paramedic
ambulance.
16. Symptoms of substance abuse.
17. Psychiatric disturbances.
J. Women who arrive at any emergency room in active labor shall
be considered as an emergency situation and the contractor
shall reimburse providers of care accordingly.
K. If within thirty (30) minutes after receiving a request from a
hospital emergency department for a specialty consultation,
the contractor fails to identify an appropriate specialist who
is available and willing to assume the care of the enrollee,
the emergency department may arrange for medically necessary
emergency services by an appropriate specialist, and the
contractor shall not deny coverage for these services due to
lack of prior authorization. The contractor shall not require
prior authorization for specialty care emergency services for
treatment of any immediately life-threatening medical
condition.
L. The contractor shall establish and maintain policies and
procedures for emergency dental services for all enrollees.
1. Within the contractor's Enrollment/Service Area, the
contractor will ensure that:
a. Enrollees shall have access to emergency
dental services on a twenty-four (24) hour,
seven (7) day a week basis.
b. The contractor shall bear full
responsibility for the provision of
emergency dental services, and shall assure
the availability of a back-up provider in
the event that an on-call provider is
unavailable.
2. Outside the contractor's Service Area, the contractor
shall ensure that:
a. Enrollees shall be able to seek emergency
dental services from any licensed dental
provider without the need for prior
authorization from the contractor while
outside the Service Area (including out-
of-state services covered by the Medicaid
program).
M. The contractor shall reimburse ambulance and MICU
transportation providers responding to "911" calls whether or
not the patient's condition is determined, retrospectively, to
be an emergency.
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4.2.2 FAMILY PLANNING SERVICES AND SUPPLIES
A. General. Except where specified in Section 4.1, the
contractor's enrollees are permitted to obtain family planning
services and supplies from either the contractor's family
planning provider network or from any other qualified Medicaid
family planning provider. The DMAHS shall reimburse family
planning services provided by non-participating providers
based on the Medicaid fee schedule.
B. Non-Participating Providers. The contractor shall cooperate
with non-participating family planning providers accessed at
the enrollee's option by establishing cooperative working
relationships with such providers for accepting referrals from
them for continued medical care and management of complex
health care needs and exchange of enrollee information, where
appropriate, to assure provision of needed care within the
scope of this contract. The contractor shall not deny coverage
of family planning services for a covered diagnostic,
preventive or treatment service solely on the basis that the
diagnosis was made by a non-participating provider.
4.2.3 OBSTETRICAL SERVICES REQUIREMENTS/ISSUES
A. Obstetrical services shall be provided in the same amount,
duration, and scope as the Medicaid HealthStart program.
Guidelines, standards, and required program provisions are
found in Section B.4.2 of the Appendices.
B. The contractor shall not limit benefits for postpartum
hospital stays to less than forty-eight (48) hours following a
normal vaginal delivery or less than ninety-six (96) hours
following a cesarean section, unless the attending provider,
in consultation with the mother, makes the decision to
discharge the mother or the newborn before that time and the
provisions of N.J.S.A. 26:2J-4.9 are met.
1. The contractor shall not provide monetary payments or
rebates to mothers to encourage them to accept less
than the minimum protections provided for in this
Article.
2. The contractor shall not penalize, reduce, or limit
the reimbursement of an attending provider because
the provider provided care in a manner consistent
with this Article.
4.2.4 PRESCRIBED DRUGS AND PHARMACY SERVICES
A. General. The contractor shall provide all medically necessary
legend and non-legend drugs which are also covered by the
Medicaid program and ensure the availability of quality
pharmaceutical services for all enrollees including drugs
prescribed by Mental Health/Substance Abuse providers. See
Article 4.4C for additional information pertaining to MH/SA
pharmacy benefits.
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B. Use of Formulary. The contractor may use a formulary as long
as the following minimum requirements are met:
1. The contractor shall only exclude coverage of drugs
or drug categories permitted under 1927(d) of the
Social Security Act as amended by OBRA 1993. In
addition, the contractor shall include in its
formulary, if it chooses to operate a formulary, any
FDA-approved drugs that may allow for clinical
improvement or are clinically advantageous for the
management of a disease or condition.
2. The contractor's formulary shall be developed by a
Pharmacy and Therapeutics (P&T) Committee that shall
represent the needs of all its enrollees including
enrollees with special needs. Network physicians and
dentists shall have the opportunity to participate in
the development of the formulary and, prior to any
changes to a drug formulary, to review, consider and
comment on proposed changes. The formulary shall be
reviewed in its entirety and updated at least
annually.
3. The formulary for the DMAHS pharmacy benefit and any
revision thereto shall be reviewed and approved by
DMAHS.
4. The formulary shall include only FDA approved drug
products. For each Specific Therapeutic Drug (STD)
class, the selection of drugs included for each drug
class shall be sufficient to ensure the availability
of covered drugs with the least need for prior
authorization to be initiated by providers of
pharmaceutical services and include FDA approved
drugs to best serve the medical needs of enrollees
with special needs. In addition, the formulary shall
be revised periodically to assure compliance with
this requirement.
5. The contractor shall authorize the provision of a
drug not on the formulary requested by the PCP or
referral provider on behalf of the enrollee if the
approved prescriber certifies medical necessity for
the drug to the contractor for a determination.
Medically accepted indications shall be consistent
with Section 1927(k)(6) of the Social Security Act.
The contractor shall have in place a DMAHS-approved
prior approval process for authorizing the dispensing
of such drugs. In addition:
a. Any prior approval issued by the contractor
shall take into consideration prescription
refills related to the original pharmacy
service.
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b. A formulary shall not be used to deny
coverage of any Medicaid covered outpatient
drug determined medically necessary through
the review and appeal process. The prior
approval process shall be used to ensure
drug coverage consistent with the policies
of the New Jersey Medicaid program.
c. Prior approval may be used for covered drug
products under the following conditions:
i. For prescribing and dispensing
medically necessary non-formulary
drugs.
ii. To limit drug coverage consistent
with the policies of the Medicaid
program.
iii. To minimize potential drug
over-utilization.
iv. To accommodate exceptions to
Medicaid drug utilization review
standards related to proper
maintenance drug therapy.
d. Except for the use of approved generic drug
substitution of brand drugs, under no
circumstances shall the contractor permit
the therapeutic substitution of a prescribed
drug without a prescriber's authorization.
e. The contractor shall not penalize the
prescriber or enrollee, financially or
otherwise, for such requests and approvals.
f. Determinations shall be made within
twenty-four (24) hours of receipt of all
necessary information. A seventy-two
(72)-hour supply of medication shall be
permitted without prior authorization in
emergency situations or if a determination
has not been made within the required
timeframe.
g. Denials of off-formulary requests or
offering of an alternative medication shall
be provided to the prescriber and/or
enrollee in writing. All denials shall be
reported to the DMAHS quarterly.
6. The contractor shall publish and distribute hard copy
or on-line, at least annually, its current formulary
(if the contractor uses a formulary) to all
prescribing providers and pharmacists. Updates to the
formulary shall be distributed in all formats within
sixty (60) days of the changes.
7. If the formulary includes generic equivalents, the
contractor shall provide for a brand name exception
process for prescribers to use when medically
necessary.
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8. The contractor shall establish and maintain a
procedure, approved by DMAHS, for internal review and
resolution of complaints, such as timely access and
coverage issues, drug utilization review, and claim
management based on standards of drug utilization
review.
C. Pharmacy Lock-In Program. The contractor may implement a
pharmacy lock-in program including policies, procedures and
criteria for establishing the need for the lock-in which must
be prior approved by DMAHS and must include the following
components to the program:
1. Enrollees shall be notified prior to the lock-in and
must be permitted to choose or change pharmacies for
good cause.
2. A seventy-two (72)-hour emergency supply of
medication at pharmacies other than the designated
lock-in pharmacy shall be permitted to assure the
provision of necessary medication required in an
interim/urgent basis when the assigned pharmacy does
not immediately have the medication.
3. Care management and education reinforcement of
appropriate medication/pharmacy use shall be
provided. A plan for an education program for
enrollees shall be developed and submitted for review
and approval.
4. The continued need for lock-in shall be periodically
(at least every two years) evaluated by the
contractor for each enrollee in the program.
5. Prescriptions from all participating prescribers
shall be honored and may not be required to be
written by the PCP only.
6. The contractor shall fill medications prescribed by
mental health/substance abuse providers, subject to
the limitations described in Article 4.4C.
7. The contractor shall submit quarterly reports on
Pharmacy Lock-in participants. See Section A.7.17 of
the Appendices (Table 15).
D. The contractor shall develop criteria and protocols to avoid
enrollee injury due to the prescribing of drugs by more than
one provider.
4.2.5 LABORATORY SERVICES
A. Urgent/Emergent Results. The contractor shall develop policies
and procedures to require providers to notify enrollees of
laboratory and radiology results within twenty-four (24) hours
of receipt of results in urgent or emergent cases. The
contractor may allow its providers to arrange an appointment
to discuss laboratory/radiology results within 24 hours of
receipt of results when it is deemed
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face to face discussion with the enrollee/authorized person
may be necessary. Urgent/emergency appointment standards must
be followed (see Article 5.12). Rapid strep test results must
be available to the enrollee within 24 hours of the test.
B. Routine Results. The contractor shall assure that its
providers establish a mechanism to notify enrollees of
non-urgent or non-emergent laboratory and radiology results
within ten business days of receipt of the results.
4.2.6 EPSDT SCREENING SERVICES
A. The contractor shall comply with EPSDT program requirements
and performance standards found below.
1. The contractor shall provide EPSDT services.
2. NJ FamilyCare Plans B and C. For children eligible
solely through NJ FamilyCare Plans B and C, coverage
includes all preventive screening and diagnostic
services, medical examinations, immunizations,
dental, vision, lead screening and hearing services.
Includes only those treatment services identified
through the examination that are included under the
contractor's benefit package or specified services
through the FFS program. Other services identified
through an EPSDT examination that are not included in
the New Jersey Care 2000+ covered benefits package
are not covered.
3. Enrollee Notification. The contractor shall provide
written notification to its enrollees under
twenty-one (21) years of age when appropriate
periodic assessments or needed services are due and
must coordinate appointments for care.
4. Missed Appointments. The contractor shall implement
policies and procedures and shall monitor its
providers to provide follow up on missed appointments
and referrals for problems identified through the
EPSDT exams. Reasonable outreach shall be documented
and must consist of: mailers, certified mail as
necessary; use of MEDM system provided by the State;
and contact with the Medicaid District Office (MDO),
DDD, or DYFS regional offices in the case of DYFS
enrollees to confirm addresses and/or to request
assistance in locating an enrollee.
5. PCP Notification. The contractor shall provide each
PCP, on a calendar quarter basis, a list of the PCP's
enrollees who have not had an encounter during the
past year and/or who have not complied with the EPSDT
periodicity and immunization schedules for children.
Primary care
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sites/PCPs and/or the contractor shall be required to
contact these enrollees to arrange an appointment.
Documentation of the outreach efforts and responses
is required.
6. Reporting Standards. The contractor shall submit
quarterly reports, hard copy and on diskette, of
EPSDT services. See Section A.7.16 of the Appendices
(Table 14).
B. Section 1905(r) of the Social Security Act (42 U.S.C. * 1396d)
and federal regulation 42 C.F.R. * 441.50 et seq. requires
EPSDT services to include:
1. EPSDT Services which include:
a. A comprehensive health and developmental
history including assessments of both
physical and mental health development and
the provision of all diagnostic and
treatment services that are medically
necessary to correct or ameliorate a
physical or mental condition identified
during a screening visit. The contractor
shall have procedures in place for referral
to the State or its agent for non-covered
mental health/substance abuse services.
b. A comprehensive unclothed physical
examination including:
- Vision and hearing screening;
- Dental inspection; and
- Nutritional assessment.
c. Appropriate immunizations according to age,
health history and the schedule established
by the Advisory Committee on Immunization
Practices (ACIP) for pediatric vaccines (See
Section B.4.3 of the Appendices). Contractor
and its providers must adjust for periodic
changes in recommended types and schedule of
vaccines. Immunizations must be reviewed at
each screening examination as well as during
acute care visits and necessary
immunizations must be administered when not
contraindicated. Deferral of administration
of a vaccine for any reason must be
documented.
d. Appropriate laboratory tests: A recommended
sequence of screening laboratory
examinations must be provided by the
contractor. The following list of screening
tests is not all inclusive:
- Hemoglobin/hematocrit/EP
- Urinalysis
- Tuberculin test - intradermal,
administered annually and when
medically indicated
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- Lead screening using blood lead
level determinations must be done
for every Medicaid-eligible and NJ
FamilyCare child:
- between nine (9) months
and eighteen (18) months,
preferably at twelve (12)
months of age
- at 18-26 months,
preferably at twenty-four
(24) months of age
- test any child between
twenty-seven (27) to
seventy-two (72) months
of age not previously
tested
- Additional laboratory tests may be
appropriate and medically indicated
(e.g., for ova and parasites) and
shall be obtained as necessary.
e. Health education/anticipatory guidance.
f. Referral for further diagnosis and treatment
or follow-up of all abnormalities which are
treatable/correctable or require maintenance
therapy uncovered or suspected (referral may
be to the provider conducting the screening
examination, or to another provider, as
appropriate.)
g. EPSDT screening services shall reflect the
age of the child and be provided
periodically according to the following
schedule:
- Neonatal exam
- Under six (6) weeks
- Two (2) months
- Four (4) months
- Six (6) months
- Nine (9) months
- Twelve (12) months
- Fifteen (15) months
- Eighteen (18) months
- Twenty-four (24) months
- Annually through age twenty (20)
2. Vision Services. At a minimum, include diagnosis and
treatment for defects in vision, including
eyeglasses. Vision screening in an infant means, at a
minimum, eye examination and observation of responses
to visual stimuli. In an older child, screening for
distant visual acuity and ocular alignment shall be
done for each child beginning at age three.
3. Dental Services. Dental services may not be limited
to emergency services. Dental screening in this
context means, at a minimum, observation of tooth
eruption, occlusion pattern, presence of caries, or
oral infection. A referral to a dentist at or after
one year of age is
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recommended. A referral to a dentist is mandatory at
three years of age and annually thereafter through
age twenty (20) years.
4. Hearing Services. At a minimum, include diagnosis and
treatment for defects in hearing, including hearing
aids. For infants identified as at risk for hearing
loss through the New Jersey Newborn Hearing Screening
Program, hearing screening should be conducted prior
to three months of age using professionally
recognized audiological assessment techniques. For
all other children, hearing screening means, at a
minimum, observation of an infant's response to
auditory stimuli and audiogram for a child three (3)
years of age and older. Speech and hearing assessment
shall be a part of each preventive visit for an older
child.
5. Mental Health/Substance Abuse. Include a mental
health/substance abuse assessment documenting
pertinent findings. When there is an indication of
possible MH/SA issues, a mental health/substance
abuse screening tool(s) found in Section B.4.9 of the
Appendices or a DHS - approved equivalent shall be
used to evaluate the enrollee.
6. Such other necessary health care, diagnostic
services, treatment, and other measures to correct or
ameliorate defects, and physical and mental/substance
abuse illnesses and conditions discovered by the
screening services.
7. Lead Screening. The contractor shall provide a
screening program for the presence of lead toxicity
in children which shall consist of two components:
verbal risk assessment and blood lead testing.
a. Verbal Risk Assessment - The provider shall
perform a verbal risk assessment for lead
toxicity at every periodic visit between the
ages of six (6) and seventy-two (72) months
as indicated on the schedule. The verbal
risk assessment includes, at a minimum, the
following types of questions:
i. Does your child live in or
regularly visit a house built
before 1960? Does the house have
chipping or peeling paint?
ii. Was your child's day care
center/preschool/babysitter's home
built before 1960? Does the house
have chipping or peeling paint?
iii. Does your child live in or
regularly visit a house built
before 1960 with recent, ongoing,
or planned renovation or
remodeling?
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iv. Have any of your children or their
playmates had lead poisoning?
v. Does your child frequently come in
contact with an adult who works
with lead? Examples include
construction, welding, pottery, or
other trades practiced in your
community.
vi. Do you give your child home or folk
remedies that may contain lead?
Generally, a child's level of risk for
exposure to lead depends upon the answers to
the above questions. If the answer to all
questions are negative, a child is
considered at low risk for high doses of
lead exposure. If the answers to any
question is affirmative or "I don't know," a
child is considered at high risk for high
doses of lead exposure. Regardless of risk,
each child must be tested between nine (9)
months and eighteen (18) months, preferably
at twelve (12) months of age, at 18-26
months, preferably at two (2) years, and any
child between twenty-seven (27) and
seventy-two (72) months of age not
previously tested. A child's risk category
can change with each administration of the
verbal risk assessment.
b. Blood Lead Testing - All screening must be
done through a blood lead level
determination. The contractor must implement
a screening program to identify and treat
high-risk children for lead-exposure and
toxicity. The screening program shall
include blood level screening, diagnostic
evaluation and treatment with follow-up care
of children whose blood lead levels are
elevated. The EP test is no longer
acceptable as a screening test for lead
poisoning; however, it is still valid as a
screening test for iron deficiency anemia.
Screening blood lead testing may be
performed by either a capillary sample
(fingerstick) or a venous sample. However,
all elevated blood levels (equal to or
greater than ten (10) micrograms per one (1)
deciliter) obtained through a capillary
sample must be confirmed by a venous sample.
The blood lead test must be performed by a
New Jersey Department of Health and Senior
Services licensed laboratory. The frequency
with which the blood test is to be
administered depends upon the results of the
verbal risk assessment. For children
determined to be at low risk for high doses
of lead exposure, a screening blood lead
test must be performed once between the ages
of nine (9) and eighteen (18) months,
preferably at twelve (12) months, once
between 18-26 months, preferably at
twenty-four (24) months, and for any child
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between twenty-seven (27) and seventy-two
(72) months not previously tested. For
children determined to be at high risk for
high doses of lead exposure, a screening
blood test must be performed at the time a
child is determined to be a high risk
beginning at six months of age if there is
pertinent information or evidence that the
child may be at risk at younger ages than
stated in 4.2.6B.1.d.
i. If the initial blood lead test
results are less than ten (10)
micrograms per deciliter, a verbal
risk assessment is required at every
subsequent periodic visit through
seventy-two (72) months of age,
with mandatory blood lead testing
performed according to the schedule
in 4.2.6B.7.
ii. If the child is found to have a
blood lead level equal to or greater
than ten (10) micrograms per
deciliter, providers should use
their professional judgment, in
accordance with the CDC guidelines
regarding patient management and
treatment, as well as follow-up
blood test.
iii. If a child between the ages of
twenty-four (24) months and
seventy-two (72) months has not
received a screening blood lead
test, the child must receive the
blood lead test immediately,
regardless of whether the child is
determined to be a low or high risk
according to the answers to the
above-listed questions.
iv. When a child is found to have a
blood lead level equal to or
greater than twenty (20) mg/dl, the
contractor shall ensure its PCPs
cooperate with the local health
department in whose jurisdiction
the child resides to facilitate the
environmental investigation to
determine and remediate the source
of lead. This cooperation shall
include sharing of information
regarding the child's care,
including the scheduling and
results of follow-up blood lead
tests.
4.2.7 IMMUNIZATIONS
A. General. The contractor shall ensure that its providers
furnish immunizations to its enrollees in accordance with the
most current recommendations for vaccines and periodicity
schedule of the Advisory Committee on Immunization Practices
(ACIP) (See Section B.4.3 of the Appendices) and any
subsequent revision to the schedule as formally recommended by
the ACIP, whether or not included as a contract amendment. To
the extent possible, the State will provide copies of updated
schedules and vaccine recommendations.
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B. New Vaccines. New vaccines and/or new scheduling or method of
administration shall be provided as recommended by the ACIP.
The contractor shall monitor periodic recommendations and
disseminate updated instruction to its providers and assure
appropriate payment adjustment to its providers.
C. The contractor shall build in provisions for appropriate
reimbursement for catch-up immunizations its providers shall
provide for those pediatric enrollees who have missed
age-appropriate vaccines.
D. Vaccines for Children Program
1. Contractor's providers must enroll with the
Department of Health and Senior Services' Vaccines
for Children (VFC) Program and use the free vaccine
for its enrollees if the vaccine is covered by VFC.
(See Section B.4.4 of the Appendices for list of
vaccines to be covered by the NJ DHSS VFC program.)
The contractor shall not receive from DHS any
reimbursement for the cost of VFC-covered vaccines.
2. For non-VFC vaccines the contractor shall reimburse
its providers for the cost of both administration and
the vaccines.
E. To the extent possible, and as permitted by New Jersey
statutes and regulations, the contractor and its network
providers shall participate in the Statewide immunization
registry database, when it becomes fully operational.
F. The contractor shall provide immunizations recommended by
local health departments based on local epidemiological
conditions.
4.2.8 CLINICAL TRIALS
A. The contractor shall permit participation in an approved
clinical trial to a qualified enrollee (as defined in 4.2.8B),
and the contractor:
1. May not deny the enrollee participation in the
clinical trial referred to in 4.2.8B.2.
2. Subject to 4.2.8C, may not deny (or limit or impose
additional conditions on) the coverage of routine
patient costs for items and services furnished in
connection with participation in the trial.
3. May not discriminate against the enrollee on the
basis of the enrollee's participation in such trial.
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B. Qualified Enrollee Defined. For purposes of this Article, the
term "qualified enrollee" means an enrollee under the
contractor's coverage who meets the following conditions:
1. The enrollee has a life-threatening or serious
illness for which no standard treatment is effective;
2. The enrollee is eligible to participate in an
approved clinical trial with respect to treatment of
such illness;
3. The enrollee and the referring physician conclude
that the enrollee's participation in such trial would
be appropriate; and
4. The enrollee's participation in the trial offers
potential for significant clinical benefit for the
enrollee.
C. Payment. The contractor shall provide for payment for medical
problems/complications and for routine patient costs described
in Article 4.2.8A2 but is not required to pay for costs of
items and services that are reasonably expected to be paid for
by the sponsors of an approved clinical trial.
D. Approved Clinical Trial. For purposes of this Article, the
term "approved clinical trial" means a clinical research study
or clinical investigation that meets the following
requirements:
1. The trial is approved and funded by one or more of
the following:
a. The National Institutes of Health
b. A cooperative group or center of the
National Institutes of Health
c. The Department of Veterans Affairs
d. The Department of Defense
e. The Food and Drug Administration, in the
form of an investigational new drug (IND)
exemption
2. The facility and personnel providing the treatment
are capable of doing so by virtue of their experience
or training.
3. There is no alternative noninvestigational therapy
that is clearly superior.
4. The available clinical or preclinical data provide a
reasonable expectation that the protocol treatment
will be at least as effective as the
noninvestigational alternative.
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E. Coverage of Investigational Treatment. The contractor should
make a determination for coverage/denial of experimental
treatment for a terminal condition based on the following:
1. The treating physician refers the case to a
contractor internal review group not associated with
the case or referral center.
2. If the internal review group denies the referral, a
second, ad hoc group with two or more experts in the
field and not involved with the case must review the
case.
F. Experimental treatments for rare disorders shall not be
automatically excluded from coverage but decisions regarding
their medical necessity should be considered by a medical
review board established by the contractor. Routine costs
associated with investigational procedures that are part of an
approved research trial are considered medically appropriate.
Under no circumstances shall the contractor implement a
medical necessity standard that arbitrarily limits coverage on
the basis of the illness or condition itself.
4.2.9 HEALTH PROMOTION AND EDUCATION PROGRAMS
The contractor shall identify relevant community issues (such as TB
outbreaks, violence) and health education needs of its enrollees, and
implement plans that are culturally appropriate to meet those needs,
issues relevant to each of the target population groups of enrollees
served, as defined in Article 5.2, and the promotion of health. The
contractor shall use community-based needs assessments and other
relevant information available from State and local governmental
agencies and community groups. Health promotion activities shall be
made available in formats and presented in ways that meet the needs of
all enrollee groups including elderly enrollees and enrollees with
special needs, including enrollees with cognitive impairments. The
contractor shall comply with all applicable State and federal statutes
and regulations on health wellness programs. The contractor shall
submit a written description of all planned health education activities
and targeted implementation dates for DMAHS's approval, prior to
implementation, including culturally and linguistically appropriate
materials and materials developed to accommodate each of the enrolled
target population groups. Thereafter, the plan shall be reviewed,
revised, and pre-approved by the Department annually.
Health promotion topics shall include, but are not limited to, the
following:
A. General health education classes
B. Smoking cessation programs, with targeted outreach for
adolescents and pregnant women
C. Childbirth education classes
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D. Nutrition counseling, with targeted outreach for pregnant
women, elderly enrollees, and enrollees with special needs
E. Signs and symptoms of common diseases and complications
F. Early intervention and risk reduction strategies to avoid
complications of disability and chronic illness
G. Prevention and treatment of alcohol and substance abuse
H. Coping with losses resulting from disability or aging
I. Self care training, including self-examination
J. Need for clear understanding of how to take over-the-counter
and prescribed medications and the importance of coordinating
all such medications
K. Understanding the difference between emergent, urgent and
routine health conditions
4.3 COORDINATION WITH ESSENTIAL COMMUNITY PROVIDERS
4.3.1 GENERAL
The contractor shall identify and establish working relationships for
coordinating care and services with external organizations that
interact with its enrollees, including State agencies, schools, social
service organizations, consumer organizations, and civic/community
groups, such as an Hispanic coalition.
4.3.2 HEAD START PROGRAMS
A. The contractor shall demonstrate to DMAHS that it has
established working relationships with Head Start programs
(See Section B.4.5 of the Appendices for a list of Head Start
Programs). Such relationships will include an exchange of
information on the following:
1. Policies and procedures for referrals for routine,
urgent and emergent care.
2. Policies and procedures for scheduling appointments
for routine and urgent care.
3. Policies and procedures for the exchange of
information of Head Start participants who are
contractor enrollees.
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4. Policies and procedures for follow-up and assuring
the provision of health care services.
5. Policies and procedures for appealing denials of
service and/or reductions in the level of service.
6. Policies and procedures for Head Start staff in
supporting enforcement of contractor's health care
delivery system policies and procedures for accessing
all health care needs.
7. Policies and procedures addressing the need through
prior authorization to utilize the contractor's
established provider network and what will be done
for out-of-network referrals in cases where the
contractor does not have an appropriate participating
provider in accordance with Article 4.8.7.
8. Policies and procedures for providing comprehensive
medical examinations in accordance with EPSDT
standards and addressing the need for an examination
based on a Head Start referral if the enrollee has
had an age-appropriate EPSDT examination (for
infants) or an EPSDT examination (for children two
(2) to five (5) years old) within six (6) months of
the referral date.
9. Policies and Procedures for Head Start's role in
prevention activities or programs developed by the
contractor.
B. The contractor shall evaluate referred Head Start patients to
determine the need for treatment/therapies for problems
identified by staff of those programs. The contractor/PCP
shall be responsible for providing treatment and follow-up
information for medically necessary care.
C. The contractor shall review referrals and provide appointments
in accordance with Article 5.12. Denials of service requests
or reduction in level of service, only after an evaluation is
completed, shall be in writing, following the requirements in
Article 4.6.4.
4.3.3 SCHOOL-BASED YOUTH SERVICES PROGRAMS
A. The contractor shall demonstrate to DMAHS that it has
established a working linkage with school based youth services
programs (SBYSP) that meet credentialing and scope of service
requirements for services offered by these programs which are
covered MCE services. (See Section B.4.6 of the Appendices for
a list of SBYSPs).
1. SBYSP service provision must meet MCE contract
requirements, e.g., twenty-four (24)-hour coverage.
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2. SBYSP employees must meet credentialing requirements.
B. Such working linkages shall include, at minimum, an exchange
of information on the following:
1. Policies and procedures for referrals for routine,
urgent and emergent care, and standing referrals.
2. Policies and procedures for scheduling appointments
for routine and urgent care.
3. Policies and procedures for the exchange of
information of SBYSP participants who are contractor
enrollees.
4. Policies and procedures for follow-up and assuring
the provision of health care services.
5. Policies and procedures for appealing denials of
service and/or reductions in the level of service.
6. Policies and procedures for SBYSP staff in supporting
enforcement of contractor's health care delivery
system policies and procedures for accessing all
health care needs.
7. Policies and procedures addressing the need through
prior authorization to utilize the contractor's
established provider network and what will be done
for out-of-network referrals in cases where the
contractor does not have an appropriate participating
provider in accordance with Article 4.8.7.
8. Policies and procedures for providing comprehensive
medical examinations in accordance with EPSDT
standards and addressing the need for an examination
based on a SBYSP if the enrollee has had an age-
appropriate EPSDT examination (for infants) or an
EPSDT examination (for children two (2) to five (5)
years) within six (6) months of the referral date.
9. Policies and Procedures for the SBYSP's role in
prevention activities or programs developed by the
contractor.
C. The contractor shall evaluate referred SBYSP patients to
determine the need for treatment/therapies for problems
identified by staff of those programs. The contractor/PCP
shall be responsible for providing treatment and follow-up
information for medically necessary care for SBYSPs
participants where there is no formal
contractual/reimbursement relationship.
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D. The contractor shall review referrals and provide appointments
in accordance with Article 5.12. Denials of service requests
or reduction in level of service, only after an evaluation is
completed, shall be in writing, following the requirements in
Article 4.6.4.
E. The contractor shall provide the DMAHS with a description of
its plans to meet the requirements of this contract provision
in establishing a working linkage with SBYSPs.
4.3.4 LOCAL HEALTH DEPARTMENTS
The contractor shall demonstrate to DMAHS that it has established a
working linkage with local health departments (LHDs) that meet
credentialing and scope of service requirements.
The contractor should include linkages with LHDs especially for meeting
the lead screening and toxicity treatment compliance standards required
in this contract. The contractor shall refer lead-burdened children to
LHDs for environmental investigation to determine and remediate the
source of lead.
4.3.5 WIC PROGRAM REQUIREMENTS/ISSUES
The contractor shall require its providers to refer potentially
eligible women (pregnant, breast-feeding and postpartum), infants, and
children up to age five, to established community Women, Infants and
Children (WIC) programs. The referral shall include the information
needed by WIC programs in order to provide appropriate services. The
required information to be included with the referral is found on the
sample forms in Section B.4.8 of the Appendices, the New Jersey WIC
program medical referral form, and must be completed with the current
(within sixty (60) days) height, weight, hemoglobin, or hematocrit, and
any identified medical/nutritional problems for the initial WIC
referral and for all subsequent certifications. The contractor shall
submit a quarterly WIC referral report. (See Section A.7.14 of the
Appendices (Table 12).)
4.3.6 COMMUNITY LINKAGES
The contractor shall describe any relationships being explored,
planned, and/or existing between the contractor and provider entities
including for example:
A. Public health clinics or agencies
B. DYFS contracted Child Abuse Regional Diagnostic Centers
C. Environmental health clinics
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D. Women's health clinics
E. Family Planning/Reproductive health clinics
F. Developmental disabilities clinics
4.4 COORDINATION WITH MENTAL HEALTH AND SUBSTANCE ABUSE
SERVICES
The State shall retain a separate Mental Health/Substance Abuse system
for the coordination and monitoring of most mental health/substance
abuse conditions. The contractor shall xxxxxxx XX/SA services to
clients of DDD. However, as described below, the contractor shall
retain responsibility for MH/SA screening, referrals, prescription
drugs, higher-mode transportation, and for treatment of the conditions
identified in Article 4.1.2B.
A. Screening Procedures. Mental health and substance abuse
problems shall be systematically identified and addressed by
the enrollee's PCP at the earliest possible time following
initial participation of the enrollee in the contractor or
after the onset of a condition requiring mental health and/or
substance abuse treatment. PCPs and other providers shall
utilize mental health/substance abuse screening tools as set
forth in Section B.4.9 of the Appendices as well as other
mechanisms to facilitate early identification of mental health
and substance abuse needs for treatment. The contractor may
request permission to use alternative screening tools. The use
of alternative screening tools shall be pre-approved by DMAHS.
The lack of motivation of an enrollee to participate in
treatment shall not be considered a factor in determining
medical necessity and shall not be used as a rationale for
withholding or limiting treatment of an enrollee.
The contractor shall present its policies and procedures
regarding how its providers will identify enrollees with MH/SA
service needs, how they will encourage these enrollees to
begin treatment, and the screening tools to be used to
identify enrollees requiring MH/SA services. The contractor
should refer to the DSM-IV Primary Care Version in development
of its procedures.
B. Referrals. The contractor shall be responsible for referring
or coordinating referrals of enrollees as indicated to Mental
Health/Substance Abuse providers. In order to facilitate this,
the contractor may contact DMHS or its agent (e.g., if the
State contracts with a third party administrator (TPA) for a
list of MH/SA providers. Enrollees may be referred to a MH/SA
provider by the PCP, family members, other providers, State
agencies, the contractor's staff, or may self-refer.
1. The contractor shall be responsible for referrals
from MH/SA providers for medical diagnostic work-up
to formulate a diagnosis or to effect the treatment
of a MH/SA disorder and ongoing medical care for any
enrollee
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with a MH/SA diagnosis and shall coordinate the care
with the MH/SA provider. This includes the
responsibility for physical examinations (with the
exception of physical examinations performed in
direct connection with the administration of
Methadone, which will remain FFS), neurological
evaluations, laboratory testing and radiologic
examinations, and any other diagnostic procedures
that are necessary to make the diagnostic
determination between a primary MH/SA disorder and an
underlying physical disorder, as well as for medical
work-ups required for medical clearances prior to the
provision of psychiatric medication or
electroconvulsive therapy (ECT), or for transfer to a
psychiatric/SA facility. Routine laboratory
procedures ordered by treating MH/SA providers in
conjunction with MH/SA treatment, for routine blood
testing performed in conjunction with the
administration of Clozapine and the other drugs
listed in Article 4.1.4B for non-DDD enrollees, are
not the responsibility of the contractor.
2. The contractor shall develop a referral process to be
used by its providers which shall include providing a
copy of the medical consultation and diagnostic
results to the MH/SA provider. The contractor shall
develop procedures to allow for notification of an
enrollee's MH/SA provider of the findings of his/her
physical examination and laboratory/radiological
tests within twenty-four (24) hours of receipt for
urgent cases and within five business days in
non-urgent cases. This notification shall be made by
phone with follow-up in writing when feasible.
C. Pharmacy Services. Except for the drugs specified in Article
4.1.4 (Clozapine, Risperidone, Olanzapine, etc.), all pharmacy
services are covered by the contractor. This includes drugs
prescribed by the contractor or MH/SA providers. The
contractor shall only restrict or require a prior
authorization for prescriptions or pharmacy services
prescribed by MH/SA providers if one of the following
exceptions is demonstrated:
1. The drug prescribed is not related to the treatment
of substance abuse/dependency/addiction or mental
illness or to any side effects of the
psychopharmacological agents. These drugs are to be
prescribed by the contractor's PCP or specialists in
the contractor's network.
2. The prescribed drug does not conform to standard
rules of the contractor's pharmacy plan.
3. The contractor, at its option, may require a prior
authorization (PA) process if the number of
prescriptions written by the MH/SA provider for
MH/SA-related conditions exceed four (4) per month
per enrollee. For drugs that require weekly
prescriptions, these prescriptions shall be counted
as one per month and not as four separate
prescriptions. The
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contractor's PA process for the purposes of this
section shall require review and prior approval by
DMAHS.
D. Prescription Abuse. If the contractor suspects prescription
abuse by a MH/SA provider, the contractor shall contact DMAHS
for investigation and decision of potentially excluding the
provider from the NJ Medicaid program. The contractor shall
provide the Department with any and all documentation.
E. Inpatient Hospital Services for Enrollees who are not clients
of DDD with both a Physical Health as well as a Mental
Health/Substance Abuse Diagnosis. The contractor's financial
and medical management responsibilities are as follows:
1. If the inpatient hospital admission of an enrollee
who is not a client of DDD is for a physical health
primary diagnosis, the contractor shall be
responsible for inpatient hospital costs and medical
management. Where psychiatric consultation is
required to assist the contractor with mental
health/substance abuse management, the State or its
agent (e.g., a TPA) shall be responsible for
authorizing the psychiatric consult/services provided
during the inpatient stay. The State shall not
require service authorization for at least one
psychiatric consultation per inpatient admission.
When a substance abuse disorder is known to be the
primary diagnosis of an enrollee and a co-occurring
psychiatric disorder is not a management concern,
then the State or its agent may authorize that the
consult/services be by an ASAM certified physician.
The contractor shall coordinate inpatient MH/SA
consultations and services with the enrollee's MH/SA
provider as well as discharge planning and follow-up.
2. If the inpatient hospital admission of an enrollee
who is not a client of DDD is for a mental
health/substance abuse primary diagnosis, the
inpatient stay will be paid by the State through the
FFS program. The contractor shall provide and pay for
participating providers who may be called in as
consultants to manage any physical problems.
F. Transportation. The contractor shall be responsible for all
transportation through ambulance, Mobile Intensive Care Units
(MICUs), and invalid coach modalities, even if the enrollee is
being transported to a Medicaid or NJ FamilyCare service that
is not included in the contractor's benefit package including
to MH/SA services.
4.5 ENROLLEES WITH SPECIAL NEEDS
4.5.1 INTRODUCTION
For purposes of this contract, adults with special needs includes
complex/chronic medical conditions requiring specialized health care
services, including persons with
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physical, mental, substance abuse, and/or developmental disabilities,
including such persons who are homeless. Children with special health
care needs are those who have or are at increased risk for a chronic
physical, developmental, behavioral, or emotional condition and who
also require health and related services of a type or amount beyond
that required by children generally.
In addition to the standards set forth in this Article, contractor
shall make all reasonable efforts and accommodations to ensure that
services provided to enrollees with special needs are equal in quality
and accessibility to those provided to all other enrollees.
4.5.2 GENERAL REQUIREMENTS
A. Identification and Service Delivery. The contractor shall have
in place all of the following to identify and serve enrollees
with special needs:
1. Methods for identifying persons at risk of, or having
special needs who should be referred for a
comprehensive needs assessment. (See Articles 4.5.4B
and 4.6.5D for information on Complex Needs
Assessments). Such methods should include the
application of screening procedures/instruments for
new enrollees as well as the conditions and
indicators listed in Article 4.6.5D.1 and 2. These
include review of hospital and pharmacy utilization
and policies and procedures for providers or, where
applicable, authorized persons, to make referrals of
assessment candidates and for enrollees to self-refer
for a Complex Needs Assessment.
2. Methods and guidelines for determining the specific
needs of referred individuals who have been
identified through a Complex Needs Assessment as
having complex needs and developing care plans that
address their service requirements with respect to
specialist physician care, durable medical equipment,
medical supplies, home health services, social
services, transportation, etc. Article 4.5.4D
contains additional information on Individual Health
Care Plans.
3. Care management systems to ensure all required
services, as identified through a Complex Needs
Assessment, are furnished on a timely basis, and that
communication occurs between participating and non-
participating providers (to the extent the latter are
used). Articles 4.5.4 and 4.6.5 contain additional
information on care management.
4. Policies and procedures to allow for the continuation
of existing relationships with non-participating
providers, when appropriate providers are not
available within network or it is otherwise
considered by the contractor to be in the best
medical interest of the enrollee with special
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needs. Articles 4.5.2D and 4.8.7G contain more
specific standards for use of non-participating
providers.
5. Methods to assure that access to all
contractor-covered services, including
transportation, is available for enrollees with
special needs whose disabilities substantially impede
activities of daily living. The contractor shall
reasonably accommodate enrollees with disabilities
and shall ensure that physical and communication
barriers do not prohibit enrollees with disabilities
from obtaining services from the contractor.
6. Services for enrollees with special needs must be
provided in a manner responsive to the nature of a
person's disability/specific health care need and
include adequate time for the provision of the
service.
B. The contractor shall ensure that any new enrollee identified
(either by the information on the Plan Selection form at the
time of enrollment or by contractor providers after
enrollment) as having complex/chronic conditions receives
immediate transition planning. The planning shall be completed
within a timeframe appropriate to the enrollee's condition,
but in no case later than ten (10) business days from the
effective date of enrollment when the Plan Selection form has
an indication of special health care needs or within thirty
(30) days after special conditions are identified by a
provider. This transition planning shall not constitute the
IHCP described in Sections 4.5.4 and 4.6.5. Transition
planning shall provide for a brief, interim plan to ensure
uninterrupted services until a more detailed plan of care is
developed. The transition planning process includes, but is
not limited to:
1. Review of existing care plans.
2. Preparation of a transition plan that ensures
continuous care during the transfer into the
contractor's network.
3. If durable medical equipment had been ordered prior
to enrollment but not received by the time of
enrollment, the contractor must coordinate and
follow-through to ensure that the enrollee receives
necessary equipment.
C. Outreach and Enrollment Staff. The contractor shall have
outreach and enrollment staff who are trained to work with
enrollees with special needs, are knowledgeable about their
care needs and concerns, and are able to converse in the
different languages common among the enrolled population,
including TDD/TT and American Sign Language if necessary.
D. Specialty Care. The contractor shall have a procedure by which
a new enrollee upon enrollment, or an enrollee upon diagnosis,
who requires very complex, highly specialized health care
services over a prolonged period of time, or with (i)
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a life-threatening condition or disease or (ii) a degenerative
and/or disabling condition or disease, either of which
requires specialized medical care over a prolonged period of
time, may receive a referral to a specialist or a specialty
care center with expertise in treating the life-threatening
disease or specialized condition, who shall be responsible for
and capable of providing and coordinating the enrollee's
primary and specialty care.
If the contractor or primary care provider in consultation
with the contractor's medical director and a specialist, if
any, determines that the enrollee's care would most
appropriately be coordinated by such specialist/specialty care
center, the contractor shall refer the enrollee. Such referral
shall be pursuant to a care plan approved by the contractor,
in consultation with the primary care provider if appropriate,
the specialist, care manager, and the enrollee (or, where
applicable, authorized person). The contractor-participating
specialist/specialty care center acting as both primary and
specialty care provider shall be permitted to treat the
enrollee without a referral from the enrollee's primary care
provider and may authorize such referrals, procedures, tests
and other medical services as the enrollee's primary care
provider would otherwise be permitted to provide or authorize,
subject to the terms of the care plan. If the
specialist/specialty care center will not be providing primary
care, then the contractor's rules for referrals apply.
Consideration for policies and procedures should be given for
a standing referral when on-going, long-term specialty care is
required.
If the contractor refers an enrollee to a non
contractor-participating provider, services provided pursuant
to the approved care plan shall be provided at no additional
cost to the enrollee. In no event shall the contractor be
required to permit an enrollee to elect to have a non
contractor-participating specialist/specialty care center.
For purposes of this Article a specialty care center shall
mean the Centers of Excellence identified in Section B.4.10 of
the Appendices. These centers have special expertise in
treating life-threatening diseases/conditions and degenerative
/disabling diseases/conditions.
E. Dental. While the contractor must assure that enrollees with
special needs have access to all medically necessary care, the
State considers dental services to be an area meriting
particular attention. The contractor, therefore, shall accept
for network participation dental providers with expertise in
the dental management of enrollees with developmental
disabilities. All current providers of dental services to
enrollees with developmental disabilities shall be considered
for participation in the contractor's dental provider network.
Credentialing and recredentialing standards must be
maintained. The contractor shall make provisions for providers
of dental services to enrollees with developmental
disabilities to allow for limiting their dental practices at
their choice to only those patients with developmental
disabilities.
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The contractor shall develop specific policies and procedures for the
provision of dental services to enrollees with developmental
disabilities. At a minimum, the policies and procedures shall address:
1. Special needs/issues of enrollees with developmental
disabilities, including the importance of providing
consultations and assistance to patient caregivers.
2. Provisions in the contractor's dental reimbursement system for
initial and follow-up dental visits which may require up to 60
minutes on average to allow for a comprehensive dental
examination and other services to include, but not limited to:
a visual examination of the enrollee; appropriate radiographs;
dental prophylaxis, including extra scaling and topical
applications, such as fluoride treatments; non-surgical
periodontal treatment, including root planing and scaling; the
application of dental sealants on molars and premolars;
thorough inquiries regarding patient medical histories; and
most importantly, consultations with patient caregivers to
establish a thorough understanding of proper dental management
during visits.
3. Standards for dental visits that recognize the additional time
that may be required in treatment of patients with
developmental disabilities. Standards should allow for up to
four (4) visits annually without prior authorization.
4. Provisions for home visits when medically necessary and where
available.
5. Policies and procedures to ensure that providers specializing
in the treatment of enrollees with developmental disabilities
have adequate support staff to meet the needs of such
patients.
6. Provisions for use and replacement of fixed as well as
removable prosthetic devices as medically necessary and
appropriate.
7. Provisions in the contractor's dental reimbursement system to
reimburse dentists for the costs of preoperative and
postoperative evaluations associated with dental surgery
performed on patients with developmental disabilities.
Preauthorization shall not be required for dental procedures
performed during surgery on these patients for dentally
appropriate restorative care provided under general
anesthesia. Informed consent, signed by the enrollee or
authorized person, must be obtained prior to the surgical
procedure. Provisions should be made to evaluate such
procedures as part of a post payment review process.
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0. Provisions in the contractor's dental reimbursement system for
dentists to receive reimbursement for the cost of providing
oral hygiene instructions to caregivers to maintain a
patient's overall oral health between dental visits. Such
provisions shall include designing and implementing a "dental
management" plan, coordinated by the care manager, for
overseeing a patient's oral health.
9. The care manager of an enrollee with a developmental
disability shall coordinate authorizations for dentally
required hospitalizations by consulting with the plan's dental
and medical consultants in an efficient and time-sensitive
manner.
F. After Hours. The contractor shall have policies and procedures to
respond to crisis situations after hours for enrollees with special
needs. Training sessions/materials and triage protocols for all
staff/providers who respond to after-hours calls shall address
enrollees with special needs. For example, protocols should recognize
that a non-urgent condition for an otherwise healthy individual, such
as a moderately elevated temperature, may indicate an urgent care need
in the case of a child with a congenital heart anomaly.
G. Behavior Problems. The contractor shall take appropriate steps to
ensure that its care managers, network providers and Member Services
staff are able to serve persons with behavior problems associated with
developmental disabilities, including to the extent these problems
affect their level of compliance. The contractor shall educate
providers and staff about the nature of such problems and how to
address them. The contractor shall identify providers who have
expertise in serving persons with behavior problems.
H. ADA Compliance. The contractor shall have written policies and
procedures that ensure compliance with requirements of the Americans
with Disabilities Act of 1990, and a written plan to monitor compliance
to determine the ADA requirements are being met. The plan shall be
sufficient to determine the specific actions that will be taken to
remove existing barriers and/or to accommodate the needs of enrollees
who are qualified individuals with a disability. The plan shall include
the assurance of appropriate physical access to obtain included
benefits for all enrollees who are qualified individuals with a
disability including, but not limited to, the following:
1. Street level access or accessible ramp into facilities;
2. Access to lavatory; and
3. Access to examination rooms.
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The contractor shall also address in its policies and procedures
regarding ADA compliance the following issues:
1. Provider refusal to treat qualified individuals with
disabilities, including but not limited to individuals with
HIV/AIDS.
2. Contractor's role in ensuring providers receive available
resource information on how to accommodate qualified
individuals with a disability, particularly mobility impaired
enrollees, in examination rooms and for examinations.
3. How the contractor will accommodate visual and hearing
impaired individuals and assist its providers in communicating
with these individuals.
4. How the contractor will accommodate individuals with
communication-affecting disorders and assist its providers in
communicating with these individuals.
5. Holding community events as part of its provider and consumer
education responsibilities in places of public accommodation,
i.e., facilities readily accessible to and useable by
qualified individuals with disabilities.
6. How the contractor will ensure it will link qualified
individuals with disabilities with the providers/specialists
with the knowledge and expertise in treating the illness,
condition, and special needs of the enrollees.
4.5.3 PROVIDER NETWORK REQUIREMENTS
A. General. The contractor's provider network shall include primary
care and specialist providers who are trained and experienced in
treating individuals with special needs. The contractor shall
ensure that such providers will be equally accessible to all
enrollees covered under this contract.
1. The contractor shall operate a program to provide services
for enrollees with special needs that emphasizes: (a) that
providers are educated regarding the needs of enrollees
with special needs; (b) that providers will reasonably
accommodate enrollees with special needs; (c) that
providers will assist enrollees in maximizing involvement
in the care they receive and in making decisions about such
care; and (d) that providers maximize for enrollees with
special needs independence and functioning through health
promotions and preventive care, decreased hospitalization
and emergency room care, and the ability to be cared for at
home.
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0. The contractor shall describe how its provider network will
respond to the cultural and linguistic needs of enrollees
with special needs.
3. The network shall include primary care providers and
dentists whose clinical practice has specialized to some
degree in treating one or more groups of children and
adults with complex/chronic or disabling conditions. To the
extent possible, children and adults with complex physical
conditions should be in the care of board certified
pediatricians and family practitioners or internists,
respectively, or subspecialists, as appropriate.
4. The network shall include adult and pediatric
subspecialists for cardiology, hematology/oncology,
gastroenterology, emergency medicine, endocrinology,
infectious disease, orthopedics, neurology, neurosurgery,
ophthalmology, physiatry, pulmonology, surgery, and
urology, as well as providers who have knowledge and
experience in behavioral-developmental pediatrics,
adolescent health, geriatrics, and chronic illness
management.
5. The network shall include an appropriate and accessible
number of institutional facilities, professional allied
personnel, home care and community based services to
perform the contractor-covered services included in this
contract.
B. SCHSNA. The contractor shall include in its provider network
Special Child Health Services Network Agencies (SCHSNA) for
children with special health care needs. These agencies are
designated and approved by the Department of Health and Senior
Services and include Pediatric Ambulatory Tertiary Centers
(pediatric tertiary centers may also be used when a pediatric
subspecialty is not sufficiently accessible in a county to meet
the needs of the child), Regional Cleft Lip/Palate Centers,
Pediatric AIDS/HIV Network, Comprehensive Regional Sickle
Cell/Hemoglobinopathies Treatment Centers, PKU Treatment Centers,
Genetic Testing and Counseling Centers, and Hemophilia Treatment
Centers, and others as designated from time to time by the
Department of Health and Senior Services. A list of such providers
is found in Section B.4.10 of the Appendices.
C. Credentialing. The contractor shall collect and maintain, as part
of its credentialing process or through special survey process,
information from licensed practitioners including pediatricians
and pediatric subspecialists about the nature and extent of their
experience in serving children with special health care needs
including developmental disabilities.
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4.5.4 CARE MANAGEMENT AND COORDINATION OF CARE FOR PERSONS
WITH SPECIAL NEEDS
A. The contractor shall provide coordination of care to actively link
the enrollee to providers, medical services, residential, social
and other support services as needed. For persons with special
needs, care management shall be provided, but, for those with
higher needs, as determined through the Complex Needs Assessment
(the CNA is described in Article 4.6.5), the contractor shall
provide care management at a higher level of intensity. (See
Section B.4.12 of the Appendices for a flowchart of the three
levels of care management.) Specific requirements for this highest
level of care management are described below.
B. Complex Needs Assessment. For enrollees with special needs, the
contractor shall perform a Complex Needs Assessment no later than
thirty (30) days (or earlier, if urgent) from initial enrollment
if special needs are indicated on the Plan Selection Form or from
the point of identification of special needs. See 4.6.5 for a
description of the CNA.
C. Experience and Caseload. Care managers for enrollees who require a
higher level of care management will have the same role and
responsibilities as the care manager for the lower intensity care
management and additionally will address the complex intensive
needs of the enrollee identified as being at "high risk" of
adverse medical outcomes absent active intervention by the
contractor. For example, a visually-impaired, insulin-dependent
diabetic who requires frequent glucose monitoring, nutritional
guidance, vision checks, and assistance in coordination with
visits with multiple providers, therapeutic regimen, etc. The
contractor shall provide intensive acute care services to treat
individuals with multiple complex conditions. The number of
medical and social services required by an enrollee in this level
of care management will generally be greater, thus the number of
linkages to be created, maintained, and monitored, including the
promotion of communication among providers and the consumer and of
continuity of care, will be greater. The contractor shall provide
these enrollees greater assistance with scheduling
appointments/visits. The intensity and frequency of interaction
with the enrollee and other members of the treatment team will
also be greater. The care manager shall contact the enrollee
bi-weekly or as needed.
1. At a minimum, the care manager for this level of care
management shall include, but is not limited to,
individuals with an undergraduate or graduate degree in
nursing or a graduate degree in social work and with at
least two (2) years experience serving enrollees with
special needs.
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2. The contractor shall ensure that the care manager's
caseload is adjusted, as needed, to accommodate the work
and level of effort needed to meet the needs of the entire
case mix of assigned enrollees including those determined
to be high risk.
3. The contractor should include care managers with experience
working with pediatric as well as adult enrollees with
special needs.
D. IHCPs. The contractor through its care manager shall ensure that
an Individual Health Care Plan (IHCP) is developed and implemented
as soon as possible, according to the circumstances of the
enrollee. The contractor shall ensure the full participation and
consent of the enrollee or, where applicable, authorized person
and participation of the enrollee's PCP and other case managers
identified through the Complex Needs Assessment (e.g. DDD case
manager) in the development of the plan.
E. The contractor shall provide written notification to the enrollee,
or authorized person, of the level of care management approved and
the name of the care manager as soon as the IHCP is completed. The
contractor shall have a mechanism to allow for changing levels of
care management as needs change.
F. Offering of Service. The contractor shall offer and document the
enrollee's response for this higher level care management to
enrollees (or, where applicable, authorized persons) who, upon
completion of a Complex Needs Assessment, are determined to have
complex needs which merit development of an IHCP and comprehensive
service coordination by a care manager. Enrollees shall have the
right to decline coordination of care services; however, such
refusal does not preclude the contractor from case managing the
enrollee's care.
4.5.5 CHILDREN WITH SPECIAL HEALTH CARE NEEDS
A. The contractor shall provide services to children with special
health care needs, who may have or are suspected of having serious
or chronic physical, developmental, behavioral, or emotional
conditions (short-term, intermittent, persistent, or terminal),
who manifest some degree of delay or disability in one or more of
the following areas: communication, cognition, mobility,
self-direction, and self-care; and with specified clinically
significant disturbance of thought, behavior, emotions, or
relationships that can be described as a syndrome or pattern,
generally resulting from neurochemical dysfunction, negative
environmental influences, or some combination of both. Services
needed by these children may include but are not limited to
psychiatric care and substance abuse counseling for DDD clients
(appropriate referrals for all other pediatric enrollees);
medications; crisis intervention; inpatient hospital services; and
intensive care management to assure adherence to treatment
requirements.
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B. The contractor shall be responsible for establishing:
1. Methods for well child care, health promotion, and disease
prevention, specialty care for those who require such care,
diagnostic and intervention strategies, home therapies, and
ongoing ancillary services, as well as the long-term
management of ongoing medical complications.
2. Care management systems for assuring that children with
serious, chronic, and rare disorders receive appropriate
diagnostic work-ups on a timely basis.
3. Access to specialty centers in and out of New Jersey for
diagnosis and treatment of rare disorders. A listing of
specialty centers is included in Section B.4.10 of the
Appendices.
4. Policies and procedures to allow for continuation of
existing relationships with out-of-network providers, when
considered to be in the best medical interest of the
enrollee.
C. Linkages. The contractor shall have methods for coordinating care
and creating linkages with external organizations, including but
not limited to school districts, child protective service
agencies, early intervention agencies, behavioral health, and
developmental disabilities service organizations. At a minimum,
linkages shall address:
1. Contractor's process for generating or receiving referrals,
and sharing information;
2. Contractor's process for obtaining consent from enrollees
or, where applicable, authorized persons to share
individual beneficiary medical information; and
3. Ongoing coordination efforts (regularly scheduled meetings,
newsletters, joint community based project).
D. IEPs. The contractor shall cooperate with school districts to
provide medically necessary contractor-covered services when
included as a recommendation in an enrollee's Individualized
Education Program (IEP) developed by the school district's child
study team, e.g. recommended medications or DME. The contractor
shall work with local school districts to develop and implement
procedures for linking and coordinating services for children who
need to receive medical services under an Individualized Education
Plan, in order to prevent duplication of services, and to provide
for cost effective services. Those services which are included in
the IEP as required services are paid for by the school district,
e.g. physical therapy. Services covered under the Special
Education
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Medicaid Initiative (SEMI) program, or not included in Article 4.1
of this contract, or not available under EPSDT are not the
contractor's responsibility. The provision of services shall be
based on medical necessity as defined in this contract.
E. Early Intervention. The contractor shall cooperate with and
coordinate its services with local Early Intervention Programs to
provide medically necessary (as defined in this contract)
contractor-covered services included in the Individualized Family
Support Plan (IFSP). These programs are comprehensive, community
based programs of integrated developmental services which use a
family centered approach to facilitate the developmental progress
of children between the ages of birth and three (3) years of age
whose developmental patterns are atypical, or are at serious risk
to become atypical through the influence of certain biological or
environmental risk factors. At a minimum, the contractor must have
policies and procedures for identifying children who are
candidates for early intervention, making referrals through
Special Child Health Services County Case Management Units (See
Appendix B.4.11) in accordance with the Department of Health and
Senior Services procedures for referrals, and sharing information
with early intervention providers.
4.5.6 CLIENTS OF THE DIVISION OF DEVELOPMENTAL DISABILITIES
A. The contractor shall provide all physical health services required
by this contract as well as the MH/SA services included in the
Medicaid State Plan to enrollees who are clients of DDD. The
contractor shall include in its provider network a specialized
network of providers who will deliver both physical as well as
MH/SA services (in accordance with Medicaid program standards) to
clients of DDD, and ensure continuity of care within that network.
B. The contractor's specialized network shall provide disease
management services for clients of DDD, which shall include
participation in:
1. Care Management, including Complex Needs Assessment,
development and implementation of IHCP, referral,
coordination of care, continuity of care, monitoring, and
follow-up and documentation.
2. Coordination of care across multi-disciplinary treatment
teams to assist PCPs in identifying the providers within
the network who will meet the specific needs and health
care requirements of clients of DDD with both physical
health and MH/SA needs and provide continuity of care with
an identified provider who has an established relationship
with the patient.
3. Apply quality improvement techniques/protocols to effect
improved quality of life outcomes.
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guidelines that will produce overall quality outcomes for
specific diseases/conditions identified in clients of DDD.
5. Medical treatment.
C. The specialized provider network shall consist of credentialed
providers for physical health and MH/SA services, who have
experience and expertise in treating clients of DDD who have both
physical health and MH/SA needs, and who can provide internal
management of the complex care needs of these enrollees. The
contractor shall ensure that the specialized provider network will
be able to deliver identified physical health and MH/SA outcomes.
D. Clients of DDD may, at their option, receive their physical health
and/or MH/SA services from any qualified provider in the
contractor's network. They are not required to receive their
services through the contractor's specialized network.
E. Individuals who are both DYFS clients and clients of DDD who
voluntarily enroll shall receive MH/SA services through the
contractor's network.
4.5.7 PERSONS WITH HIV/AIDS
A. Pregnant Women. The contractor shall implement a program to
educate, test and treat pregnant women with HIV/AIDS to reduce
perinatal transmission of HIV from mother to infant. All pregnant
women shall receive HIV education and counseling and HIV testing
with their consent as part of their regular prenatal care. A
refusal of testing shall be documented in the patient's medical
record. Additionally, counseling and education regarding perinatal
transmission of HIV and available treatment options (the use of
Zidovudine [AZT] or most current treatment accepted by the medical
community for treating this disease) for the mother and newborn
infant should be made available during pregnancy and/or to the
infant within the first months of life. The contractor shall
submit a quarterly report on HIV referrals and treatment. (See
Section A.7.15 of the Appendices (Table 13).)
B. Prevention. The contractor shall address the HIV/AIDS prevention
needs of uninfected enrollees, as well as the special needs of
HIV+ enrollees. The contractor shall establish:
1. Methods for promoting HIV prevention to all enrollees in
the contractor's plan. HIV prevention information shall be
consistent with the enrollee's age, sex, and risk factors
as well as culturally and linguistically appropriate.
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treatment.
3. A process to facilitate access to specialists and/or
include HIV/AIDS specialists as PCPs.
C. Traditional Providers. The contractor shall include traditional
HIV/AIDS providers in its networks, including HIV/AIDS Specialty
Centers (Centers of Excellence), and shall establish linkages with
AIDS clinical educational programs to keep current on up-to-date
treatment guidelines and standards.
D. Current Protocols. The contractor shall establish policies and
procedures for its providers to assure the use of the most current
diagnosis and treatment protocols and standards established by the
DHSS and the medical community.
D. Care Management. The contractor shall develop and implement an
HIV/AIDS care management program with adequate capacity to provide
services to all enrollees who would benefit from HIV/AIDS care
management services. Contractors shall establish linkage with Xxxx
Xxxxx CARE Act grantees for these services either through a
contract, MOA, or other cooperative working agreement approved by
the Department.
F. ADDP. The contractor shall have policies and procedures for
supplying DHSS application forms and referring qualified NJ
FamilyCare enrollees to the AIDS Drug Distribution Program (ADDP).
Qualified individuals, described in Article 8.5.16, receive
protease inhibitors and certain anti-retrovirals solely through
the ADDP. The contractor shall ensure timely referral for
registration with the program to assure these individuals receive
appropriate and timely treatment.
4.6 QUALITY MANAGEMENT SYSTEM
A. The contractor shall provide for medical care and health services
that comply with federal and State Medicaid and NJ FamilyCare
standards and regulations and shall satisfy all applicable
requirements of the federal and State statutes and regulations
pertaining to medical care and services.
1. The contractor shall fulfill all its obligations under this
contract so that all health care services required by its
enrollees under this contract will meet quality standards
within the acceptable medical practice of care for that
individual, consistent with the medical community standards
of care, and such services will comply with equal amount,
duration, and scope requirements in this contract, as
described in Article 4.1.
B. The contractor shall use its best efforts to ensure that persons
and entities providing care and services for the contractor in the
capacity of physician, dentist, CNP/CNS, physician's assistant,
CNM, or other medical professional meet
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applicable licensing, certification, or qualification requirements
under New Jersey law or applicable state laws in the state where
service is provided, and that the functions and responsibilities
of such persons and entities in providing medical care and
services under this contract do not exceed those permissible under
New Jersey law. This shall also include knowledge, training and
experience in providing care to individuals with special needs.
4.6.1 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PLAN
A. General. The contractor shall implement and maintain a Quality
Assessment and Performance Improvement program (QAPI) that is
capable of producing prospective, concurrent, and retrospective
analyses. Delegation of any QAPI activities shall not relieve the
contractor of its obligations to perform all QAPI functions.
B. Goals. The contractor's QAPI shall be based on HCFA Guidelines and
shall:
1. Provide for health care that is medically necessary with an
emphasis on the promotion of health in an effective and
efficient manner;
2. Assess the appropriateness and timeliness of the care
provided;
3. Evaluate and improve, as necessary, access to care and
quality of care with a focus on improving enrollee
outcomes; and
4. Focus on the clinical quality of medical care rendered to
enrollees.
C. Required Standards. The contractor's QAPI shall include all
standards described in New Jersey modified QARI/QISMC (See Section
B.4.14 of the Appendices). The following standards shall be
included in addition to the QARI/QISMC requirements:
1. QM Committee. The contractor shall have adequate general
liability insurance for members of the QM committee and
subcommittees, if any. The committee shall include
representation by providers who serve enrollees with
special needs.
2. Medical Director. The contractor shall have on staff a
Medical Director who is currently licensed in New Jersey as
a Doctor of Medicine or Doctor of Osteopathic Medicine. The
Medical Director shall be responsible for:
a. The development, implementation and medical
interpretation of medical policies and procedures to
guide and support the provision of medical care to
enrollees;
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b. Oversight of provider recruitment activities;
c. Reviewing all providers' applications and making
recommendations to those with contracting authority
regarding credentialing and reappointing all
providers prior to the providers' contracting (or
renewal of contract) with the contractor's plan;
d. Continuing surveillance of the performance of
providers in their provision of health care to
enrollees;
e. Administration of all medical activities of the
contractor;
f. Continuous assessment and improvement of the quality
of care provided to enrollees;
g. Serving as Chairperson of Quality Management
Committee; [Note: the medical director may designate
another physician to serve as chairperson with prior
approval from DMAHS.]
h. Oversight of provider education, in-service training
and orientation;
i. Assuring that adequate staff and resources are
available for the provision of proper medical care
to enrollees; and
j. The review and approval of studies and responses to
DMAHS concerning QM matters.
3. Enrollee Rights and Responsibilities. Shall include the
right to the Medicaid Fair Hearing Process for Medicaid
enrollees.
4. Medical Record standards shall address both Medical and
Dental records. Records shall also contain notation of any
cultural/linguistic needs of the enrollee.
5. Provider Credentialing. Before any provider may become part
of the contractor's network, that provider shall be
credentialed by the contractor. The contractor must comply
with Standard IX of NJ modified QARI/QISMC (Section B.4.14
of the Appendices). Additionally, the contractor's
credentialing procedures shall include verification that
providers and subcontractors have not been suspended,
debarred, disqualified, terminated or otherwise excluded
from Medicaid, Medicare, or any other federal or state
health care program. The contractor shall obtain federal
and State lists of suspended/debarred providers from the
appropriate agencies.
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0. Institutional and Agency Provider Credentialing. The
contractor shall have written policies and procedures for
the initial quality assessment of institutional and agency
providers with which it intends to contract. At a minimum,
such procedures shall include confirmation that a provider
has been reviewed and approved by a recognized accrediting
body and is in good standing with State and federal
regulatory bodies. If a provider has not been approved by a
recognized accrediting body, the contractor shall develop
and implement standards of participation. For home health
agency and hospice agency providers, the contractor shall
verify that the providers are licensed and meet Medicare
certification participation requirements.
7. Delegation/subcontracting of QAPI activities shall not
relieve the contractor of its obligation to perform all
QAPI functions. The contractor shall submit a written
request and a plan for active oversight of the QAPI
activities to DMAHS for review and approval prior to
subcontracting/delegating any QAPI responsibilities.
4.6.2 QAPI ACTIVITIES
The contractor shall carry out the activities described in its QAPI.
The contractor shall develop and submit to DMAHS annually an annual
work plan of expected accomplishments which includes a schedule of
clinical standards to be developed, medical care evaluations to be
completed, and other key quality assurance activities to be completed.
The contractor shall also prepare and submit to DMAHS an annual report
on quality assurance activities which demonstrate the contractor's
accomplishments, compliance and/or deficiencies in meeting its previous
year's work plan and should include studies undertaken, subsequent
actions, and aggregate data on utilization and clinical quality of
medical care rendered.
The contractor's quality assurance activities shall include, at a
minimum:
A. Guidelines. The contractor shall develop guidelines for the
management of selected diagnoses and basic health maintenance,
and shall distribute all standards, protocols, and guidelines
to all providers.
B. Treatment Protocols. The contractor may use treatment
protocols, however, such protocols shall allow for adjustments
based on the enrollee's medical condition and contributing
family and social factors.
C. Monitoring. The contractor shall have procedures for
monitoring the quality and adequacy of medical care including:
1) assessing use of the distributed guidelines and 2)
assessing possible under-treatment/under-utilization of
services.
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D. Focused Evaluations. The contractor shall have procedures for
focused medical care evaluations to be employed when
indicators suggest that quality may need to be studied. The
contractor shall also have procedures for conducting
problem-oriented clinical studies of individual care.
E. Follow-up. The contractor shall have procedures for prompt
follow-up of reported problems and complaints involving
quality of care issues.
F. Utilization Data. The contractor shall conduct a quarterly
analysis of utilization data, including inpatient utilization,
and shall follow-up on cases of potential under- and
over-utilization. Over- and under-utilization shall be
determined based on comparison to established medical
community standards. See Section A.7.7 of the Appendices
(Table 5) for a description of utilization data to be
submitted to the Department.
G. Data Collection. The contractor shall have procedures for
gathering and trending data including outcome data.
H. Mortality Rates. The contractor shall review inpatient
hospital mortality rates of its enrollees.
I. Corrective Action. The contractor shall have procedures for
informing providers of identified deficiencies, conducting
ongoing monitoring of corrective actions, and taking
appropriate follow-up actions, such as instituting progressive
sanctions and appeal processes. The contractor shall conduct
reassessments to determine if corrective action yields
intended results.
J. Discharge Planning. The contractor shall have procedures to
ensure adequate discharge planning, and to include
coordination with services enrollees with special needs.
K. Ethical Issues. The contractor shall comply and monitor its
providers for compliance with state and federal laws and
regulations concerning ethical issues, including but not
limited to:
- Advance Directives
- Family Planning services for minors
- Other issues as identified
Contractor shall submit report annually or within thirty (30)
days to DMAHS with changes or updates to the policies.
L. Emergency Care. The contractor shall have methods to track
emergency care utilization and to take follow-up action,
including individual counseling, to improve appropriate use of
urgent and emergency care settings.
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M. New Medical Technology. The contractor shall have policies and
procedures for criteria which are based on scientific evidence
for the evaluation of the appropriate use of new medical
technologies or new applications of established technologies
including medical procedures, drugs, devices, assistive
technology devices, and DME.
N. Informed Consent. The contractor is required and shall require
all participating providers to comply with the informed
consent forms and procedures for hysterectomy and
sterilization as specified in 42 C.F.R. Part 441, Sub-part B,
and shall include the annual audit for such compliance in its
quality assurance reviews of participating providers. Copies
of the forms are included in Section B.4.15 of the Appendices.
O. Continuity of Care. The contractor's Quality Management Plan
shall include a continuity of care system including a
mechanism for tracking issues over time with an emphasis on
improving health outcomes, as well as preventive services and
maintenance of function for enrollees with special needs.
P. HEDIS. The contractor shall submit annually, on a date
specified by the State, HEDIS 3.0 data or more updated
version, stratified by eligibility group: 1) aged, blind, and
disabled; 2) AFDC/TANF; and 3) NJ FamilyCare and aggregate
population data as well as, if available, the contractor's
commercial and Medicare enrollment HEDIS data for its
aggregate, enrolled commercial and Medicare population in the
State or region (if these data are collected and reported to
DHSS, a copy of the report should be submitted also to DMAHS)
the following clinical indicator measures:
Report Period
Reporting Set Measures by Contract Year
---------------------- ----------------
childhood immunization status annually
adolescent immunization status annually
well-child care annually
prenatal care in the first trimester annually
low birth weight babies annually
check ups after delivery annually
prenatal care utilization annually
Q. Quality Improvement Projects (QIPs). The contractor shall
participate in QIPs defined annually by the State with input
from the contractor. The State will, with input from the
contractor and possibly other MCEs, define measurable
improvement goals and QIP-specific measures which shall serve
as the focus for each QIP. The contractor shall be responsible
for designing and implementing strategies for achieving each
QIP's objectives. At the beginning of each contract
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year the contractor shall present a plan for designing and
implementing such strategies, which shall receive approval
from the State prior to implementation. The contractor shall
then submit semiannual progress reports summarizing
performance relative to each of the objectives of each
contract year.
For year one the QIPs shall be the two areas identified below.
The external review organization (ERO) under contract with DHS
shall prepare a final report for year one that will contain
data, using State-approved sampling and measurement
methodologies, for each of the two measures below. Future
contract year QIPs shall be defined by the DHS and
incorporated into the contract by amendment.
For each measure the DHS will identify a baseline and a
compliance standard. The baselines in the following chart are
the year one QIPs. They are based on 1995 and 1996 focused
studies conducted by the ERO or MCE self-reported data (for
immunizations). Baseline data, target standards, and
compliance standards shall be established or updated by the
State.
If DHS determines that the contractor is not in compliance
with the requirements of the annual QIP objectives, either
based on the contractor's progress report or the ERO's report,
the contractor shall prepare and submit a corrective action
plan for DHS approval.
1. Well-Child Care (EPSDT)
The QIP for Well-Child Care shall focus upon achieving
compliance with the EPSDT periodicity schedule (See Article
4.2.6) in the following three priority areas:
Clinical Area Baseline Target Standard Compliance Std.
------------- -------- --------------- ---------------
Age-appropriate
Comprehensive exams
0 -- 24 months 28% 80% 50%
2 -- 4 yr olds 28% 80% 50%
4 -- 6 yr olds (at least 1 visit) 63% 80% 65%
12 -- 20 yr olds (at least 1 visit) 45% 80% 50%
Immunizations
2 year olds (combined rate) 75% 80% 80%
Lead screens (6 months through 39% 80% 50%
4 yr olds)
Annual Dental Visit --
3 -- 12 yr olds 23% 80% 50%
13 -- 21 yr olds 10% 80% 40%
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2. Prenatal Care and Pregnancy Outcome
The QIP for Prenatal Care and Pregnancy Outcome shall focus
upon achieving improvements in compliance with prenatal care
protocols and in obtaining positive pregnancy outcomes
Clinical Area Baseline Target Compliance
Standard Std.
Initial visit in first trimester or
within 6 wks of enrollment 58% 85% 70%
Adequate frequency of prenatal 55% 85% 70%
care
Low birth weight babies
1500 grams or less 1% -- 1%
2500 grams or less 8% -- 6%
Post partum exam within 60
days after delivery 39% 75% 50%
R. Care for Persons with Disabilities and the Elderly (Defined as SSI-Aged
and New Jersey Care - Aged enrollees and SSI and New Jersey Care
enrollees with disabilities)
1. General. The contractor's Quality Committee shall promote
improved or clinical outcomes and enhanced quality of life for
elderly enrollees and enrollees with disabilities. The Quality
Committee shall:
a. Oversee quality of life indicators, such as:
i. Degree of personal autonomy;
ii. Provision of services and supports that
assist people in exercising medical and
social choices;
iii. Self-direction of care to the greatest
extent appropriate; and
iv. Maximum use of natural support networks.
b. Review persistent or significant complaints from
elderly enrollees and enrollees with disabilities or
their authorized person, identified through
contractors' complaint procedures and through
external oversight;
c. Review quality assurance policies, standards and
written procedures to ensure they adequately address
the needs of elderly enrollees and enrollees with
disabilities;
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d. Review utilization of services, including any
relationship to adverse or unexpected outcomes
specific to elderly enrollees and enrollees with
disabilities;
e. Develop written procedures and protocols for at least
the following:
i. Assessing the quality of complex health
care/care management;
ii. Ensuring contractor compliance with the
Americans with Disabilities Act; and
iii. Instituting effective health management
protocols for elderly enrollees and
enrollees with disabilities.
f. Develop and test methods to identify and collect
quality measurements including measures of treatment
efficacy of particular relevance to elderly enrollees
and enrollees with disabilities.
g. The contractor shall submit an annual report of the
quality activities of this Article.
2. Initiatives for Aged. The contractor shall implement specific
initiatives for the aged population through the development of
programs and protocols approved by DMAHS including:
a. The contractor shall develop a program to ensure
provision of the pneumococcal vaccine and influenza
immunizations, as recommended by the Centers for
Disease Control (CDC). The adult preventive
immunization program shall include the following
components:
i. Development, distribution, and measurement
of PCP compliance with practice guidelines;
ii. Educational outreach for enrollees and
practitioners;
iii. Access for ambulatory and homebound
enrollees; and
iv. Mechanism to report to DMAHS, via encounter
data, all immunizations given.
b. The contractor shall develop a program to ensure the
provision of preventive cancer screening services
including, at a minimum, mammography and prostate
cancer screening. The program shall include the
following components:
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i. Measurement of provider compliance with
performance standards;
ii. Education outreach for both enrollees and
practitioners regarding preventive cancer
screening services;
iii. Mammography services for women ages
sixty-five (65) to seventy-five (75) offered
at least annually;
iv. Screen for prostate cancer scheduled for
enrollees aged sixty-five (65) to
seventy-five (75) at least every two (2)
years; and
v. Documentation on medical records of all
tests given, positive findings and actions
taken to provide appropriate follow-up care.
c. The contractor shall develop specific programs for
the care of enrollees identified with congestive
heart failure, chronic obstructive lung disease
(COPD), diabetes, hypertension, and depression. The
program shall include the following:
i. Written quality of care plan to monitor
clinical management, including diagnostic,
pharmacological, and functional standards
and to evaluate outcomes of care;
ii. Measurement and distribution to providers of
reports on outcomes of care;
iii. Educational programming for enrollees and
significant caregivers which emphasizes
self-care and maximum independence;
iv. Educational materials for clinical providers
in the best practices of managing the
disease;
v. Evaluation of effectiveness of each program
by measuring outcomes of care; and
d. The contractor shall develop a program to manage the
care for enrollees identified with cognitive
impairments. The program shall include the following:
i. Written quality of care plans to monitor
clinical management, including functional
standards, and to evaluate outcomes of care;
ii. Measurement and distribution to providers of
reports on outcomes of care;
iii. Educational programming for significant
caregivers which emphasizes community based
care and support systems for caregivers; and
iv. Educational materials for clinical providers
in the best practices of managing cognitive
impairments.
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e. Initiatives to Prevent Long Term
Institutionalization: Contractor shall develop a
program to prevent unnecessary or inappropriate
nursing facility admissions for the ABD, dually
eligible population. This program shall include, but
is not limited to, the following:
i. Identification of medical and social
conditions that indicate risk of being
institutionalized;
ii. Monitoring and risk assessment mechanisms
that assist PCPs and others to identify
enrollees at-risk of institutionalization;
iii. Protocols to ensure the timely provision of
appropriate preventive care services to
at-risk enrollees. Such protocols should
emphasize continuity of care and
coordination of services; and
iv. Provision of home/community services covered
by the contractor as needed.
f. Abuse and Neglect Identification Initiative:
Contractor shall develop a program on prevention,
awareness, and treatment of abuse and neglect of
enrollees, to include the following:
i. Diagnostic tools for identifying enrollees
who are experiencing or who are at risk of
abuse and neglect;
ii. Protocols and interventions to treat abuse
and neglect of enrollees, including ongoing
evaluation of the effectiveness of these
protocols and interventions; and
iii. Coordination of these efforts through the
PCP.
3. QIP for Persons with Disabilities and the Elderly. The
contractor shall cooperate with the DMAHS and the ERO in
providing the data and in participating in the QIP studies for
persons with disabilities and the elderly. The study and final
report will be conducted and prepared by the ERO.
a. Preventive Medicine
i. Influenza vaccinations rates: percentage of
enrollees who have received an influenza
vaccination in the past year;
ii. Pneumonia vaccination rate: percentage of
enrollees who have received the pneumonia
vaccination at any time.
iii. Biennial eye examination: percentage of
enrollees receiving vision screening in the
past two (2) years;
iv. Biennial hearing examination: percentage of
enrollees receiving hearing screening in the
past two (2) years;
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v. Screening for smoking: percentage of
enrollees who reported smoking tobacco, and
percentage of those encouraged to stop
smoking during the past year;
vi. Screening for drug abuse: percentage of
enrollees reporting alcohol utilization in
the substance abuse risk areas, and
percentage of those referred for counseling;
and
vii. Screening for colon cancer: percentage of
enrollees who received this service in the
past two (2) years.
b. Congestive Heart Failure (CHF):
i. The number of enrollees diagnosed with CHF:
ii. The number hospitalized for CHF and average
lengths of stay;
iii. Percentage of enrollees for whom Angiotensin
Converting Enzyme (ACE) Inhibitors were
prescribed;
iv. Percentage for whom cardiac arrhythmias were
diagnosed;
v. CHF readmission rate (the number of
enrollees admitted more than once for CHF
during the past year);
vi. CHF readmission rate ratio (the ratio of
enrollees admitted more than once for CHF
compared to enrollees admitted only once);
vii. Percentage who died during the past year in
hospitals; and
viii. Percentage who died during the past year in
non-hospital settings.
c. Hypertension:
i. The number of enrollees identified as
hypertensive using HEDIS measures
ii. Percentage who received a blood test for
cholesterol or LDL.
S. For the elderly and enrollees with disabilities, the contractor shall
monitor and report outcomes annually to DMAHS of the following quality
indicators of potential adverse outcomes and provide for appropriate
education, outreach and care management, and quality improvement
activities as indicated:
1. Aspiration pneumonia
2. Injuries, fractures, and contusions
3. Decubiti
4. Seizure management
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T. MH/SA Services for Clients of DDD. In addition to including clients of
DDD and MH/SA services for clients of DDD in other required reports,
the contractor shall monitor and report on the following measures: 1)
timely outpatient follow-up to intensive treatment, defined as the
percentage of enrollees discharged from acute treatment who receive
ambulatory services within 7 days; and 2) adequacy of outpatient
follow-up, defined as the percentage of enrollees discharged from an
inpatient hospital who attend a minimum of one ambulatory service
appointment per month for four months.
U. The contractor shall provide to DMAHS for review and approval a written
description of its compensation methodology for marketing
representatives, including details of commissions, financial
incentives, and other income.
V. Provider Performance Measures. The contractor shall conduct a multi-
dimensional assessment of a provider's performance, and utilize such
measures in the evaluation and management of those providers. Data
shall be supplied to providers for their management activities. The
contractor shall indicate in its QAPI/Utilization Management Plan how
it will address this provision subject to DHS approval. At a minimum,
the evaluation management approach shall address the following:
1. Resource utilization of services, specialty and ancillary
services;
2. Clinical performance measures on outcomes of care;
3. Maintenance and preventive services;
4. Enrollee experience and perceptions of service delivery; and
5. Access.
For MH/SA services provided to enrollees who are clients of DDD the
contractor shall report MH/SA utilization data to its providers.
W. Member Satisfaction. The State will assess member satisfaction of
contractor services by conducting surveys employing the Consumer
Assessments of Health Plans Study (CAHPS) survey, or another survey
instrument specified by the State. The survey shall be stratified to
capture statistically significant results for all categories of New
Jersey Care 2000+ enrollees including AFDC/TANF, DYFS, SSI and New
Jersey Care Aged, Blind and Disabled, NJ FamilyCare, pregnant and
parenting women, and racial and linguistic minorities. Sample size,
sample selection, and implementation methodology shall be determined by
the State, with contractor input, to assure comparability of results
across State contractors.
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The State will select an independent survey administrator to perform
the survey on behalf of all of the State's New Jersey Care 2000+
contractors.
The contractor shall fully cooperate with the State and the independent
survey administrator such that final, analyzed survey results shall be
available from the survey administrator to the State, in a format
approved by the State, by a date specified by the State of each
contract year. Within sixty (60) days of receipt of the final, analyzed
survey results sent to the contractor, it shall identify leading
sources of enrollee dissatisfaction, specify additional measurement or
intervention efforts developed to address enrollee dissatisfaction, and
a timeline, subject to State approval, indicating when such activities
will be completed. A status report on the additional measurement or
intervention efforts shall be submitted to the State by a date
specified by DMAHS. The contractor shall respond to and submit a
corrective action to address and correct problems and deficiencies
found through the survey.
If the contractor conducts a member satisfaction survey of its own, it
shall send to DMAHS the results of the survey.
X. Focus Groups. The State will annually conduct four focus groups with
enrolled populations identified by the State and communicated in
writing to the contractor. Objectives for the focus groups will be
collaboratively developed by the State and the contractor. For the
first contract year, two focus groups each will be conducted with
enrollees who have communication-affecting disorders and with enrollees
who are elderly.
Focus group results will be reported by the State. The contractor shall
identify opportunities for improvement identified through the focus
groups, specify additional measurement or intervention efforts
developed to address the opportunities for improvement, and a timeline,
subject to State approval, indicating when such activities will be
completed. A status report on the additional measurement or
intervention efforts shall be submitted annually to the State by a date
specified by DMAHS.
Y. ERO. Other "areas of concern" shall be monitored through the external
review process. The External Review Organization (ERO) shall, in its
monitoring activities, validate the contractor's protocols, sampling,
and review methodologies.
Z. Community/Health Education Advisory Committee. The contractor shall
establish and maintain a community advisory committee, consisting of
persons being served by the contractor, including enrollees or
authorized persons, individuals and providers with knowledge of and
experience with serving elderly people or people with disabilities; and
representatives from community agencies that do not provide
contractor-covered services but are important to the health and
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well-being of members. The committee shall meet at least quarterly and
its input and recommendations shall be employed to inform and direct
contractor quality management activities and policy and operations
changes. The contractor shall submit a narrative annual report
indicating the constituencies on this committee, as well as the
committee's activities throughout the year.
AA. Provider Advisory Committee. The contractor shall establish and
maintain a provider advisory committee, consisting of providers
contracting with the contractor to serve enrollees. At least two
providers on the committee shall maintain practices that predominantly
serve Medicaid beneficiaries and other indigent populations, in
addition to at least one other practicing provider on the committee who
has experience and expertise in serving enrollees with special needs.
The committee shall meet at least quarterly and its input and
recommendations shall be employed to inform and direct contractor
quality management activities and policy and operations changes. The
contractor shall submit a narrative annual report indicating the
constituencies on this committee, as well as the committee's activities
throughout the year.
4.6.3 REFERRAL SYSTEMS
A. The contractor shall have a system whereby enrollees needing specialty
medical and dental care will be referred timely and appropriately. The
system shall address authorization for specific services with specific
limits or authorization of treatment and management of a case when
medically indicated (e.g., treatment of a terminally ill cancer patient
requiring significant specialist care). The contractor shall maintain
and submit a flow chart accurately describing the contractor's referral
system, including the title of the person(s) responsible for approving
referrals. The following items shall be contained within the referral
system:
1. Procedures for recording and tracking each authorized
referral.
2. Documentation and assurance of completion of referrals.
3. Policies and procedures for identifying and rescheduling
broken referral appointments with the providers and/or
contractor as appropriate (e.g. EPSDT services).
4. Policies and procedures for accepting, resolving and
responding to verbal and written enrollee requests for
referrals made to the PCP and/or contractor as appropriate.
Such requests shall be logged and documented. Requests that
cannot be decided upon immediately shall be responded to in
writing no later than five (5) business days from the date of
receipt of the request (with a call made to the enrollee on
final disposition) and postmarked the next day.
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5. Policies and procedures for proper notification of the
enrollee and where applicable, authorized person, the
enrollee's provider, and the enrollee's care manager,
including notice of right to appeal and/or right to a request
a second opinion when services are denied.
6. A referral form which can be given to the enrollee or, where
applicable, an authorized person to take to a specialist.
7. Referral form mailed, faxed, or sent by electronic means
directly to the referral provider.
8. Telephoned authorization for urgent situations or when deemed
appropriate by the enrollee's PCP or the contractor.
9. Where applicable, the contractor must also notify the
contractor care manager or authorized person.
B. The contractor shall provide a mechanism to assure the facilitation of
referrals when traveling by an enrollee (especially when very ill) from
one location to another to pick-up and deliver forms can cause undue
hardship for the enrollee. Referrals from practitioners or prior
authorizations by the contractor shall be sent/processed within two (2)
working days of the request, one (1) day for urgent cases. The
contractor shall have procedures to allow enrollees to receive a
standing referral to a specialist in cases where an enrollee needs
ongoing specialty care.
C. The contractor shall not impose an arbitrary number of attempted dental
treatment visits by a PCD as a condition prior to the PCD initiating
any specialty referral requests.
D. The contractor shall authorize any reasonable referral request from a
PCP/PCD without imposing any financial penalties to the same PCP/PCD.
E. All final decisions regarding denials of referrals, PAs, treatment and
treatment plans for non-emergency services shall be made by a physician
and/or peer physician specialist or by a dentist/dental specialist in
the case of dental services. Prior authorization decisions for
non-emergency services shall be made within ten (10) business days or
sooner as required by the needs of the enrollee.
4.6.4 UTILIZATION MANAGEMENT
A. Utilization Review Plan. The contractor shall develop a written
Utilization Review Plan that includes all standards described in the NJ
modified QARI/QISMC (See Section B.4.14 of the Appendices). The written
plan shall also include policies and procedures that address the
following:
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0. The contractor shall not deny benefits to require enrollees
and providers to go through the appeal process in an effort to
forestall and reduce needed benefits. The contractor shall
provide all medically necessary services covered by the NJ
Division of Medical Assistance and Health Services program in
this contract. If a dispute arises concerning the provision of
a service or the level of service, the service, if initiated,
shall be continued until the issue is resolved.
2. Utilization Management Committee. The committee shall have
written parameters for operating and will meet on a regular
schedule, defined to be at least quarterly. Committee members
shall be clearly identified and representative of the
contractor's providers, accountable to the medical director
and governing body, and shall maintain appropriate
documentation of the committee's activities, findings,
recommendations, and actions.
3. Data Collection and Reporting. The plan shall provide for
systematic utilization data collection and analysis, including
profiling of provider utilization patterns and patient
results. The contractor must use aggregate data to establish
utilization patterns, allow for trend analysis, and develop
statistical profiles of both individual providers and all
network providers. Such data shall be regularly reported to
the contractor management and contractor providers. The plan
shall also provide for interpretation of the data to
providers.
4. Corrective Action. The plan shall include procedures for
corrective action and follow-up activities when problems in
utilization are identified.
5. Roles and Responsibilities. The plan shall clearly define the
roles, functions, and responsibilities of the utilization
management committee and medical director.
6. Prohibitions on Compensation. The contractor or the
contractor's delegated utilization review agent shall not
permit or provide compensation or anything of value to its
employees, agents or contractors based on:
a. Either a percentage of the amount by which a claim is
reduced for payment or the number of claims or the
cost of services for which the person has denied
authorization or payment; or
b. Any other method that encourages the rendering of an
adverse determination.
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0. Retrospective Review. If a health care service has been
pre-authorized or approved, the specific standards, criteria
or procedures used in the determination shall not be modified
pursuant to retrospective review.
8. Collection of Information. Only such information as is
necessary to make a determination shall be collected. During
prospective or concurrent review, copies of medical records
shall only be required when necessary to verify that the
health care services subject to review are medically
necessary. In such cases, only the relevant sections of the
records shall be required. Complete or partial medical records
may be requested for retrospective reviews. In no event shall
such information be reviewed by persons other than health care
professionals, registered health information technicians,
registered health information administrators, or
administrative personnel who have received appropriate
training and who will safeguard patient confidentiality.
9. Prohibited Actions. Neither the contractor's UM committee nor
its utilization review agent shall take any action with
respect to an enrollee or a health care provider that is
intended to penalize or discourage the enrollee or the
enrollee's health care provider from undertaking an appeal,
dispute resolution or judicial review of an adverse
determination.
B. Prior Authorization. The contractor shall have policies and procedures
for prior-authorization. Prior authorization shall be conducted by a
currently licensed, registered or certified health care professional,
including a registered nurse or a physician who is appropriately
trained in the principles, procedures and standards of utilization
review. The following timeframes and requirements shall apply to all
prior authorization determinations:
1. Routine determinations. Prior authorization determinations for
non-urgent services shall be made and a notice of
determination provided by telephone and in writing to the
provider within ten (10) business days (or sooner as required
by the needs of the enrollee) of receipt of necessary
information sufficient to make an informed decision.
2. Urgent determinations. Prior authorization determinations for
urgent services shall be made within twenty-four (24) hours of
receipt of the necessary information.
3. Determination for Services that have been delivered.
Determinations involving health care services which have been
delivered shall be made within thirty (30) days of receipt of
the necessary information.
4. Adverse Determinations. A physician and/or a physician peer
reviewer shall make the final determination in all adverse
determinations.
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0. Continued/Extended Services. A utilization review agent shall
make a determination involving continued or extended health
care services, or additional services for an enrollee
undergoing a course of continued treatment prescribed by a
health care provider and provide notice of such determination
to the enrollee or the enrollee's designee, which may be
satisfied by notices to the enrollee's health care provider,
by telephone and in writing within one (1) business day of
receipt of the necessary information. Notification of
continued or extended services shall include the number of
extended services approved, the new total of approved
services, the date of onset of services and the next review
date. For services that require multiple visits, a series of
tests, etc. to complete the service, the authorized time
period shall be adequate to cover the anticipated span of time
that best fits the service needs and circumstances of each
individual enrollee.
6. Reconsiderations. The contractor shall have policies and
procedures for reconsideration in the event that an adverse
determination is made without an attempt to discuss such
determination with the referring provider. Determinations in
such cases shall be made within the timeframes established for
initial considerations.
7. The contractor shall provide written notification to enrollees
and/or, where applicable, an authorized person at the time of
denial, deferral or modification of a request for prior
approval to provide a medical/dental service(s), when the
following conditions exist:
a. The request is made by a medical/dental or other
health care provider who has a formal arrangement
with the contractor to provide services to the
enrollee.
b. The request is made by the provider through the
formal prior authorization procedures operated by the
contractor.
c. The service for which prior authorization is
requested is a Medicaid covered service for which the
contractor has established a prior authorization
requirement.
d. The prior authorization decision is being made at the
ultimate level of responsibility within the
contractor's organization for approving, denying,
deferring or modifying the service requested but
prior to the point at which the enrollee must
initiate the contractor's grievance procedure.
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0. Notice of Action. Written notification shall be given on a
standardized form approved by the Department and shall inform
the provider, enrollee or authorized person of the following:
a. The effective date of the denial, reduction of
service, or other medical coverage determination;
b. The enrollee's rights to, and method for obtaining, a
State hearing (Fair Hearing and/or IURO) to contest
the denial, deferral or modification action;
c. The enrollee's right to represent himself/herself at
the State hearing or to be represented by legal
counsel, friend or other spokesperson;
d. The action taken by the contractor on the request for
prior authorization and the reason for such action
including clinical rationale and the underlying
contractual basis or Medicaid authority;
e. The name and address of the contractor;
f. Notice of internal (contractor) appeal rights and
instructions on how to initiate such appeal;
g. Notice of the availability, upon request, of the
clinical review criteria relied upon to make the
determination;
h. The notice to the enrollee shall inform the enrollee
that he or she may file an appeal concerning the
contractor's action using the contractor's appeal
procedure prior to or concurrent with the initiation
of the State hearing process;
i. The contractor shall notify enrollees, and/or
authorized persons within the time frames set forth
in this contract;
9. In no instance shall the contractor apply prior authorization
requirements and utilization controls that effectively
withhold or limit medically necessary services, or establish
prior authorization requirements and utilization controls that
would result in a reduced scope of benefits for any enrollee.
C. Appeal Process for UM Determinations. The contractor shall have
policies and procedures for the appeal of utilization management
determinations and similar determinations. In the case of an enrollee
who was receiving a covered service (from the contractor, another
contractor, or the Medicaid Fee-for-Service
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program) prior to the determination, the contractor shall continue to
provide the same level of service while the determination is in appeal.
However, the contractor may require the enrollee to receive the service
from within the contractor's provider network, if equivalent care can
be provided within network.
1. The contractor shall provide that an enrollee, and any
provider acting on behalf of the enrollee with the enrollee's
consent (enrollee's consent shall not be required in the case
of a deceased patient, or when an enrollee has relocated and
cannot be found), may appeal any UM decision resulting in a
denial, termination, or other limitation in the coverage of
and access to health care services in accordance with this
contract and as defined in C.2 under the procedures described
in this Article. Such enrollees and providers shall be
provided with a written explanation of the appeal process upon
the conclusion of each stage in the appeal process.
2. Appealable decision means, at a minimum, any of the following:
a. An adverse determination under a utilization review
program;
b. Denial of access to specialty and other care;
c. Denial of continuation of care;
d. Denial of a choice of provider;
e. Denial of coverage of routine patient costs in
connection with an approved clinical trial;
f. Denial of access to needed drugs;
g. The imposition of arbitrary limitation on medically
necessary services; or
h. Denial of payment for a benefit.
3. Hearings. If the contractor provides a hearing to the enrollee
on the appeal, the enrollee shall have the right to
representation. The contractor shall permit the enrollee to be
accompanied by a representative of the enrollee's choice to
any proceedings and grievances. Such hearing must take place
in community locations convenient and accessible to the
enrollee.
4. The appeal process shall consist of an informal internal
review by the contractor (stage 1 appeal), a formal internal
review by the contractor (stage 2 appeal), and a formal
external review (stage 3 appeal) by an independent utilization
review organization under the DHSS and/or the Medicaid Fair
Hearing process shall be in accordance with N.J.A.C 10:49 et
seq. Stages 1-3 appeals shall be in accordance with N.J.A.C.
8:38-8.
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5. Utilization Management Grievances. Appropriate clinical
personnel shall be involved in the investigation and
resolution of all UM grievances. The processing of all such
grievances shall be incorporated in the contractor's quality
management activities and shall be reviewed periodically (at
least quarterly) by the Medical Director/Dental Director.
6. Nothing in this Article shall be construed as removing any
legal rights of enrollees under State or federal law,
including the right to file judicial actions to enforce rights
or request a Medicaid Fair Hearing for Medicaid enrollees in
accordance with their rights under State and federal laws and
regulations. All written notices to Medicaid/NJ FamilyCare
Plan A enrollees shall include a statement of their right to
access the Medicaid Fair Hearing process at any time.
D. Drug Utilization Review Program (DUR): The contractor shall establish
and maintain a drug utilization review (DUR) program that satisfies the
minimum requirements for prospective and retrospective DUR as described
in 1927(g) of the Social Security Act, amended by the Omnibus Budget
Reconciliation Act (OBRA) of 1990. The contractor shall include review
of Mental Health/Substance Abuse drugs in its DUR program. The State or
its agent shall provide its expertise in developing review protocols
and shall assist the contractor in analyzing MH/SA drug utilization.
Results of the review shall be provided to the State or its agent and,
where applicable, to the contractor's network providers. The State or
its agent will take appropriate corrective action to report its actions
and outcomes to the contractor.
1. DUR standards shall encourage proper drug utilization by
ensuring maximum compliance, minimizing potential fraud and
abuse, and taking into consideration both the quality and cost
of the pharmacy benefit.
2. The contractor shall implement a claims adjudication system,
preferably on-line, which shall include a prospective review
of drug utilization, and include age-specific edits.
3. The prospective and retrospective DUR standards established by
the contractor shall be consistent with those same standards
established by the Medicaid Drug Utilization Review Board.
DMAHS shall approve the effective date for implementation of
any DUR standards by the contractor as well as any subsequent
changes within thirty (30) days of such change.
4.6.5 CARE MANAGEMENT
A. Care Management Standards. The contractor shall develop and implement
care management as defined in Article 1 with adequate capacity to
provide services to all enrollees who would benefit from care
management services. In addition, the
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contractor shall develop a higher level of care management for
enrollees with special needs, as described in Article 4.5.4. Specific
care management activities shall include at least the following:
1. An effective mechanism to initiate and discontinue care
management services in both inpatient and outpatient settings,
in addition to catastrophic incidents.
2. An effective mechanism to coordinate services required by
enrollees, including community support services. When
appropriate, such activities shall be coordinated with those
of the Division of Family Development (DFD), Division of Youth
and Family Services (DYFS), Division of Mental Health Services
(DMHS), Division of Developmental Disabilities, Special Child
Health Services County Case Management Units, Division of
Addiction Services, and community agencies.
3. Care plans specifically developed for each care managed
enrollee which ensure continuity and coordination of care
among the various clinical and non-clinical disciplines and
services.
4. A process to evaluate and improve individual care management
services as well as the effectiveness of care management as a
whole.
5. Protocols for the following care management activities:
a. Pregnancy services including HealthStart program
requirements;
b. All EPSDT services and coordination for children with
elevated blood lead levels;
c. Mental health/substance abuse services coordination;
d. HIV/AIDS services coordination; and
e. Dental services for enrollees with developmental
disabilities.
B. Early Identification. The contractor shall develop policies and
procedures for early identification of enrollees who require care
management. The contractor shall include in its policies and procedures
a review of the following possible indicators of complex care needs:
1. Poor health or functional status, as reported by the enrollee
or authorized person;
2. Existence of a care plan;
3. Existence of a case manager;
4. Request for an assessment from the enrollee or authorized
person;
5. Request for an assessment from a State agency or private
agency contracting with DDD involved with the enrollee;
6. A chronic condition;
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0. A recent hospitalization or admission to a nursing facility;
8. Recent critical social events, such as the death or relocation
of a family member or a move to a new home;
9. Existence of multiple medical or social service systems or
providers in the life of the enrollee;
10. Use of prescription drugs, particularly multiple drugs; and
11. Use of interpreter or any special services.
C. Complex Needs Assessment. The contractor shall have protocols and tools
for performing and reviewing/updating Complex Needs Assessments.
1. The Complex Needs Assessment must cover at least the following
risk factors:
a. Medical status and history, including primary and
secondary diagnosis and current and past medications
prescribed
b. Functional status
c. Physical well-being
d. Mental health status
e. History of tobacco, alcohol and drug use or abuse
f. Identification of existing and potential formal and
informal supports
g. Determination of willingness and capacity of family
members or, where applicable, authorized persons and
others to provide informal support
h. Condition and proximity to services of current
housing, and access to appropriate transportation
i. Identification of current or potential long term
service needs
j. Need for medical supplies and DME
2. When any of the following conditions are met, the contractor
shall ensure that a Complex Needs Assessment is conducted, or
an existing assessment is reviewed, within a time frame that
meets the needs of the enrollee but within no more than thirty
(30) days:
a. Special needs are identified at the time of
enrollment or any time thereafter;
b. An enrollee or authorized person requests an
assessment;
c. The enrollee's PCP requests an assessment;
d. A State agency involved with an enrollee requests an
assessment; or
e. An enrollee's status otherwise indicates.
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D. Plan of Care. The contractor, through its care manager, shall ensure
that a plan of care is developed and implementation has begun within
thirty (30) business days of the date of a needs assessment, or sooner,
according to the circumstances of the enrollee. The contractor shall
ensure the full participation and consent of the enrollee or, where
applicable, authorized person and participation of the enrollee's PCP
and other case managers identified through the Complex Needs Assessment
(e.g., DDD case manager) in the development of the plan. The plan shall
specify treatment goals, identify medical service needs, relevant
social and support services, appropriate linkages and timeframe as well
as provide an ongoing accurate record of the individual's clinical
history. The care manager shall be responsible for implementing the
linkages identified in the plan and monitoring the provision of
services identified in the plan. This includes making referrals,
coordinating care, promoting communication, ensuring continuity of
care, and conducting follow-up. The care manager shall also be
responsible for ensuring that the plan is updated as needed, but at
least annually. This includes early identification of changes in the
enrollee's needs.
E. Referrals. The contractor shall have policies and procedures to process
and respond within ten (10) business days to care management referrals
from network providers, state agencies, private agencies under contract
with DDD, self-referrals, or, where applicable, referrals from an
authorized person.
F. Continuity of Care
1. The contractor shall establish and operate a system to assure
that a comprehensive treatment plan for every enrollee will
progress to completion in a timely manner without unreasonable
interruption.
2. The contractor shall construct and maintain policies and
procedures to ensure continuity of care by each provider in
its network.
3. An enrollee shall not suffer unreasonable interruption of
his/her active treatment plan. Any interruptions beyond the
control of the provider will not be deemed a violation of this
requirement.
4. If an enrollee has already had a medical or dental treatment
procedure initiated prior to his/her enrollment in the
contractor's plan, the initiating treating provider must
complete that procedure (not the entire treatment plan). See
4.1.1.E for details.
G. Documentation. The contractor shall document all contacts and linkages
to medical and other services in the enrollee's case files.
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H. Informing Providers. The contractor shall inform its PCPs and
specialists of the availability of care management services, and must
develop protocols describing how providers will coordinate services
with the care managers.
I. Care Managers. The contractor shall establish a distinct care
management function within the contractor's plan. This function shall
be overseen by a Care Management Supervisor, as described in Article
7.3. Care managers shall be dedicated to providing care management and
may be employees or contracted agents of the contractor. The care
manager, in conjunction with and with approval from, the enrollee's
PCP, shall make referrals to needed services. The care management
system shall recognize three levels set forth in Section B.4.12 of the
Appendices. Level 3 is described in Article 4.5.4.
1. The care manager for the first level of care management shall
have as a minimum a license as a registered nurse or a
Bachelor's degree in social work, health or behavioral
science.
2. For level two of care management, in addition to the
requirements in 4.6.5I.1. above, the care managers shall also
have at least one (1) year of experience serving enrollees
with special needs.
3. The contractor shall have procedures to monitor the adequacy
of staffing and must adjust staffing ratios and caseloads as
appropriate based on its staffing assessment.
J. Care management shall also be made available to enrollees who exhibit
inappropriate, disruptive or threatening behaviors in a medical
practitioner's office when such behaviors may relate to or result from
the existence of the enrollee's special needs.
K. Hours of Service. The contractor shall make care management services
available during normal office hours, Monday through Friday.
4.7 MONITORING AND EVALUATION
4.7.1 GENERAL PROVISIONS
A. For purposes of monitoring and evaluating the contractor's performance
and compliance with contract provisions, to assure overall quality
management (QM), and to meet State and federal statutes and regulations
governing monitoring, DMAHS or its agents shall have the right to
monitor and evaluate on an on-going basis, through inspection or other
means, the contractor's provision of health care services and
operations including, but not limited to, the quality, appropriateness,
and timeliness of services provided under this contract and the
contractor's compliance with its internal QM program. DMAHS shall
establish the scope of
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review, review sites, relevant time frames for obtaining information,
and the criteria for review, unless otherwise provided or permitted by
applicable laws, rules, or regulations.
B. The contractor shall cooperate with and provide reasonable assistance
to DMAHS in monitoring and evaluation of the services provided under
this contract.
C. The contractor hereby agrees to medical audits in accordance with the
protocols for care specified in this contract, in accordance with
medical community standards for care, and of the quality of care
provided all enrollees, as may be required by appropriate regulatory
agencies.
D. The contractor shall cooperate with DMAHS in carrying out the
provisions of applicable statutes, regulations, and guidelines
affecting the administration of this contract.
E. The contractor shall distribute to all subcontractors providing
services to enrollees, informational materials approved by DMAHS that
outlines the nature, scope, and requirements of this contract.
F. The contractor, with the prior written approval of DMAHS, shall print
and distribute reporting forms and instructions, as necessary whenever
such forms are required by this contract.
G. The contractor shall make available to DMAHS copies of all standards,
protocols, manuals and other documents used to arrive at decisions on
the provision of care to its DMAHS enrollees.
H. The contractor shall use appropriate clinicians to evaluate the
clinical data, and must use multi-disciplinary teams to analyze and
address systems issues.
I. Contractor shall develop an incentive system for providers to assure
submission of encounter data. At a minimum, the system shall include:
1. Mandatory provider profiling that includes complete and timely
submissions of encounter data. Contractor shall set specific
requirements for profile elements based on data from encounter
submissions.
2. Contractor shall set up data submission requirements based on
encounter data elements for which compliance performance will
be both rewarded and/or sanctioned.
J. The contractor shall include in its quality management system
reviews/audits which focus on the special dental needs of enrollees
with developmental disabilities. Using encounter data reflecting the
utilization of dental services and
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other data sources, the contractor shall measure clinical outcomes;
have these outcomes evaluated by clinical experts; identify quality
management tools to be applied; and recommend changes in clinical
practices intended to improve the quality of dental care to enrollees
with developmental disabilities.
4.7.2 EVALUATION AND REPORTING - CONTRACTOR RESPONSIBILITIES
A. The contractor shall collect data and report to the State its findings
on the following:
1. Encounter Data: The contractor shall prepare and submit
encounter data to DMAHS. Instructions and formats for this
report are specified in Section B.3.3 of the Appendices of
this contract.
2. Grievance Reports: The contractor shall provide to DMAHS
quarterly reports of all grievances in accordance with
Articles 5.15 and the contractor's approved grievance process
included in this contract. See Section A.7.5 of the Appendices
(Table 3).
3. Appointment Availability Studies: The contractor shall conduct
a review of appointment availability and submit a report to
DMAHS semi-annually. The report must list the average time
that enrollees wait for appointments to be scheduled in each
of the following categories: baseline physical, routine,
specialty, and urgent care appointments. DMAHS must approve
the methodology for this review in advance in writing. The
contractor shall assess the impact of appointment waiting
times on the health status of enrollees with special needs.
4. Twenty-four (24) Hour Access Report: The contractor shall
submit to DMAHS an annual report describing its twenty-four
(24) hour access procedures for enrollees. The report must
include the names and addresses of any answering services that
the contractor uses to provide twenty-four (24) hour access.
5. The contractor shall submit to DMAHS, on a quarterly basis,
records of early discharge information which pertain to
hospital stays for newborns and mothers.
6. The contractor shall monitor, evaluate, and submit an annual
report to DMAHS on the incidence of HIV/AIDS patients, the
impact of the contractor's program to promote HIV prevention
(Article 4.5.7), counseling, treatment and quality of life
outcomes, mortality rates.
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7. Additional Reports: The contractor shall prepare and submit
such other reports as DMAHS may request. Unless otherwise
required by law or regulation, DMAHS shall determine the
timeframe for submission based on the nature of the report and
give the contractor the opportunity to discuss and comment on
the proposed requirements before the contractor is required to
submit such additional reports.
8. The contractor shall submit to the Division, on a quarterly
basis, documentation of its ongoing internal quality assurance
activities. Such documentation shall include at a minimum:
a. Agenda of quality assurance meetings of its medical
professionals; and
b. Attendance sheets with attendee signatures.
B. Clinical areas requiring improvement shall be identified and documented
with a corrective action plan developed and monitored by the State.
1. Implementation of remedial/corrective action. The QAPI shall
include written procedures for taking appropriate remedial
action whenever, as determined under the QAPI, inappropriate
or substandard services are furnished, or services that should
have been furnished were not. Quality assurance actions which
result in the termination of a medical provider shall be
immediately forwarded by the contractor to DMAHS. Written
remedial/corrective action procedures shall include:
a. Specification of the types of problems requiring
remedial/corrective action;
b. Specification of the person(s) or body responsible
for making the final terminations regarding quality
problems;
c. Specific actions to be taken;
d. Provision of feedback to appropriate health
professionals, providers and staff;
e. The schedule and accountability for implementing
corrective actions;
f. The approach to modifying the corrective action if
improvements do not occur; and
g. Procedures for notifying a primary care
physician/provider group that a particular
physician/provider is no longer eligible to provide
services to enrollees.
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2. Assessment of effectiveness of corrective actions. The
contractor shall monitor and evaluate corrective actions taken
to assure that appropriate changes have been made. In
addition, the contractor shall track changes in practice
patterns.
3. The contractor shall assure follow-up on identified issues to
ensure that actions for improvement have been effective and
provide documentation of same.
4. The findings, conclusions, recommendations, actions taken, and
results of the actions taken as a result of QM activity, shall
be documented and reported to appropriate individuals within
the organization and through the established QM channels. The
contractor shall document coordination of QM activities and
other management activities.
C. The contractor shall conduct an annual satisfaction survey of a
statistically valid sample of its participating providers who provide
services to DMAHS enrollees. The contractor shall submit a copy of the
survey instrument and methodology to DMAHS. The survey should include
as a minimum questions that address provider opinions of the impact of
the referral, prior authorization and provider appeals processes on
his/her practice/services, reimbursement methodologies, care management
assistance from the contractor. The contractor shall communicate the
findings of the survey to DMAHS in writing within one hundred twenty
(120) days after conducting the survey. The written report shall also
include identification of any corrective measures that need to be taken
by the contractor as a result of the findings, a time frame in which
such corrective action will be taken by the contractor and recommended
changes as needed for subsequent use.
4.7.3 MONITORING AND EVALUATION - DEPARTMENT ACTIVITIES
The contractor shall permit the Department and the United States Department of
Health and Human Services or its agents to have the right to inspect, audit or
otherwise evaluate the quality, appropriateness and timeliness of services
performed under this contract, including through a medical audit. Medical audit
by Department staff shall include, at a minimum, the review of:
A. Health care delivery system for patient care;
B. Utilization data;
C. Medical evaluation of care provided and patient outcomes for specific
enrollees as well as for a statistical representative sample of
enrollee records;
D. Health care data elements submitted electronically to DMAHS;
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E. Annual, on-site review of the contractor's operations with necessary
follow-up reviews and corrective actions;
F. The grievances and complaints (recorded in a separately designated
complaint log for DMAHS enrollees) relating to medical care including
their disposition;
G. Minutes of all quality assurance committee meetings conducted by the
contractor's medical staff. Such reviews will be conducted on-site at
the contractor's facilities or administrative offices.
4.7.4 INDEPENDENT EXTERNAL REVIEW ORGANIZATION REVIEWS
A. The contractor shall cooperate with the external review organization
(ERO) audits and provide the information requested and in the time
frames specified (generally within sixty (60) days or as indicated in
the notice), including medical and dental records, QAPI reports and
documents, and financial information. Contractors shall submit a plan
of action to correct, evaluate, respond to, resolve, and follow-up on
any identified problems reported by such activities.
B. The scope of the ERO reviews shall be as follows:
1. Annual, onsite review of contractor's operations with
necessary follow-up reviews and corrective actions.
2. The contractor's quality management plan and activities.
3. Individual medical record reviews.
4. Randomly selected studies.
5. Focus studies utilizing where possible HEDIS measurements and
comparison to Healthy People 2010 Objectives and/or Healthy
New Jersey 2010 standards and/or EPSDT or HealthStart
standards as appropriate.
6. Validation review of the contractor's QM/HEDIS studies
required in this contract.
7. Validation and evaluation of encounter data.
8. Health care data analysis.
9. Monitoring to ensure enrollees are issued written
determinations, including appeal rights and notification of
their right to a Medicaid Fair Hearing as well as a review by
the DHSS IURO.
10. Ad hoc studies and reviews.
11. ERO reviews for dental services include but are not limited
to:
a. New Jersey licensed Dental Consultants of the ERO
will review a random sample of patient charts and
conduct provider interviews. A random number of
patients will receive screening examinations.
b. Auditors will review appointment logs, referral logs,
health education material, and conduct staff
interviews.
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c. Audit documents will be completed by appropriate
consultant/auditor.
4.8 PROVIDER NETWORK
4.8.1 GENERAL PROVISIONS
A. The contractor shall establish and maintain at all times a complete
provider network consisting of traditional providers for primary and
specialty care, including primary care physicians, other approved
non-physician primary care providers, physician specialists,
non-physician practitioners, hospitals (including teaching hospitals),
Federally Qualified Health Centers and other essential community
providers/safety-net providers, and ancillary providers. The provider
network shall be reviewed and approved by DMAHS and the sufficiency of
the number of participating providers shall be determined by DMAHS in
accordance with the standards found in Article 4.8.8 "Provider Network
Requirements."
B. The contractor shall ensure that its provider network includes, at a
minimum:
1. Sufficient number, available and physically accessible, of
physician and non-physician providers of health care to cover
all services in the amount, duration, and scope included in
the benefits package under this contract. The number of
enrollees assigned to a PCP shall be decreased by the
contractor if necessary to maintain the appointment
availability standards. The contractor's network, at a
minimum, shall be sufficient to serve at least 33 percent of
all individuals eligible for managed care in each urban county
it serves. The contractor's network, at a minimum, shall be
sufficient to serve at least 50 percent of all individuals
eligible for managed care in the remaining non-urban counties
it serves, i.e., Cape May, Hunterdon, Salem, Sussex, and
Xxxxxx.
2. A number and distribution of Primary Care Physicians shall be
such as to accord to all enrollees a ratio of at least one (1)
full time equivalent Primary Care Physician who will serve no
more than 1,500 enrollees and one FTE primary care dentist for
1,500 enrollees. Exemption to the 1:1,500 ratio limit may be
granted by DMAHS if criteria specified further below are met.
3. Providers who can accommodate the different languages of the
enrollees including bilingual capability for any language
which is the primary language of five (5) percent or more of
the enrolled DMAHS population.
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0. Providers, including dentists, pediatricians, physiatrists,
gynecologists, family practitioners, internists, neurologists,
nurse practitioners or other individual specialists, who are
experienced in treating enrollees with special needs. This
includes dentists who provide service to persons with
developmental disabilities and who may have to take additional
time in providing a specific service. Each contractor shall
demonstrate the availability and accessibility of
institutional facilities and professional allied personnel,
home care and community based services to perform the agreed
upon services.
5. Medical primary care network shall include internists,
pediatricians, family and general practice physicians. The
contractor shall have the option to include
obstetricians/gynecologists as PCPs as well as other physician
specialists as primary care providers for enrollees with
special needs who will supervise and coordinate their care via
a team approach providing that the contract with the physician
specialist is, at a minimum, the same as for all other PCPs
and that enrollees are enrolled with the physician specialist
in the same manner and with the same physician/enrollee ratio
requirements as for all other primary care physicians. The
contractor shall include certified nurse midwives in its
provider network where they are available and willing to
participate in accordance with 1905 (a)(17) of the Social
Security Act. CNPs/CNSs included as PCPs or specialists in the
network may provide a scope of services that comply with their
licensure requirements.
6. A CNP/CNS to enrollee ratio may not exceed one CNP or one CNS
to 1000 enrollees per contractor or 1500 enrollees cumulative
across plans.
7. Compliance with the standards delineated in Article 4.8.
C. All providers and subcontractors shall, at a minimum, meet Medicaid
provider requirements and standards as well as all other federal and
State requirements. For example, a home health agency subcontractor
shall meet Medicare certification participation requirements and be
licensed by the Department of Health and Senior Services; hospice
providers shall meet Medicare certification participation requirements;
providers for mammography services shall meet the Food and Drug
Administration (FDA) requirements.
D. The contractor shall include in its network at least one (1) hospital
located in the inner city urban area and at least 1 non-urban-based
hospital in every county. For those counties with only one (1)
hospital, the contractor shall include that hospital in its network
subject to good faith negotiations.
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E. The contractor shall offer a choice of two specialists in each county
where available. If only one or no providers of a particular specialty
is available, the contractor shall provide documentation of the lack of
availability and propose alternative specialty providers in neighboring
counties.
F. The contractor shall include in its network mental health/substance
abuse providers for Medicaid covered MH/SA services with expertise to
serve enrollees who are clients of the Division of Developmental
Disabilities.
G. Changes in large provider groups, IPAs or subnetworks such as pharmacy
benefits manager, vision network, or dental network shall be submitted
to DMAHS for review and prior approval at least ninety (90) days before
the anticipated change. The submission shall include contracts,
provider network files, enrollee/provider notices and any other
pertinent information.
H. Requirement to contract with FQHC. The contractor shall contract for
primary care services with at least one Federally Qualified Health
Center (FQHC) located in each enrollment area based on the availability
and capacity of the FQHCs in that area. FQHC providers shall meet the
contractor's credentialing and program requirements.
4.8.2 PRIMARY CARE PROVIDER REQUIREMENTS
A. The contractor shall offer each enrollee a choice of two (2) or more
primary care physicians furnished by the contractor. Where applicable,
this offer can be made to an authorized person. An enrollee with
special needs shall be given the choice of a primary care provider
which must include a pediatrician, general/family practitioner, and
internist, and may include physician specialists and nurse
practitioners. The PCP shall supervise the care of the enrollee with
special needs who requires a team approach. Subject to any limitations
in the benefits package, each primary care provider shall be
responsible for overall clinical direction, serve as a central point of
integration and coordination of covered services listed in Article 4.1,
provide a minimum of twenty (20) hours per week of personal
availability as a primary care provider; provide health counseling and
advice; conduct baseline and periodic health examinations; diagnose and
treat covered conditions not requiring the referral to and services of
a specialist; arrange for inpatient care, for consultation with
specialists, and for laboratory and radiological services when
medically necessary; coordinate referrals for dental care, especially
in accordance with EPSDT requirements; coordinate the findings of
laboratories and consultants; and interpret such findings to the
enrollee and the enrollee's family (or, where applicable, an authorized
person), all with emphasis on the continuity and integration of medical
care; and, as needed, shall participate in care management and
specialty care management team processes. The primary care
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provider shall also be responsible, subject to any limitations in the
benefits package, for determining the urgency of a consultation with a
specialist and, if urgent, shall arrange for the consultation
appointment.
Justification to include a specialist as a PCP or justification for a
physician practicing in an academic setting for less than twenty (20)
hours per week must be provided to DMAHS. Include in the justification
for the specialist as a PCP the number of enrollees to be served as a
PCP and as a specialist, full details of the services and scope of
services to be provided, and coverage arrangements documenting
twenty-four (24) hours/seven (7) days a week coverage.
B. The PCP shall be responsible for supervising, coordinating, managing
the enrollee's health care, providing initial and primary care to each
enrollee, for initiating referrals for specialty care, maintaining
continuity of each enrollee's health care and maintaining the
enrollee's comprehensive medical record which includes documentation of
all services provided to the enrollee by the PCP, as well as any
specialty or referral services. The contractor shall establish policies
and procedures to ensure that PCPs are adequately notified of specialty
and referral services. PCPs who provide professional inpatient services
to the contractor's enrollees shall have admitting and treatment
privileges in a minimum of one general acute care hospital that is
under subcontract with the contractor and is located within the
contractor's service area. The PCP shall be an individual, not a
facility, group or association of persons, although he/she may practice
in a facility, group or clinic setting.
1. The PCP shall provide twenty-four (24) hour, seven (7) day a
week access; and
2. Make referrals for specialty care and other medically
necessary services, both in-network and out-of-network.
3. Enrollees with special needs requiring very complex, highly
specialized health care services over a prolonged period of
time, and by virtue of their nature and complexity would be
difficult for a traditional PCP to manage or with a
life-threatening condition or disease, or with a degenerative
and/or disabling condition or disease may be offered the
option of selecting an appropriate physician specialist (where
available) in lieu of a traditional PCP. Such physicians
having the clinical skills, capacity, accessibility, and
availability shall be specially credentialed and contractually
obligated to assume the responsibility for overall health care
coordination and assuring that the special needs person
receives all necessary specialty care related to their special
need, as well as providing for or arranging all routine
preventive care and health maintenance services, which may not
customarily be provided by or the responsibility of such
specialist physicians.
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4. Where a specialist acting as a PCP is not available for
chronically ill persons or enrollees with complex health care
needs, those enrollees shall have the option to select a
traditional PCP upon enrollment, with the understanding that
the contractor may permit a more liberal, direct specialty
access (See section 4.5.2) to a specific specialist for the
explicit purpose of meeting those specific specialty service
needs. The PCP shall in this case retain all responsibility
for provision of primary care services and for overall
coordination of care, including specialty care.
5. If the enrollee's existing PCP is a participating provider in
the contractor's network, and if the enrollee wishes to retain
the PCP, contractor shall ensure that the PCP is assigned,
even if the PCP's panel is otherwise closed at the time of the
enrollee's enrollment.
C. In addition to offering, at a minimum, a choice of two or more primary
care physicians, the contractor shall also offer an enrollee or, where
applicable, an authorized person the option of choosing a certified
nurse midwife, certified nurse practitioner or clinical nurse
specialist whose services must be provided within the scope of his/her
license. The contractor shall submit to DMAHS for review a detailed
description of the CNP/CNS's responsibilities and health care delivery
system within the contractor's plan.
4.8.3 PROVIDER NETWORK FILE REQUIREMENTS
The contractor shall provide a provider network file, to be reported by
hard copy and diskette in a format and software application system
determined by DMAHS that will include the names and addresses of every
provider in the contractor's network. The format for computer diskette
submission is found in Section A.4.1 of the Appendices.
A. The contractor shall provide the DMAHS a full network, monthly, on
computer diskette in accordance with the specifications provided in
Section A.4.1 of the Appendices. The network file shall include an
indicator for new additions and deletions and shall include:
1. Any and all changes in participating primary care providers,
including, for example, additions, deletions, or closed
panels, must be reported monthly to DMAHS;
2. Any and all changes in participating physician specialists,
health care providers, CNPs/CNSs, ancillary providers, and
other subcontractors must be reported to DMAHS on a monthly
basis; and
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B. The contractor shall provide the HBC with a full network on a monthly
basis in accordance with the specifications found in Section A.4.1 of
the Appendices. The diskettes shall be sent to OMHC, DMAHS for
distribution.
4.8.4 PROVIDER DIRECTORY REQUIREMENTS
The contractor shall prepare a provider directory which shall be
presented in the following manner. Fifty (50) copies of the provider
directory, and any updates, shall be provided to the HBC, and one copy
shall be provided to DMAHS.
A. Primary care providers who will serve enrollees listed by
- County, by city, by specialty
- Provider name and degree; specialty board
eligibility/certification status; office address(es) (actual
street address); telephone number; fax number if available;
office hours at each location; indicate if a provider serves
enrollees with disabilities and how to receive additional
information such as type of disability; hospital affiliations;
transportation availability; special appointment instructions
if any; languages spoken; disability access; and any other
pertinent information that would assist the enrollee in
choosing a PCP.
B. Contracted specialists and ancillary services providers who will serve
enrollees
- Listed by county, by city, by physician specialty, by
non-physician specialty, and by adult specialist and by
pediatric specialist for those specialties indicated in
Section 4.8.8.C.
C. Subcontractors
- Provide, at a minimum, a list of all other health care
providers by county, by service specialty, and by name. The
contractor shall demonstrate its ability to provide all of the
services included under this contract.
4.8.5 CREDENTIALING/RECREDENTIALING REQUIREMENTS/ISSUES
The contractor shall develop and enforce credentialing and
recredentialing criteria for all provider types which should follow the
HCFA's credentialing criteria, as delineated in the NJ modified
QARI/QISMC standards found in Article 4.6.1 and Section B.4.14 of the
Appendices.
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4.8.6 LABORATORY SERVICE PROVIDERS
A. The contractor shall ensure that all laboratory testing sites providing
services under this contract, including those provided by primary care
physicians, specialists, other health care practitioners, hospital
labs, and independent laboratories have either a Clinical Laboratory
Improvement Amendment (CLIA) certificate of waiver or a certificate of
registration along with a CLIA identification number. Those laboratory
service providers with a certificate of waiver shall provide only those
tests permitted under the terms of their waiver. Laboratories with
certificates of registration may perform a full range of laboratory
tests.
1. The contractor shall provide to DMAHS, on request, copies of
certificates that its own laboratory or any other laboratory
it conducts business with, has a CLIA certificate for the
services it is performing as fulfillment of requirements in
42 C.F.R. * 493.1809.
2. If the contractor has its own laboratory, the contractor shall
to submit at the time of initial contracting a written list of
all diagnostic tests performed in its own laboratory if
applicable and those tests which are referred to other
laboratories annually and within fifteen (15) working days of
any changes.
3. If a new laboratory subcontractor is added or if a laboratory
subcontractor is terminated during the contract year, the
contractor shall provide this information to DMAHS within
thirty (30) days of the effective date of the subcontractor's
addition or termination. The contractor shall provide a copy
of a new subcontractor's certificate of waiver or certificate
of registration within ten (10) days of operation.
B. The contractor shall contract with clinical diagnostic laboratories
that have a compliance plan to help avoid activities that might be
regarded as fraudulent. The compliance plan shall, at a minimum,
include the following:
1. Written standards of conduct for employees;
2. Development and distribution of written policies that promote
the laboratory's commitment to compliance and that address
specific areas of potential fraud, such as billing, marketing,
and claims processing;
3. The designation of a chief compliance officer or other
appropriate high-level corporate structure or official who
is charged with the responsibility of operating the compliance
program;
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0. The development and offering of education and training
programs to all employees;
5. The use of audits and/or other evaluation techniques to
monitor compliance and ensure a reduction in identified
problem areas;
6. The development of a code of improper/illegal activities and
the use of disciplinary action against employees who have
violated internal compliance policies or applicable laws or
who have engaged in wrongdoing;
7. The investigation and remediation of identified systemic and
personnel problems;
8. The promotion of and adherence to compliance as an element in
evaluating supervisors and managers;
9. The development of policies addressing the non-employment or
retention of sanctioned individuals;
10. The maintenance of a hotline to receive complaints and the
adoption of procedures to protect the anonymity of
complainants; and
11. The adoption of requirements applicable to record creation and
retention.
C. The contractor shall maintain a sufficient network of drawing/specimen
collection stations (may include independent lab stations, hospital
outpatient departments, provider offices, etc.) to ensure ready access
for all enrollees.
4.8.7 SPECIALTY PROVIDERS AND CENTERS (ALSO ADDRESSED IN 4.5)
A. The contractor shall include in its network pediatric medical
subspecialists, pediatric surgical specialists, and consultants. Access
to these services shall be provided when referred by a pediatrician.
B. The contractor shall include in its provider network Centers of
Excellence (designated by the DHSS; See Appendix B.4.10) for children
with special health care needs. Inclusion of such agencies or their
equivalent may be by direct contracting, consultant, or on a referral
basis. Payment mechanism and rates shall be negotiated directly with
the center.
C. The contractor shall include primary care providers experienced in
caring for enrollees with special needs.
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D. The contractor shall include providers who have knowledge and
experience in identifying child abuse and neglect and should include
Child Abuse Regional Diagnostic Centers or their equivalent through
either direct contracting, consultant or on a referral basis. A list of
Child Abuse Regional Diagnostic Centers is in Section B.4.16 of the
Appendices.
E. The contractor shall have a procedure by which an enrollee who needs
ongoing care from a specialist may receive a standing referral to such
specialist. If the contractor, or the primary care provider in
consultation with the medical director of the contractor and
specialist, if any, determines that such a standing referral is
appropriate, the organization shall make such a referral to a
specialist. The contractor shall not be required to permit an enrollee
to elect to have a non-participating specialist if network provider of
equivalent expertise is available. Such referral shall be pursuant to a
treatment plan approved by the contractor in consultation with the
primary care provider, the specialist, the care manager, and the
enrollee or, where applicable, authorized person. Such treatment plan
may limit the number of visits or the period during which such visits
are authorized and may require the specialist to provide the primary
care provider with regular updates on the specialty care provided, as
well as all necessary medical information.
F. The contractor shall have a procedure by which an enrollee as described
in Articles 4.5.2D may receive a referral to a specialist or specialty
care center with expertise in treating such conditions in lieu of a
traditional PCP.
G. If the contractor determines that it does not have a health care
provider with appropriate training and experience in its panel or
network to meet the particular health care needs of an enrollee, the
contractor shall make a referral to an appropriate out-of-network
provider, pursuant to a treatment plan approved by the contractor in
consultation with the primary care provider, the non-contractor
participating provider and the enrollee or where applicable, authorized
person, at no additional cost to the enrollee. The contractor shall
provide for a review by a specialist of the same or similar specialty
as the type of physician or provider to whom a referral is requested
before the contractor may deny a referral.
4.8.8 PROVIDER NETWORK REQUIREMENTS
Provider networks and all provider types within the network shall be
reviewed on a county basis, i.e., must be located within the county except
where indicated. The contractor shall monitor the capacity of each of its
providers and decrease ratio limits as needed to maintain appointment
availability standards.
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A. Primary Care Provider Ratios
PCP ratios shall be reviewed and calculated by provider specialty on a
county basis and on an index city basis, i.e., the major city of each
county where the majority of the Medicaid and NJ FamilyCare
beneficiaries reside.
Physician
A primary care physician shall be a General Practitioner, Family
Practitioner, Pediatrician, or Internist. Obstetricians/Gynecologists
and other physician specialists may also participate as primary care
providers providing they participate on the same contractual basis as
all other PCPs and contractor enrollees are enrolled with the
specialists in the same manner and with the same PCP/enrollee ratio
requirements applied.
1. 1 FTE PCP per 1500 enrollees per contractor; 1 FTE per 2000
enrollees, cumulative across all contractors.
2. 1 FTE PCP per 1000 DD enrollees per contractor; 1 FTE per
1500 DD enrollees cumulative across all contractors.
Dentist
The contractor shall include and make available sufficient number of
primary care dentists from the time of initial enrollment in the
contractor's plan. Pediatric dentists shall be included in the network
and may be both primary care and specialty care providing primary care
ratio limits are maintained.
1. 1 FTE primary care dentist per 1500 enrollees per contractor;
1 FTE per 2000 enrollees, cumulative across all contractors.
Certified Nurse Midwife (CNM)
If the contractor includes CNMs in its provider network as PCPs, it
shall utilize the following ratios for CNMs as PCPs.
1. 1 FTE CNM per 1000 enrollees per contractor; 1 FTE CNM per
1500 enrollees across all contractors.
2. A minimum of two (2) providers shall be initially available
for selection at the enrollee's option. Additional providers
shall be included as capacity limits are needed.
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Certified Nurse Practitioner/Clinical Nurse Specialist (CNP/CNS)
If the contractor includes CNPs/CNSs in the provider network as PCPs,
it shall utilize the following ratios.
1. 1 FTE CNP or 1 CNS per 1000 enrollees per contractor; 1 FTE
CNP or 1 FTE CNS per 1500 enrollees cumulative across all
contractors.
2. A minimum of two (2) providers where available shall be
initially available for selection at the enrollee's option.
Additional providers shall be included as capacity limits are
reached.
B. Primary Care Providers [Non-Institutional File]
The contractor shall contract with the following primary care
providers. All provider types within the network shall be located
within the enrollment area, i.e., county, except where indicated.
1. The contractor shall include contracted providers for:
a. General/Family Practice Physicians
b. Internal Medicine Physicians
c. Pediatricians
d. Dentists -- adult and pediatric
2. Certified Nurse Midwives and Nurse Practitioners
[Non-Institutional File]
The contractor shall include in the network and provide access
to CNMs/CNPs/CNSs at the enrollee's option. If there are no
contracted CNMs/CNPs/CNSs in the contractor's network in an
enrollment area, then the contractor shall reimburse for these
services out of network.
a. Certified Nurse Midwife
b. Clinical Nurse Specialist
c. Certified Nurse Practitioner
3. Optional Primary Care Provider Designations
The contractor may include as primary care providers:
a. OB/GYNs who will provide such services in accordance
with the requirements and responsibilities of a
primary care provider.
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b. Other physician specialists who have agreed to
provide primary care to enrollees with special needs
and will provide such services in accordance with the
requirements and responsibilities of a primary care
provider.
c. Physician Assistants in accordance with their
licensure and scope of practice provisions.
C. Physician Specialists [Non-Institutional File]
The contractor shall contract with physician specialists, listed below,
and should include two (2) providers per specialty to permit enrollee
choice. All specialty types within the enrollment area network are
reviewed on a county basis, i.e., must be located within the county.
Where certain specialists are not available within the county, the
contractor shall provide written documentation (not just a statement
that there are no specialists available) of the lack of a specialist
located in the county and a detailed description of how, by whom, and
where the specialty care will be provided. The contractor shall utilize
an official resource, such as the Board of Medical Examiners, for
determining presence or absence of specialists with offices located in
the county. Specialists shall have admitting privileges in at least one
participating hospital in the county in which the specialist will be
seeing enrollees.
The contractor shall submit prior to execution of this contract and
semi-annually thereafter, a capacity assessment (form found in Section
A.4.2 of the Appendices) demonstrating adequate capacity. Access
standards shall be maintained at all times.
The contractor shall provide a detailed description of accessibility
and capacity for each physician who will serve as both a PCP and a
specialist; and/or who will serve with more than one specialty. The
description shall include at a minimum a certification that the
physician is actively practicing in each specialty, has been
credentialed in each specialty, and a description of the provider's
availability in each specialty (i.e. percent of time and number of
hours per week in each specialty). The credentialing criteria used to
determine a provider's appropriateness for a specialty shall indicate
whether the provider is board eligible, board certified, or has
completed an accredited fellowship in the specialty.
The contractor shall include contracted providers for:
1. Allergy/Immunology
2. Anesthesiology
3. Cardiology -- adult and pediatric
4. Cardiovascular surgery
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5. Colorectal surgery
6. Dermatology
7. Emergency Medicine
8. Endocrinology -- adult and pediatric
9. Gastroenterology -- adult and pediatric
10. General Surgery -- adult and pediatric
11. Geriatric Medicine
12. Hematology -- adult and pediatric
13. Infectious Disease -- adult and pediatric
14. Neonatology
15. Nephrology -- adult and pediatric
16. Neurology -- adult and pediatric
17. Neurological surgery
18. Obstetrics/gynecology
19. Oncology -- adult and pediatric
20. Ophthalmology
21. Orthopedic Surgery
22. Otology, Rhinology, Laryngology (ENT)
23. Physical Medicine (for inpatient rehabilitation services)
24. Plastic Surgery
25. Psychiatry (for clients of DDD)
26. Pulmonary Disease -- adult and pediatric
27. Radiation Oncology
28. Radiology
29. Rheumatology -- adult and pediatric
30. Thoracic surgery
31. Urology
D. Non-Physician Providers [Non-Institutional File]
The contractor shall include contracted providers for:
1. Chiropractor
2. Dentists (including primary care, prosthodontia and
specialists for endodontia, orthodontia, periodontia, and
oral/maxillary surgery)
3. Optometrist
4. Podiatrist
5. Audiologist
6. Psychologist (for clients of DDD)
E. Ancillary Providers [Institutional File]
The contractor shall include contracted providers for:
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0. Durable Medical Equipment
2. Federally Qualified Health Centers
3. Hearing Aid Providers
4. Home Health Agency -- must be approved on a county-specific
basis
5. Hospice Agency
6. Hospitals -- inpatient and outpatient services; at least two
per county with one urban where the majority of Medicaid
beneficiaries reside
7. Laboratory with one (1) drawing station per every five mile
radius within a county
8. Medical Supplier
9. Optical appliance providers
10. Organ Transplant Providers/Centers
11. Pharmacy
12. Private Duty Nursing Agency (service area which includes a 50
mile radius from its home administrative base office must be
approved on a county-specific basis)
13. Prosthetist, Orthotist, and Pedorthist
14. Radiology centers including diagnostic and therapeutic
15. Transportation providers (ambulance, MICUs, invalid coach)
F. The contractor shall also establish relationships with physician
specialists and subspecialists [Non-Institutional File] for:
1. Pain Management
2. Medical Toxicology
3. Adolescent Medicine
4. Maternal and Fetal Medicine
5. Medical Genetics
6. Developmental and Behavioral Pediatrics
G. Specialty Centers (Centers of Excellence) shall be included in the
network [Institutional File]
1. Providers and health care facilities for the care and
treatment of HIV/AIDS (list of available centers found in
Section B.4.13 of the Appendices).
2. Special Child Health Services Network Agencies for:
a. Pediatric Ambulatory Tertiary Centers
b. Regional Cleft Lip/Palate Centers
c. Pediatric HIV Treatment Centers
d. Comprehensive Regional Sickle Cell/Hemoglobinpathies
Treatment Centers
e. PKU Treatment Centers
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f. Other as designated from time to time by the
Department of Health and Senior Services.
3. Other:
a. Genetic Testing and Counseling Centers
b. Hemophilia Treatment Centers
H. Other Specialty Centers/Providers [Institutional File]
Contractor should establish relationships with the following
providers/centers on a consultant or referral basis.
1. Xxxxx Bifida Centers/providers
2. Adult Scoliosis
3. Autism and Attention Deficits
4. Spinal Cord Injury
5. Lead Poisoning Treatment Centers
6. Child Abuse Regional Diagnostic Centers
7. County Case Management Units
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I. Provider Network Access Standards and Ratios
A -- Miles per 2 B -- Miles per 1 Min. No. Capacity Limit
Specialty Urban Non-Urban Urban Non-urban Required per County Per Provider
--------------- ------ --------- ----- --------- ------------------- --------------
PCP Children GP 6 15 2 10 2 1: 1,500
FP 6 15 2 10 2 1: 1,500
Peds 6 15 2 10 2 1: 1,500
Adults GP 6 15 2 10 2 1: 1,500
FP 6 15 2 10 2 1: 1,500
IM 6 15 2 10 2 1: 1,500
CNP/CNS 6 15 2 10 2 1: 800
CNM 12 25 6 15 2 1: 1,500
Dentist, Primary Care 6 15 2 10 2 1: 1,500
Allergy 15 25 10 15 2 1: 75,000
Anesthesiology 15 25 10 15 2 1: 17,250
Cardiology 15 25 10 15 2 1: 100,000
Cardiovascular surgery 15 25 10 15 2 1: 166,000
Chiropractor 15 25 10 15 2 1: 10,000
Colorectal surgery 15 25 10 15 2 1: 30,000
Dermatology 15 25 10 15 2 1: 75,000
Emergency Medicine 15 25 10 15 2 1: 19,000
Endocrinology 15 25 10 15 2 1: 143,000
Endodontia 15 25 10 15 1 1: 30,000
Gastroenterology 15 25 10 15 2 1: 100,000
General Surgery 15 25 10 15 2 1: 30,000
Geriatric Medicine 6 15 2 10 2 1: 1,500
Hematology 15 25 10 15 2 1: 100,000
Infectious Disease 15 25 10 15 2 1: 125,000
Neonatology 15 25 10 15 2 1: 100,000
Nephrology 15 25 10 15 2 1: 125,000
Neurology 15 25 10 15 2 1: 100,000
Neurological Surgery 15 25 10 15 2 1: 166,000
Obstetrics/Gynecology 15 25 10 15 2 1: 7,100
Oncology 15 25 10 15 2 1: 100,000
Ophthalmology 15 25 10 15 2 1: 60,000
Optometrist 15 25 10 15 2 1: 8,000
Oral Surgery 15 25 10 15 2 1: 20,000
Orthodontia 15 25 10 15 1 1: 20,000
Orthopedic Surgery 15 25 10 15 2 1: 28,000
Otolaryngology (ENT) 15 25 10 15 2 1: 53,000
Periodontia 15 25 10 15 1 1: 30,000
Physical Medicine 15 25 10 15 2 1: 75,000
Plastic Surgery 15 25 10 15 2 1: 250,000
Podiatrist 15 25 10 15 2 1: 20,000
Prosthodontia 15 25 10 15 1 (where available) 1: 30,000
Psychiatrist 15 25 10 15 2 1: 30,000
Psychologist 15 25 10 15 2 1: 30,000
Pulmonary Disease 15 25 10 15 2 1: 100,000
Radiation Oncology 15 25 10 15 2 1: 100,000
Radiology 15 25 10 15 2 1: 25,000
Rheumatology 15 25 10 15 2 1: 150,000
Ther. -- Audiology 12 25 6 15 2 1: 100,000
Thoracic Surgery 15 25 10 15 2 1: 150,000
Urology 15 25 10 15 2 1: 60,000
Fed Qual Health Ctr 1 1/county if available
Hospital 20 35 10 15 2 2 per county
Pharmacies 10 15 5 12 1: 1,000
Laboratory N/A N/A 5 12
DME/Med Supplies 12 25 6 15 1 1: 50,000
Hearing Aid 12 25 6 15 1 1: 50,000
Optical Appliance 12 25 6 15 2 1: 50,000
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J. Geographic Access
The following lists guidelines for urban geographic access for the DMAHS
population. (Standards for non-urban areas are included in the table in H.
above.) The State shall review (and approve) exceptions on a case-by-case
basis to determine appropriateness for each situation.
For each contractor and for each municipality in each county in which the
contractor is operational, the access shall be reviewed in accordance with
the number and percentage of:
1. Beneficiary children who reside within 6 miles of 2 PCPs whose
specialty is Family Practice, General Practice or Pediatrics or 2
CNPs/CNSs; within 2 miles of 1 PCP whose specialty is Family Practice,
General Practice or Pediatrics or 1 CNP or 1 CNS
2. Beneficiary adults who reside within 6 miles of 2 PCPs whose specialty
is Family Practice, General Practice or Internal Medicine or 2 CNPs or
2 CNSs; within 2 miles of 1 PCP whose specialty is Family Practice,
General Practice or Internal Medicine or 1 CNP or 1 CNS
3. Beneficiaries who reside within 6 miles of 2 providers of general
dentistry services; within 2 miles of 1 provider of general dentistry
services
4. Beneficiaries who reside within 10 miles of 2 pharmacies; within 5
miles of 1 pharmacy
5. Beneficiaries who reside within 15 miles of at least 2 specialists in
each of the following specialties: all physician and dental
specialists, Podiatry, Optometry, Chiropractic; within 10 miles of at
least 1 provider in each type of specialty noted above
6. Beneficiaries who reside within 15 miles of 2 acute care hospitals;
within 10 miles of one acute care hospital
7. Beneficiaries who reside within 12 miles of 2 of each of the following
provider types: durable medical equipment, medical supplier, hearing
aid supplier, optical appliance supplier, certified nurse midwife;
within 6 miles of one of each type of provider
8. Beneficiaries who reside within 5 miles of a laboratory/drawing
station.
9. Beneficiaries with desired access and average distance to 1, 2 or more
providers
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00. Beneficiaries without desired access and average distance to 1, 2 or
more providers
Access Standards
1. 90% of the enrollees must be within 6 miles of 2 PCPs in an urban
setting
2. 85% of the enrollees must be within 15 miles of 2 PCPs in a non-urban
setting
3. Covering physicians must be within 15 miles in urban areas and 25
miles in non-urban areas.
Travel Time Standards
The contractor shall adhere to the 30 minute standard, i.e., enrollees will
not live more than 30 minutes away from their PCPs, PCDs or CNPs/CNSs. The
following guidelines shall be used in determining travel time.
1. Normal conditions/primary roads -- 20 miles
2. Rural or mountainous areas/secondary routes -- 20 miles
3. Flat areas or areas connected by interstate highways -- 25 miles
4. Metropolitan areas such as Newark, Camden, Trenton, Paterson, Jersey
City -- 30 minutes travel time by public transportation or no more
than 6 miles from PCP
5. Other medical service providers must also be geographically accessible
to the enrollees.
6. Exception: SSI or New Jersey Care-ABD enrollees and clients of DDD may
choose to see network providers outside of their county of residence.
K. Conditions for Granting Exceptions to the 1:1500 Ratio Limit for Primary
Care Physicians
1. A physician must demonstrate increased office hours and must maintain
(and be present for) a minimum of 20 hours per week in each office.
2. In private practice settings where a physician employs or directly
works with nurse practitioners who can provide patient care within the
scope of their practices, the capacity may be increased to 1 PCP FTE
to 2500 enrollees. The PCP must be immediately available for
consultation,
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supervision or to take over treatment as needed. Under no
circumstances will a PCP relinquish or be relieved of direct
responsibility for all aspects of care of the patients enrolled
with the PCP.
3. In private practice settings where a primary care physician
employs or is assisted by other licensed physicians, the capacity
may be increased to 1 PCP FTE to 2500 enrollees.
4. In clinic practice settings where a PCP provides direct personal
supervision of medical residents with a New Jersey license to
practice medicine in good standing with State Board of Medical
Examiners, the capacity may be increased with the following
ratios: 1 PCP to 1500 enrollees; 1 licensed medical resident per
1000 enrollees. The PCP must be immediately available for
consultation, supervision or to take over treatment as needed.
Under no circumstances will a PCP relinquish or be relieved of
direct responsibility for all aspects of care of the patients
enrolled with the PCP.
5. Each provider (physician or nurse practitioner) must provide a
minimum of 15 minutes of patient care per patient encounter and
be able to provide four visits per year per enrollee.
6. The contractor shall submit for prior approval by DMAHS a
detailed description of the PCP's delivery system to accommodate
an increased patient load, work flow, professional relationships,
work schedules, coverage arrangements, 24 hour access system.
7. The contractor shall provide information on total patient load
across all plans, private patients, Medicaid fee-for-service
patients, other.
8. The contractor shall adhere to the access standards required in
the contractor's contract with the Department.
9. There will be no substantiated complaints or demonstrated
evidence of access barriers due to an increased patient load.
10. The Department will make the final decision on the
appropriateness of increasing the ratio limits and what the limit
will be.
L. Conditions for Granting Exceptions to the 1:1500 Ratio Limit for
Primary Care Dentists.
1. A PCD must provide a minimum of 20 hours per week per office.
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2. In clinic practice settings where a PCD provides direct personal
supervision of dental residents who have a temporary permit from
the State Board of Dentistry in good standing and also dental
students, the capacity may be increased with the following
ratios: 1 PCD to 1500 enrollees per contractor; 1 dental resident
per 1000 enrollees per contractor; 1 FTE dental student per 200
enrollees per contractor. The PCD shall be immediately available
for consultation, supervision or to take over treatment as
needed. Under no circumstances shall a PCD relinquish or be
relieved of direct responsibility for all aspects of care of the
patients enrolled with the PCD.
3. In private practice settings where a PCD employs or is assisted
by other licensed dentists, the capacity may be increased to 1
PCD FTE to 2500 enrollees.
4. In private practice settings where a PCD employs dental
hygienists or is assisted by dental assistants, the capacity may
be increased to 1 PCD to 2500 enrollees. The PCD shall be
immediately available for consultation, supervision or to take
over treatment as needed. Under no circumstances shall a PCD
relinquish or be relieved of direct responsibility for all
aspects of care of the patients enrolled with the PCD.
5. Each PCD shall provide a minimum of 15 minutes of patient care
per patient encounter.
6. The contractor shall submit for prior approval by the DMAHS a
detailed description of the PCD's delivery system to accommodate
an increased patient load, work flow, professional relationships,
work schedules, coverage arrangements, 24 hour access system.
7. The contractor shall provide information on total patient load
across all plans, private patients, Medicaid fee-for-service
patients, other.
8. The contractor shall adhere to the access standards required in
the contractor's contract with the Department.
9. There must be no substantiated complaints or demonstrated
evidence of access barriers due to an increased patient load.
10. The Department will make the final decision on the
appropriateness of increasing the ratio limits and what the limit
will be.
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4.8.9 DENTAL PROVIDER NETWORK REQUIREMENTS
A. The contractor shall establish and maintain a dental provider network,
including primary and specialty care dentists, which is adequate to
provide the full scope of benefits. The contractor shall include
general dentists and pediatric dentists as primary care dentists
(PCDs). A system whereby the PCD initiates and coordinates any
consultations or referrals for specialty care deemed necessary for the
treatment and care of the enrollee is preferred.
B. The dental provider network shall include sufficient providers able to
meet the dental treatment requirements of patients with developmental
disabilities. (See Article 4.5.2E for details.)
C. The contractor shall ensure the participation of traditional and
safety-net providers within an enrollment area. Traditional providers
include private practitioners/entities who provide treatment to the
general population or have participated in the regular Medicaid
program. Safety-net providers include dental education institutions,
hospital-based dental programs, and dental clinics sponsored by
governmental agencies as well as dental clinics sponsored by private
organizations in urban/under-served areas.
4.8.10 GOOD FAITH NEGOTIATIONS
The State shall, in its sole discretion, waive the contractor's specific
network requirements in circumstances where the contractor has engaged, or
attempted to engage in good faith negotiations with applicable providers.
If the contractor asks to be waived from a specific networking requirement
on this basis, it shall document to the State's satisfaction that good
faith negotiations were offered and/or occurred. Nothing in this Article
will relieve the contractor of its responsibility to furnish the service in
question if its is medically necessary, using qualified providers.
4.8.11 PROVIDER NETWORK ANALYSIS
The contractor shall submit prior to execution of this contract and
annually thereafter a provider network accessibility analysis, using
geographic information system software, in accordance with the
specifications found in Section A.4.3 of the Appendices.
4.9 PROVIDER CONTRACTS AND SUBCONTRACTS
4.9.1 GENERAL PROVISIONS
A. Each generic type of provider contract form shall be submitted to the
DMAHS for review and prior approval to ensure required elements are
included and shall have regulatory approval prior to the effective
date of the contract. Any proposed changes to an approved contract
form shall be reviewed and prior approved by the
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DMAHS and shall have regulatory approval from DHSS and DOBI prior to
the effective date. The contractor shall comply with all DMAHS
procedures for contract review and approval submission. Letters of
Intent are not acceptable. Memoranda of Agreement (MOAs) shall be
permitted only if the MOA automatically converts to a contract within
six (6) months of the effective date and incorporates by reference all
applicable contract provisions contained herein, including but not
limited to Appendix B.7.2, which shall be attached to all MOAs.
B. Each proposed subcontracting arrangement or substantial contractual
relationship including all contract documents and any subcontractor
contracts including all provider contract forms shall be submitted to
the DMAHS for review and prior approval to ensure required elements
are included and shall have regulatory approval prior to the effective
date. Any proposed change(s) to an approved subcontracting arrangement
including any proposed changes to approved contract forms shall be
reviewed and prior approved by the DMAHS and shall have regulatory
approval from DHSS and DOBI prior to the effective date. The
contractor shall comply with all DMAHS procedures for contract review
and approval submissions.
C. The contractor shall at all times have satisfactory written contracts
and subcontracts with a sufficient number of providers in and adjacent
to the enrollment area to ensure enrollee access to all medically
necessary services listed in Article 4.1. All provider contracts and
subcontracts shall meet established requirements, form and contents
approved by DMAHS.
D. The contractor, in performing its duties and obligations hereunder,
shall have the right either to employ its own employees and agents or,
for the provision of health care services, to utilize the services of
persons, firms, and other entities by means of sub-contractual
relationships.
E. No provider contract or subcontract shall terminate or in any way
limit the legal responsibility of the contractor to the Department to
assure that all activities under this contract are carried out. The
contractor is not relieved of its contractual responsibilities to the
Department by delegating responsibility to a subcontractor.
F. All provider contracts and subcontracts shall be in writing and shall
fulfill the requirements of 42 C.F.R. Part 434 that are appropriate to
the service or activity delegated under the subcontract.
1. Provider contracts and subcontracts shall contain provisions
allowing DMAHS and HHS to evaluate through inspection or other
means, the quality, appropriateness and timeliness of services
performed under a subcontract to provide medical services (42
C.F.R. * 434.6(a)(5)).
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2. Provider contracts and subcontracts shall contain provisions
pertaining to the maintenance of an appropriate record system for
services to enrollees. (42 C.F.R. * 434.6(a)(7))
3. Each provider contract and subcontract shall contain sufficient
provisions to safeguard all rights of enrollees and to ensure
that the subcontract complies with all applicable State and
federal laws, including confidentiality. See Section B.7.2 of the
Appendices.
4. Provider contracts and subcontracts shall include the specific
provisions and verbatim language found in Appendix B.7.2. The
verbatim language requirements shall be used when entering into
new provider contracts, new subcontracts, and when renewing,
renegotiating or recontracting with providers and subcontractors
with existing contracts.
G. The contractor shall submit lists of names, addresses,
ownership/control information of participating providers and
subcontractors, and individuals or entities, which shall be
incorporated in this contract. Such information shall be updated every
quarter.
1. The contractor shall obtain prior DMAHS review and written
approval of any proposed plan for merger, reorganization or
change in ownership of the contractor and approval by the
appropriate State regulatory agencies.
2. The contractor shall comply with Article 4.9.1G.1 to ensure
uninterrupted and undiminished services to enrollees, to evaluate
the ability of the modified entity to support the provider
network, and to ensure that any such change has no adverse
effects on DMAHS's managed care program and shall comply with the
Departments of Banking and Insurance, and Health and Senior
Services statutes and regulations.
H. The contractor shall demonstrate its ability to provide all of the
services included under this contract through the approved network
composition and accessibility.
I. The contractor shall not oblige providers to violate their state
licensure regulations.
J. The contractor shall provide its providers and subcontractors with a
schedule of fees and relevant policies and procedures at least 30 days
prior to implementation.
K. The contractor shall arrange for the distribution of informational
materials to all its providers and subcontractors providing services
to enrollees, outlining the nature, scope, and requirements of this
contract.
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4.9.2 CONTRACT SUBMISSION
The contractor shall submit to DMAHS one complete, fully executed contract
for each type of provider, i.e., primary care physician, physician
specialist, non-physician practitioner, hospital and other health care
providers/services covered under the benefits package, subcontract and the
form contract of any subcontractor's provider contracts. The use of a
signature stamp is not permitted and shall not be considered a fully
executed contract. Contracts shall be submitted with all attachments,
appendices, rate schedules, etc. A copy of the appropriate completed
contract checklist for DHS, DHSS, and DOBI shall be attached to each
contract form. Regulatory approval and approval by the Department is
required for each provider contract form and subcontract prior to use.
Submission of all other contracts shall follow the format and procedures
described below:
A. Copies of the complete fully executed contract with every FQHC.
Certification of the continued in force contracts previously submitted
will be permitted.
B. Hospital contracts shall list each specific service to be covered
including but not limited to:
1. Inpatient services;
2. Anesthesia and whether professional services of anesthesiologists
and nurse anesthetists are included;
3. Emergency room services
a. Triage fee -- whether facility and professional fees are
included;
b. Medical screening fee -- whether facility and professional
fees are included;
c. Specific treatment rates for:
(1) Emergent services
(2) Urgent services
(3) Non-urgent services
(4) Other
d. Other -- must specify
4. Neonatology -- facility and professional fees
5. Radiology
a. Diagnostic
b. Therapeutic
c. Facility fee
d. Professional services
6. Laboratory -- facility and professional services
7. Outpatient/clinic services must be specific and address
a. Physical and occupational therapy and therapists
b. Speech therapy and therapists
c. Audiology therapy and therapists
8. AIDS Centers
9. Any other specialized service or center of excellence
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00. Hospice services if the hospital has an approved hospice agency
that is Medicare certified.
11. Home Health agency services if hospital has an approved home
health agency license from the Department of Health and Senior
Services that meets licensing and Medicare certification
participation requirements.
12. Any other service.
C. FQHC contracts:
1. Shall list each specific service to be covered.
2. Shall include reimbursement schedule and methodology.
3. Shall include the credentialing requirements for individual
practitioners.
4. Shall include assurance that continuation of the FQHC contract is
contingent on maintaining quality services and maintaining the
Primary Care Evaluation Review (PCER) review by the federal
government at a good quality level. FQHCs must make available to
the contractor the PCER results annually which shall be
considered in the contractor's QM reviews for assessing quality
of care.
D. For those providers for whom a complete contract is not required, the
contractor shall submit a list of their names, addresses, Social
Security Numbers, and Medicaid provider numbers (if available). The
contractor shall attach to this list a completed, signed
"Certification of Contractor Provider Network" form (See Section A.4.4
of the Appendices). This form must be completed and signed by the
contractor's attorney or high-ranking officer with decision-making
authority.
4.9.3 PROVIDER CONTRACT AND SUBCONTRACT TERMINATION
A. The contractor shall comply with all the provisions of the New Jersey
HMO regulations at N.J.A.C. 8:38 et seq. regarding provider
termination, including but not limited to 30 day prior written notice
to enrollees and continuity of care requirements.
B. The contractor shall notify DMAHS at least 30 days prior to the
effective date of suspension, termination, or voluntary withdrawal of
a provider or subcontractor from participation in this program. If the
termination was "for cause," the contractor's notice to DMAHS shall
include the reasons for the termination.
1. Provider resource consumption patterns shall not constitute
"cause" unless the contractor can demonstrate it has in place a
risk adjustment system that takes into account enrollee
health-related differences when comparing across providers.
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2. The contractor shall assure immediate coverage by a provider of
the same specialty, expertise, or service provision and shall
submit a new contract with a replacement provider to DMAHS within
30 days of being finalized.
C. If a primary care provider ceases participation in the contractor's
organization, the contractor shall provide written notice at least
thirty (30) days from the date that the contractor becomes aware of
such change in status to each enrollee who has chosen the provider as
their primary care provider. If an enrollee is in an ongoing course of
treatment with any other participating provider who becomes
unavailable to continue to provide services to such enrollee and
contractor is aware of such ongoing course of treatment, the
contractor shall provide written notice within fifteen days from the
date that the contractor becomes aware of such unavailability to such
enrollee. Each notice shall also describe the procedures for
continuing care and choice of other providers who can continue to care
for the enrollee.
D. All provider contracts shall contain a provision that states that the
contractor shall not terminate the contract with a provider because
the provider expresses disagreement with a contractor's decision to
deny or limit benefits to a covered person or because the provider
assists the covered person to seek reconsideration of the contractor's
decision; or because a provider discusses with a current, former, or
prospective patient any aspect of the patient's medical condition, any
proposed treatments or treatment alternatives, whether covered by the
contractor or not, policy provisions of a plan, or a provider's
personal recommendation regarding selection of a health plan based on
the provider's personal knowledge of the health needs of such
patients. Nothing in this Article shall be construed to prohibit the
contractor from:
1. Including in its provider contracts a provision that precludes a
provider from making, publishing, disseminating, or circulating
directly or indirectly or aiding, abetting, or encouraging the
making, publishing, disseminating, or circulating of any oral or
written statement or any pamphlet, circular, article, or
literature that is false or maliciously critical of the
contractor and calculated to injure the contractor; or
2. Terminating a contract with a provider because such provider
materially misrepresents the provisions, terms, or requirements
of the contractor.
4.9.4 PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL COMMUNICATIONS
A. Any contract between the contractor in relation to health coverage and
a health care provider (or group of health care providers) shall not
prohibit or restrict the provider from engaging in medical
communications with the provider's patient, either explicit or
implied, nor shall any provider manual, newsletters, directives,
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letters, verbal instructions, or any other form of communication
prohibit medical communication between the provider and the provider's
patient. Providers shall be free to communicate freely with their
patients about the health status of their patients, medical care or
treatment options regardless of whether benefits for that care or
treatment are provided under the contract, if the professional is
acting within the lawful scope of practice. The health care providers
shall be free to practice their respective professions in providing
the most appropriate treatment required by their patients and shall
provide informed consent within the guidelines of the law including
possible positive and negative outcomes of the various treatment
modalities.
B. Nothing in this Article shall be construed:
1. To prohibit the enforcement, as part of a contract or agreement
to which a health care provider is a party, of any mutually
agreed upon terms and conditions, including terms and conditions
requiring a health care provider to participate in, and cooperate
with, all programs, policies, and procedures developed or
operated by the contractor to assure, review, or improve the
quality and effective utilization of health care services (if
such utilization is according to guidelines or protocols that are
based on clinical or scientific evidence and the professional
judgment of the provider) but only if the guidelines or protocols
under such utilization do not prohibit or restrict medical
communications between providers and their patients; or
2. To permit a health care provider to misrepresent the scope of
benefits covered under this contract or to otherwise require the
contractor to reimburse providers for benefits not covered.
C. The contractor shall not have to provide, reimburse, or provide
coverage of a counseling service or referral service if the contractor
objects to the provision of a particular service on moral or religious
grounds and if the contractor makes available information in its
policies regarding that service to prospective enrollees before or
during enrollment. Notices shall be provided to enrollees within 90
days after the date that the contractor adopts a change in policy
regarding such a counseling or referral service.
4.9.5 ANTIDISCRIMINATION
The contractor shall not discriminate with respect to participation,
reimbursement, or indemnification against any provider who is acting within
the scope of the provider's license or certification under applicable State
law, solely on the basis of such licensure or certification. The contractor
may, however, include providers only to the extent necessary to meet the
needs of the organization's enrollees or establish any measure designed to
maintain quality and control costs consistent with the responsibilities of
the contractor.
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4.10 EXPERT WITNESS REQUIREMENTS AND COURT OBLIGATIONS
The contractor shall comply with the following provisions concerning
expert witness testimony and court-ordered services:
A. The contractor shall bear the sole responsibility to provide
expert witness services within the State of New Jersey for any
hearings, proceedings, or other meetings and events relative to
services provided by the contractor.
B. These expert witness services shall be provided in all actions
initiated by the Department, providers, enrollees, or any other
party(ies) and which involve the Department and the contractor.
C. The contractor shall designate and identify staff person(s)
immediately available to perform the expert witness function,
subject to prior approval by the Department. The Department shall
exercise, at its sole discretion, a request for additional or
substitute employees other than the designated expert witness.
D. The contractor shall notify the Department prior to the delivery
of all expert witness services, and/or response(s) to subpoenas.
The notification shall be no later than twenty-four (24) hours
after the contractor is aware of the need to appear or of the
subpoena.
E. The contractor shall provide written analysis and expert witness
services in Fair Hearings and in court regarding any actions the
contractor has taken. In the case of a contractor's denial,
modification, or deferral of a prior authorization request, the
contractor shall present its position for the denial,
modification, or deferral of procedures during Fair Hearing
proceedings.
F. The Department will notify the contractor in a timely manner of
the nature of the subject matter to be covered and the testimony
to be presented and the date, time and location of the hearing,
proceeding, or other meeting or event at which specific expert
witness services are to be provided.
G. The contractor shall coordinate and provide court ordered medical
services (except sexual abuse evaluations). It is the
responsibility of the contractor to inform the courts about the
availability of its providers. If the court orders a non-
contractor source to provide the treatment or evaluation, the
contractor shall be liable for the cost up to the Medicaid rate if
the contractor could not have provided the service through its own
provider network or arrangements.
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4.11 ADDITIONS, DELETIONS, AND/OR CHANGES
The contractor shall submit any significant and material changes
regarding policies, procedures, changes to health care delivery system
and substantial changes to contractor operations, providers, provider
networks, subcontractors, and reports to DMAHS for final approval at
least 90 days prior to being published, distributed, and/or implemented.
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ARTICLE FIVE: ENROLLEE SERVICES
5.1 GEOGRAPHIC REGIONS
A. Service Area. The geographic region(s) for which the contractor
has been awarded a contract to establish and maintain operations
for the provision of services to Medicaid and NJ FamilyCare
beneficiaries are indicated below. The contractor shall have
complete provider networks for each of the counties included in
the region(s) approved for this contract. Coverage for partial
regions shall only be permitted through a prior approval process
by DMAHS. The contractor shall submit a phase-in plan to DMAHS.
See Article 2 for details.
___________ Region 1: Bergen, Hudson, Hunterdon, Xxxxxx,
Passaic, Somerset, Sussex, and Xxxxxx
___________ Region 2: Essex, Union, Middlesex, and Xxxxxx
___________ Region 3: Atlantic, Burlington, Camden, Cape
May, Cumberland, Gloucester, Monmouth,
Ocean, and Salem
B. Enrollment Area. For the purposes of this contract, the
contractor's enrollment area(s) and maximum enrollment limits
(cumulative during the term of the contract) shall be as follows:
Maximum
Enrollment
County: Limit:
______ Atlantic
______ Bergen
______ Burlington
______ Camden
______ Cape May
______ Cumberland
______ Essex
______ Gloucester
______ Xxxxxx
______ Hunterdon
______ Xxxxxx
______ Middlesex
______ Monmouth
______ Xxxxxx
______ Ocean
______ Passaic
______ Salem
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______ Somerset
______ Sussex
______ Union
______ Xxxxxx
5.2 AID CATEGORIES ELIGIBLE FOR CONTRACTOR ENROLLMENT
A. Except as specified in Article 5.3, all persons who are not
institutionalized, belong to one of the following eligibility
categories, and reside in any of the enrollment areas, as
identified in Article 5.1, are in mandatory aid categories and
shall be eligible for enrollment in the contractor's plan in the
manner prescribed by this contract.
1. Aid to Families with Dependent Children (AFDC)/Temporary
Assistance for Needy Families (TANF);
2. AFDC/TANF-Related, New Jersey Care...Special Medicaid
Program for Pregnant Women and Children;
3. SSI-Aged, Blind, Disabled, and Essential Spouses;
4. New Jersey Care...Special Medicaid programs for Aged,
Blind, and Disabled;
5. Division of Developmental Disabilities Clients including
the Division of Developmental Disabilities Community Care
Waiver;
6. Medicaid only or SSI-related Aged, Blind, and Disabled
7. Uninsured parents/caretakers and children who qualify for
NJ FamilyCare
8. Uninsured adults and couples without dependent children
under the age of 19 who qualify for NJ FamilyCare
B. The contractor shall enroll the entire Medicaid case, i.e., all
individuals included under the ten digit Medicaid identification
number.
C. DYFS. Individuals who are eligible through the Division of Youth
and Family Services may enroll voluntarily. All individuals
eligible through DYFS shall be considered a unique Medicaid case
and shall be issued an individual 12 digit Medicaid identification
number, and may be enrolled in his/her own contractor.
D. The contractor shall be responsible for keeping its network of
providers informed of the enrollment status of each enrollee.
E. Dual eligibles (Medicaid-Medicare) may voluntarily enroll.
5.3 EXCLUSIONS AND EXEMPTIONS
Persons who belong to one of the eligible populations (defined in 5.2B)
shall not be subject to mandatory enrollment if they meet one or more
criteria defined in this Article. Persons who fall into an "excluded"
category (Article 5.3.1A) shall not be eligible to
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enroll in the contractor's plan. Persons falling into the categories
under Article 5.3.1B are eligible to enroll on a voluntary basis. Persons
falling into a category under Article 5.3.2 may be eligible for
enrollment exemption, subject to the Department's review.
5.3.1 ENROLLMENT EXCLUSIONS
A. The following persons shall be excluded from enrollment in the
managed care program:
1. Individuals in the following Home and Community-based
Waiver programs: Model Waiver I, Model Waiver II, Model
Waiver III, Enhanced Community Options Waiver, Aids
Community Care Alternative Program (ACCAP), Community Care
Program for Elderly and Disabled (CCPED), assisted living
programs, ABC Waiver for Children, Traumatic Brain Injury
(TBI), and DYFS Code 65 children.
2. Individuals in a Medicaid demonstration program.
3. Individuals who are institutionalized in an inpatient
psychiatric institution, long term care nursing facility or
in a residential facility including Intermediate Care
Facilities for the Mentally Retarded. However, individuals
who are eligible through DYFS and are placed in a DYFS
residential center/facility or individuals in a mental
health or substance abuse residential treatment facility
are not excluded from enrolling in the contractor's plan.
4. Individuals in the Medically Needy, Presumptive Eligibility
for pregnant women, Presumptive Eligibility for NJ
FamilyCare, Home Care Expansion Program, or PACE program.
5. Infants of inmates of a public institution living in a
prison nursery.
6. Individuals already enrolled in or covered by a Medicare or
private HMO that does not have a contract with the
Department to provide Medicaid services.
7. Individuals in out-of-state placements.
8. Full time students attending school and residing out of the
country will be excluded from New Jersey Care 2000+
participation while in school.
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9. The following types of dual beneficiaries: Qualified
Medicare Beneficiaries (QMBs) not otherwise eligible for
Medicaid; Special Low- Income Medicare Beneficiaries
(SLMBs); Qualified Disabled and Working Individuals
(QDWIs); and Qualifying Individuals 1 and 2.
B. The following individuals shall be excluded from the Automatic
Assignment process described in Article 5.4C but may voluntarily
enroll:
1. Individuals whose Medicaid eligibility will terminate
within three (3) months or less after the projected date of
effective enrollment.
2. Individuals in mandatory eligibility categories who live in
a county where mandatory enrollment is not yet required
based on a phase-in schedule determined by DMAHS.
3. Individuals enrolled in or covered by either a Medicare or
commercial HMO will not be enrolled in New Jersey Care
2000+ contractor unless the New Jersey Care 2000+
contractor and the Medicare/commercial HMO are the same.
4. Individuals in the Pharmacy Lock-in or Provider Warning or
Hospice programs.
5. Individuals in eligibility categories other than AFDC/TANF,
AFDC/TANF-related New Jersey Care, SSI-Aged, Blind and
Disabled populations, the Division of Developmental
Disabilities Community Care Waiver population, New Jersey
Care - Aged, Blind and Disabled, or NJ FamilyCare Plan A.
6. Children awaiting adoption through a private agency.
7. Individuals identified as having more than one active
eligible Medicaid number.
8. DYFS Population.
C. The following individuals shall be excluded from the Automatic
Assignment process:
1. Individuals included under the same Medicaid Case Number
where one or more household member(s) are exempt.
2. Individuals participating in NJ FamilyCare Plans B, C, and
D [Managed Care is the only program option available for
these individuals].
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5.3.2 ENROLLMENT EXEMPTIONS
The contractor, its subcontractors, providers or agents shall not coerce
individuals to disenroll because of their health care needs which may
meet an exemption reason, especially when the enrollees want to remain
enrolled. Exemptions do not apply to NJ FamilyCare Plan B, Plan C, or
Plan D individuals or to individuals who have been enrolled in any
contractor for greater than one hundred and eighty (180) days. All
exemption requests are reviewed by DMAHS on a case by case basis.
Individuals may be exempted by DMAHS from enrollment in a contractor for
the following reasons:
A. First-time Medicaid/NJ FamilyCare Plan A beneficiaries who are
pregnant women, beyond the first trimester, who have an
established relationship with an obstetrician who is not a
participating provider in any contractor. These individuals will
be tracked and enrolled after sixty (60) days postpartum.
B. Individuals with a terminal illness and who have an established
relationship with a physician who is not a participating provider
in any contractor's plan.
C. Individuals with a chronic, debilitating illness or disability who
have received treatment from a physician and/or team of providers
with expertise in treating that illness with whom the individuals
have an established relationship (greater than 12 months) and who
are not participating in any contractor; and there is no other
reasonable alternative as determined by DMAHS at its sole
discretion. Such requests shall be reviewed by DMAHS on a case by
case basis. The individuals or authorized persons must provide
written documentation identifying all of the providers who provide
regular, ongoing care and who will certify their continued
involvement in the care of these individuals; also provide
documentation detailing how and who will provide medical
management for the individual.
1. Temporary exemption may be granted by DMAHS to allow the
contractor time to contract with a specific specialist
needed by an enrollee with whom there is a long-standing
established relationship (greater than twelve (12) months)
and there is no equivalent specialist available in the
network. The contractor shall establish appropriate
contractual/referral relationships with any or all
specialists needed to accommodate the needs of enrollees
with special needs.
D. Individuals who do not speak English or Spanish and who meet the
following criteria: i) have an illness requiring on-going
treatment; ii) have an established relationship with a physician
who speaks their primary language; and iii) there is no available
primary care physician in any participating contractor who speaks
the beneficiary's language. These cases shall be reviewed by DMAHS
on a case-by-case basis with no automatic exemption from initial
enrollment.
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E. Individuals who do not have a choice of at least two (2) PCPs
within thirty (30) miles of their residence.
5.4 ENROLLMENT OF MANAGED CARE ELIGIBLES
A. Enrollment. The health benefits coordinator (HBC), an agent of
DMAHS, shall enroll Medicaid and NJ FamilyCare applicants. The HBC
will explain the contractors' programs, answer any questions, and
assist eligible individuals or, where applicable, an authorized
person in selecting a contractor. Except as provided in 5.16, the
contractor shall not directly market to or assist managed care
eligibles in completing enrollment forms. The duties of the HBC
will include, but are not limited to, education, enrollment,
disenrollment, transfers, assistance through the contractor's
grievance process and other problem resolutions with the
contractor, and communications. The contractor shall cooperate
with the HBC in developing information about its plan for
dissemination to Medicaid/NJ FamilyCare beneficiaries.
B. Individuals eligible under NJ FamilyCare Plan A and NJ FamilyCare
Plan B, Plan C, and Plan D may request an application via a
toll-free number operated under contract for the State, through an
outreach source, or from the contractor. The application may be
mailed back to a State vendor. Individuals eligible under Plan A
also have the option of completing the application either via a
mail-in process or on site at the county welfare agency.
Individuals eligible under Plan B, Plan C, and Plan D have the
option of requesting assistance from the State vendor, the
contractor or one of the registered servicing centers in the
community. Assistance will also be made available at State field
offices (e.g. the Medicaid District Offices) and county offices
(e.g. Offices on Aging for grandparent caretakers).
C. Automatic Assignment. Medicaid eligible persons who reside in
enrollment areas that have been designated for mandatory
enrollment, who qualify for AFDC/TANF, New Jersey Care...Special
Medicaid programs eligibility categories, NJ FamilyCare Plan A,
and SSI populations, who do not meet the exemption criteria, and
who do not voluntarily choose enrollment in the contractor's plan,
shall be assigned automatically by DMAHS to a contractor.
5.5 ENROLLMENT AND COVERAGE REQUIREMENTS
A. General. The contractor shall comply with DMAHS enrollment
procedures. The contractor shall accept for enrollment any
individual who selects or is assigned to the contractor's plan,
whether or not they are subject to mandatory enrollment, without
regard to race, ethnicity, gender, sexual or affectional
preference or orientation, age, religion, creed, color, national
origin, ancestry, disability, health status or need for health
services.
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B. Coverage commencement. Coverage of enrollees shall commence at
12:00 a.m., Eastern Time, on the first day of the calendar month
as specified by the DMAHS with the exceptions noted in Article
5.5. The day on which coverage commences shall be the enrollee's
effective date of enrollment.
C. The contractor shall accept enrollment of Medicaid/NJ FamilyCare
eligible persons within the defined enrollment areas in the order
in which they apply or are auto-assigned to the contractor (on a
random basis with equal distribution among all participating
contractors) without restrictions, within contract limits.
Enrollment shall be open at all times except when the contract
limits have been met. A contractor shall not deny enrollment of a
person with an SSI disability or New Jersey Care Disabled category
who resides outside of the enrollment area. However, such enrollee
with a disability shall be required to utilize the contractor's
established provider network. The contractor shall accept
enrollees for enrollment throughout the duration of this contract.
D. Enrollment timeframe. As of the effective date of enrollment, and
until the enrollee is disenrolled from the contractor's plan, the
contractor shall be responsible for the provision and cost of all
care and services covered by the benefits package listed in
Article 4.1. Enrollees who become eligible to receive services
between the 1st through the end of the month shall be eligible for
Managed Care services in that month. When an enrollee is shown on
the enrollment roster as covered by a contractor's plan, the
contractor shall be responsible for providing services to that
person from the first day of coverage shown to the last day of the
calendar month of the effective date of disenrollment. DMAHS will
pay the contractor a capitation rate during this period of time.
E. Hospitalizations. For any eligible person who applies for
participation in the contractor's plan, but who is hospitalized
prior to the time coverage under the plan becomes effective, such
coverage shall not commence until the date after such person is
discharged from the hospital and DMAHS shall be liable for payment
for the hospitalization, including any charges for readmission
within forty-eight (48) hours of discharge for the same diagnosis.
If an enrollee's disenrollment or termination becomes effective
during a hospitalization, the contractor shall be liable for
hospitalization until the date such person is discharged from the
hospital, including any charges for readmission within forty-eight
(48) hours of discharge for the same diagnosis. The contractor
shall notify DMAHS within 180 days of initial hospital admission.
F. Unless otherwise required by statute or regulation, the contractor
shall not condition any Medicaid/NJ FamilyCare eligible person's
enrollment upon the performance of any act or suggest in any way
that failure to enroll may result in a loss of Medicaid/NJ
FamilyCare benefits.
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G. There shall be no retroactive enrollment in Managed Care. Services
for those beneficiaries during any retroactive period will remain
fee-for-service, except for individuals eligible under NJ
FamilyCare Plans B, C, and D who are not eligible until enrolled
in an MCE. Coverage shall continue indefinitely unless this
contract expires or is terminated, or the enrollee is no longer
eligible or is deleted from the contractor's list of eligible
enrollees.
1. Exceptions and Clarifications
a. The contractor shall be responsible for providing
services to an enrollee unless otherwise notified by
DMAHS. In certain situations, retroactive
re-enrollments may be authorized by DMAHS.
b. Deceased enrollees. If an enrollee is deceased and
appears on the recipient file as active, the
contractor shall promptly notify DMAHS. DMAHS shall
recover capitation payments made on a prorated basis
after the date of death.
c. Newborn infants. Newborn infants shall be the
responsibility of the contractor that covered the
mother on the date of birth. The contractor shall
notify DMAHS when a newborn has not been accreted to
its enrollment roster after eight weeks from the
date of birth. DMAHS will take action with the
appropriate CWA to have the infant accreted to the
eligibility file and subsequently the enrollment
roster following this notification. (See Section
B.5.1 of the Appendices, for the applicable
Notification of Newborns form and amendments
thereto). The mother's MCE shall be responsible for
the hospital stay for the newborn following delivery
and for subsequent services based on enrollment in
the contractor's plan. Capitation payments shall be
prorated to cover newborns from the date of birth.
i. SSI. Newborns born to an SSI mother who never
applies for or may not be eligible for
AFDC/TANF remain the responsibility of the
mother's MCE from the date of birth. The
contractor shall be responsible for notifying
DMAHS when a newborn has not been accreted to
its enrollment roster after eight weeks from
the date of birth.
ii. DYFS. Newborns who are placed under the
jurisdiction of the Division of Youth and
Family Services are the responsibility of the
MCE that covered the mother on the date of
birth for medically necessary newborn care.
Such
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children shall become FFS upon their
placement in a DYFS-approved out-of-home
placement.
iii. NJ FamilyCare. Newborn infants born to NJ
FamilyCare Plans B, C, and D mothers shall be
the responsibility of the MCE that covered
the mother on the date of birth for a minimum
of 60 days after the birth through the period
ending at the end of the month in which the
60th day falls unless the child is determined
eligible beyond this time period. The
contractor shall notify DMAHS of the birth
immediately in order to assure payment for
this period.
d. Enrollee no longer in contract area. If an enrollee
moves out of the contractor's enrollment area and
would otherwise still be eligible to be enrolled in
the contractor's plan, the contractor shall continue
to provide or arrange benefits to the enrollee until
the DMAHS can disenroll him/her. The contractor
shall ask DMAHS to disenroll the enrollee due to the
change of residence as soon as it becomes aware of
the enrollee's relocation. This provision does not
apply to persons with disabilities, who may elect to
remain with the contractor, or to NJ FamilyCare
Plans B, C, and D enrollees, who remain enrolled
until the end of the month in which the 60th day
after the request falls.
H. Enrollment Roster. The enrollment roster and weekly transaction
register generated by DMAHS shall serve as the official contractor
enrollment list. However, enrollment changes can occur between the
time when the monthly roster is produced and capitation payment is
made. The contractor shall only be responsible for the provision
and cost of care for an enrollee during the months on which the
enrollee's name appears on the roster, except as indicated in
Article 8.8. DMAHS shall make available data on eligibility
determinations to the contractor to resolve discrepancies that may
arise between the roster and contractor enrollment files. If DMAHS
notifies the contractor in writing of changes in the roster, the
contractor shall rely upon that written notification in the same
manner as the roster. Corrective action shall be limited to one
(1) year from the date that the change was effective.
I. Enrollment of Medicaid case. Enrollment shall be for the entire
Medicaid case, i.e., all individuals included under the ten-digit
Medicaid identification number (or 12-digit ID number in the case
of DYFS population). The contractor shall not enroll a partial
case except at the DMAHS' sole discretion.
J. Weekly Enrollment Transactions. In keeping with a schedule
established by DMAHS, DMAHS will process and forward enrollment
transactions to the contractor on a weekly basis.
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K. Capitation Recovery. Capitation payments for a full month coverage
shall be recovered from the contractor on a prorated basis when an
enrollee is admitted to a nursing facility, psychiatric care
facility or other institution including incarceration and the
individual is disenrolled from the contractor's plan on the day
prior to such admission.
L. Adjustments to Capitation. The monthly capitation payments shall
include all adjustments made by DMAHS for reasons such as but not
limited to retroactive validation as for newborns or retroactive
termination of eligibility as for death, incarceration or
institutionalization. These adjustments will be documented by
DMAHS by means of a remittance tape. With the exception of
newborns, DMAHS shall be responsible for fee-for-service payments
incurred by the enrollee during the period prior to actual
enrollment in the contractor's plan.
M. The contractor shall cooperate with established procedures whereby
DMAHS and the HBC shall monitor enrollment and disenrollment
practices.
N. Nothing in this Article or contract shall be construed to limit or
in any way jeopardize a Medicaid beneficiary's eligibility for New
Jersey Medicaid.
O. DMAHS shall arrange for the determination of eligibility of each
potential enrollee for covered services under this contract and to
arrange for the provision of complete information to the
contractor with respect to such eligibility, including
notification whenever an enrollee's Medicaid/NJ FamilyCare
eligibility is discontinued.
5.6 VERIFICATION OF ENROLLMENT
A. The contractor shall be responsible for keeping its network of
providers informed of the enrollment status of each enrollee. The
contractor shall be able to report and ensure enrollment to
network providers through either manual or electronic means.
B. The contractor shall maintain procedures to ensure that each
individual's enrollment in the contractor's plan may be verified
with the use of the Medicaid/NJ FamilyCare Eligibility
Identification Card issued by the State and/or card issued by the
contractor through:
1. Point of Service Device (POS)
2. Claims and Eligibility Real Time System (CERTS)
3. Automated Eligibility Verification System (AEVS)
C. Providers should not wait more than three (3) minutes to verify
enrollment.
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5.7 MEMBER SERVICES UNIT
A. Defined. The contractor shall have in place a Member Services Unit
to coordinate and provide services to Medicaid/NJ FamilyCare
managed care enrollees. The services as described in this Article
include, but are not limited to enrollee selection, changes,
assignment, and/or reassignment of a PCP, explanation of benefits,
assistance with filing and resolving inquiries, billing problems,
grievances and appeals, referrals, appointment scheduling and
cultural and/or linguistic needs. This unit shall also provide
orientation to contractor operations and assistance in accessing
medical and dental care.
B. Staff Training. The contractor shall develop a system to ensure
that new and current Member Services staff receive basic and
ongoing training and have expertise necessary to provide accurate
information to all Medicaid/NJ FamilyCare enrollees regarding
program benefits and contractor's procedures.
C. Communication-Affecting Conditions. The contractor shall ensure
that Member Services staff have training and experience needed to
provide effective services to enrollees with special needs, and
are able to communicate effectively with enrollees who have
communication-affecting conditions, in accordance with this
Article.
D. Language Requirements. The Member Services staff shall include
individuals who speak English, Spanish and any other language
which is spoken as a primary language by a population that exceeds
five (5) percent of the contractor's Medicaid/NJ FamilyCare
enrollees or two hundred (200) enrollees in the contractor's plan,
whichever is greater.
E. Member Services Manual. The contractor shall maintain a current
Member Services Manual to serve as a resource of information for
Member Services staff. A copy shall be provided to the Department
during the readiness site visit. On an annual basis, all changes
to the Member Services Manual shall be incorporated into the
master used for making additional distribution copies of the
manual.
F. The contractor shall provide an after-hours call-in system to
triage urgent care and emergency calls from enrollees.
G. The contractor shall have written policies and procedures for
member services to refer enrollees to a health professional to
triage urgent care and emergencies during normal hours of
operation.
H. The Contractor shall submit any significant and material changes
to its member services policies and procedures to the Department
prior to being implemented.
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5.8 ENROLLEE EDUCATION AND INFORMATION
5.8.1 GENERAL REQUIREMENTS
A. Written Material Submission to DMAHS. The contractor shall submit
the format and content of all written materials/notifications and
orientations described in this contract to DMAHS for review and
approval prior to enrollee contact/distribution. All appropriate
materials shall be submitted by DMAHS to the State Medical
Advisory Committee for review.
B. The contractor shall prepare and distribute with prior approval by
DMAHS, bilingual marketing and informational materials to
Medicaid/NJ FamilyCare beneficiaries, enrollees (or, where
applicable, an authorized person), and providers, and shall
include basic information about its plan. Information must be in
language that ensures that all beneficiaries can understand each
process. Written information shall be culturally and
linguistically sensitive.
C. The contractor shall establish a mechanism and present to DMAHS
how its enrollees will be continually educated about its policies
and procedures; the role of participants in the education process
including contractor administration, member and provider services,
care managers, and network providers; how the "educators" are made
aware of their education role; and how the contractor will assure
the State this process will be monitored to assure successful
outcomes for all enrollees, particularly enrollees with special
needs and the homeless.
5.8.2 ENROLLEE NOTIFICATION/HANDBOOK
Prior to the effective date of enrollment, the contractor shall provide
each enrolled case or, where applicable, authorized person, with a
bilingual (English/Spanish) member handbook and an Identification Card.
The handbook shall be written at the fifth grade reading level or at an
appropriate reading level for enrollees with special needs. The handbook
shall also be available on request in other languages and alternative
formats, e.g., large print, Braille, audio cassette, or diskette for
enrollees with sensory impairments or in a modality that meets the needs
of enrollees with special needs. The content and format of the handbook
shall have the prior written approval of DMAHS and shall describe all
services covered by the contractor, exclusions or limitations on
coverage, the correct use of the contractor's plan, and other relevant
information, including but not limited to the following:
A. Cover letter, explaining the member handbook, expected effective
date of enrollment, and when identification card will be received
(if not sent with the handbook);
1. The enrollee's expected effective date of enrollment;
provided that, if the actual effective date of enrollment
is different from that given to the
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enrollee or, where applicable, an authorized person, at the
time of enrollment, the contractor shall notify the
enrollee or, where applicable, an authorized person of the
change;
B. A clear description of benefits included in this contract with
exclusions, restrictions, and limitations. Clarification that
enrollees who are clients of the Division of Developmental
Disabilities will receive mental health/substance abuse services
through the contractor (may be addressed through a separate insert
to the basic handbook);
C. An explanation of the procedures for obtaining covered services;
D. An explanation of the use of the contractor's toll free telephone
number (staffed for twenty-four (24) hours per day/seven (7) days
per week communication);
E. A listing of primary care practitioners (in the format described
in Article 4.8.4);
F. An identification card clearly indicating that the bearer is an
enrollee of the contractor's plan; and the name of the primary
care practitioner and telephone number on the card; a description
of the enrollee identification card to be issued by the
contractor; and an explanation as to its use in assisting
beneficiaries to obtain services;
G. An explanation that beneficiaries shall obtain all covered
non-emergency health care services through the contractor's
providers;
H. An explanation of the process for accessing emergency services and
services which require or do not require referrals;
I. A definition of the term "emergency medical condition" and an
explanation of the procedure for obtaining emergency services,
including the need to contact the PCP for urgent care situations
and prior to accessing such services in the emergency room;
J. An explanation of the importance of contacting the PCP immediately
for an appointment and appointment procedures;
K. An explanation of where and how twenty-four (24) hour per day,
seven (7) day per week, emergency services are available,
including out-of-area coverage, and procedures for emergency and
urgent health care service;
L. A list of the Medicaid and/or NJ FamilyCare services not covered
by the contractor and an explanation of how to receive services
not covered by this contract including the fact that such services
may be obtained through the provider of their choice according to
regular Medicaid program regulations. The contractor
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may also assist an enrollee or, where applicable, an authorized
person, in locating a referral provider;
M. A notification of the enrollee's right to obtain family planning
services from the contractor or from any appropriate Medicaid
participating family planning provider (42 C.F.R. Section
431.51(b));
N. A description of the process for referral to specialty and
ancillary care providers and second opinions;
O. An explanation of the reasons for which an enrollee may request a
change of PCP, the process of effectuating that change, and the
circumstances under which such a request may be denied;
P. The reasons and process by which a provider may request an
enrollee to change to a different PCP;
Q. An explanation of an enrollee's rights to disenroll or transfer at
any time for cause; disenroll or transfer in the first 90 days
after the latter of the date the individual enrolled or the date
they receive notice of enrollment and at least every twelve (12)
months thereafter without cause and that the lock-in period does
not apply to ABD, DDD or DYFS individuals;
R. Complaints and Grievances
1. Procedures for resolving complaints, as approved by the
DMAHS;
2. A description of the grievance procedures to be used to
resolve disputes between a contractor and an enrollee,
including: the name, title, or department, address, and
telephone number of the person(s) responsible for assisting
enrollees in grievance resolutions; the time frames and
circumstances for expedited and standard grievances; the
right to appeal a grievance determination and the
procedures for filing such an appeal; the time frames and
circumstances for expedited and standard appeals; the right
to designate a representative; a notice that all disputes
involving clinical decisions will be made by qualified
clinical personnel; and that all notices of determination
will include information about the basis of the decision
and further appeal rights, if any;
3. The contractor shall notify all enrollees in their primary
language of their rights to file grievances and appeal
grievance decisions by the contractor;
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S. An explanation that Medicaid/NJ FamilyCare Plan A enrollees have
the right to a Medicaid Fair Hearing with DMAHS and the appeal
process through the DHSS for Medicaid and NJ FamilyCare enrollees,
including instructions on the procedures involved in making such a
request;
T. Title, addresses, phone numbers and a brief description of the
contractor for contractor management/service personnel;
U. The interpretive, linguistic, and cultural services available
through the contractor's personnel;
V. An explanation of the terms of enrollment in the contractor's
plan, continued enrollment, disenrollment procedures, time frames
for each procedure, default procedures, enrollee's rights and
responsibilities and causes for which an enrollee shall lose
entitlement to receive services under this contract, and what
should be done if this occurs;
W. A statement strongly encouraging the enrollee to obtain a baseline
physical and dental examination, and to attend scheduled
orientation sessions and other educational and outreach
activities;
X. A description of the EPSDT program, and language encouraging
enrollees to make regular use of preventive medical and dental
services;
Y. Provision of information to enrollees or, where applicable, an
authorized person, to enable them to assist in the selection of a
PCP;
Z. Provision of assistance to clients who cannot identify a PCP on
their own;
AA. An explanation of how an enrollee may receive mental health and
substance abuse services;
BB. An explanation of how to access transportation services;
CC. An explanation of service access arrangements for home bound
enrollees;
DD. A statement encouraging early prenatal care and ongoing continuity
of care throughout the pregnancy;
EE. A notice that an enrollee may obtain a referral to a health care
provider outside of the contractor's network or panel when the
contractor does not have a health care provider with appropriate
training and experience in the network or panel to meet the
particular health care needs of the enrollee and procedure by
which the enrollee can obtain such referral;
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FF. A notice that an enrollee with a condition which requires ongoing
care from a specialist may request a standing referral to such a
specialist and the procedure for requesting and obtaining such a
specialist referral;
GG. A notice that an enrollee with (i) a life-threatening condition or
disease or (ii) a degenerative and/or disabling condition or
disease, either of which requires specialized medical care over a
prolonged period of time may request a specialist or specialty
care center responsible for providing or coordinating the
enrollee's medical care and the procedure for requesting and
obtaining such a specialist or access to the center;
HH. A notice of all appropriate mailing addresses and telephone
numbers to be utilized by enrollees seeking information or
authorization;
II. A notice of pharmacy Lock-In program and procedures;
JJ. An explanation of the time delay of thirty (30) to forty-five (45)
days between the date of initial application and the effective
date of enrollment; however, during this interim period,
prospective Medicaid enrollees will continue to receive health
care benefits under the regular fee-for-service Medicaid program
or the HMO with which the person is currently enrolled. Enrollment
is subject to verification of the applicant's eligibility for the
Medicaid program and New Jersey Care 2000+ enrollment; and the
time delay of thirty (30) to forty-five (45) days between the date
of request for disenrollment and the effective date of
disenrollment;
KK. An explanation of the appropriate uses of the Medicaid/NJ
FamilyCare identification card and the contractor identification
card;
LL. A notification, whenever applicable, that some primary care
physicians may employ other health care practitioners, such as
nurse practitioners or physician assistants, who may participate
in the patient's care;
MM. The enrollee's or, where applicable, an authorized person's signed
authorization on the enrollment application allows release of
medical records;
NN. Notification that the enrollee's health status survey (obtained
only by the HBC) will be sent to the contractor by the Health
Benefits Coordinator;
OO. A notice that enrollment and disenrollment is subject to
verification and approval by DMAHS;
PP. An explanation of procedures to follow if enrollees receive bills
from providers of services, in or out of network;
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QQ. An explanation of the enrollee's financial responsibility for
payment when services are provided by a health care provider who
is not part of the contractor's organization or when a procedure,
treatment or service is not a covered health care benefit by the
contractor and/or by Medicaid;
RR. A written explanation at the time of enrollment of the enrollee's
right to terminate enrollment, and any other restrictions on the
exercise of those rights, to conform to 42 U.S.C.Section
1396b(m)(2)(F)(ii). The initial enrollment information and the
contractor's member handbook shall be adequate to convey this
notice and shall have DMAHS approval prior to distribution;
SS. An explanation that the contractor will contact or facilitate
contact with, and require its PCPs to use their best efforts to
contact, each new enrollee or, where applicable, an authorized
person, to schedule an appointment for a complete, age/sex
specified baseline physical, and for enrollees with special needs
who have been identified through a Complex Needs Assessment as
having complex needs, the development of an Individual Health Care
Plan at a time mutually agreeable to the contractor and the
enrollee, but not later than ninety (90) days after the effective
date of enrollment for children under twenty-one (21) years of
age, and not later than one hundred eighty (180) days after
initial enrollment for adults; for adult clients of DDD, no later
than ninety (90) days after the effective date of enrollment; and
encourage enrollees to contact the contractor and/or their PCP to
schedule an appointment;
TT. An explanation of the enrollee's rights and responsibilities which
should include, at a minimum, the following, as well as the
provisions found in Standard X in NJ modified QARI/QISMC in
Section B.4.14 of the Appendices.
1. Provision for "Advance Directives," pursuant to 42 C.F.R.
Part 489, Subpart I;
2. Participation in decision-making regarding their health
care;
3. Provision for the opportunity for enrollees or, where
applicable, an authorized person to offer suggestions for
changes in policies and procedures; and
4. A policy on the treatment of minors.
UU. Notification that prior authorization for emergency services,
either in-network or out-of-network, is not required;
VV. Notification that the costs of emergency screening examinations
will be covered by the contractor when the condition appeared to
be an emergency medical condition to a prudent layperson;
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WW. For beneficiaries subject to cost-sharing (i.e., those eligible
through NJ FamilyCare Plan C and D; See Section B.5.2 of the
Appendices), information that specifically explains:
1. The limitation on cost-sharing;
2. The dollar limit that applies to the family based on the
reported income;
3. The need for the family to keep track of the cost-sharing
amounts paid; and
4. Instructions on what to do if the cost-sharing requirements
are exceeded.
XX. An explanation on how to access WIC services;
YY. Any other information essential to the proper use of the
contractor's plan as may be required by the Division; and
ZZ. Inform enrollees of the availability of care management services.
AAA. Enrollee right to adequate and timely information related to
physician incentives.
5.8.3 ANNUAL INFORMATION TO ENROLLEES
The contractor shall distribute an updated handbook which will include
the information specified in Article 5.8.2 to each enrollee or enrollee's
family unit and to all providers at least once every twelve (12) months.
5.8.4 NOTIFICATION OF CHANGES IN SERVICES
The contractor shall revise and distribute the information specified in
Article 5.8 at least thirty (30) calendar days prior to any changes that
the contractor makes in services provided or in the locations at which
services may be obtained, or other changes of a program nature or in
administration, to each enrollee and all providers affected by that
change.
5.8.5 ID CARD
A. Except as set forth in Section 5.9.1C. the contractor shall
deliver to each new enrollee prior to the effective enrollment
date but no later than seven (7) days after the enrollee's
effective date of enrollment a contractor Identification Card for
those enrollees who have selected a PCP. The Identification Card
shall have at least the following information:
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0. Name of enrollee
2. Issue Date for use in automated card replacement process
3. Primary Care Provider Name (may be affixed by sticker)
4. Primary Care Provider Phone Number (may be affixed by
sticker)
5. What to do in case of an emergency and that no prior
authorization is required
6. Relevant copayments/Personal Contributions to Care
7. Contractor 800 number - emergency message
Any additional information shall be approved by DMAHS prior to use
on the ID card.
B. For children and individuals eligible solely through the NJ
FamilyCare Program, the identification card must clearly indicate
"NJ FamilyCare"; for children and individuals who are
participating in NJ FamilyCare Plans C and D the cost- sharing
amount shall be listed on the card. However, if the family limit
for cost- sharing has been reached, the identification card shall
indicate a zero cost-sharing amount. The State will notify the
contractor when such limits have been reached.
5.8.6 ORIENTATION AND WELCOME LETTER
A. Welcome Letter. The contractor shall mail a welcome letter to each
new enrollee or authorized person prior to the enrollee's
effective date of coverage. The welcome letter shall explain the
member handbook, the enrollee's expected effective date of
enrollment, and when the enrollee's identification card will be
received.
B. Individual or Group Orientation. The contractor shall offer
barrier free individual or group orientation, by telephone or in
person, to enrollees, family members, or, where applicable,
authorized persons who are able to be contacted regarding the
delivery system. Orientation shall normally occur within thirty
(30) days of the date of enrollment, except that the contractor
shall attempt to provide orientation within ten (10) days to each
enrollee who has been identified as having special needs. The
contractor shall provide orientation education that includes at
least the following:
1. Specific information listed within the member handbook.
2. The circumstances under which a team of professionals
(e.g., care management) is convened, the role of the team,
and the manner in which it functions.
C. Prior to conducting the first orientation, the contractor shall
submit for the readiness on-site review a curriculum that meets
the requirements of this provision to DMAHS for approval.
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5.9 PCP SELECTION AND ASSIGNMENT
The contractor shall place a high emphasis on ensuring that enrollees are
informed and have access to enroll with traditional and safety net
providers. The contractor shall place a high priority on enrolling
enrollees with their existing PCP. If an enrollee does not select a PCP,
the enrollee shall be assigned to his/her PCP of record (based upon prior
history information) if that PCP is still a participating provider with
the contractor. All contract materials shall provide equal information
about enrollment with traditional and safety net providers as that
provided about contractor operated offices. All materials, documents, and
phone scripts shall be reviewed and approved by the Department before
use.
5.9.1 INITIAL SELECTION/ASSIGNMENT
A. General. Each enrollee in the contractor's plan shall be given the
option of choosing a specific PCP in accordance with Articles 4.5
and 4.8 within the contractor's provider network who will be
responsible for the provision of primary care services and the
coordination of all other health care needs through the mechanisms
listed in this Article.
The HBC will provide the contractor with information, when
available, of existing PCP relationships via the Plan Selection
Form. The contractor shall, at the enrollee's option, maintain the
PCP-patient relationship.
B. PCP Selection. The contractor shall provide enrollees with
information to facilitate the choice of an appropriate PCP. This
information shall include, where known, the name of the enrollee's
provider of record, and a listing of all participating providers
in the contractor's network. (See Article 4.8.4 for a description
of the required listing.)
C. PCP Assignment. If the contractor has not received an enrollee's
PCP selection within ten (10) calendar days from the enrollee's
effective date of coverage or the selected PCP's panel is closed,
the contractor shall assign a PCP and deliver an ID card by the
fifteenth (15th) calendar day after the effective date of
enrollment. The assignment shall be made according to the
following criteria, in hierarchical order:
1. The enrollee shall be assigned to his/her current provider,
if known, as long as that provider is a part of the
contractor's provider network.
2. The enrollee shall be assigned to a PCP whose office is
within the travel time/distance standards, as defined in
Article 4.8.8. If the language and/or cultural needs of the
enrollee are known to the contractor, the enrollee shall be
assigned to a PCP who is or has office staff who are
linguistically and culturally competent to communicate with
the enrollee or have the
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ability to interpret in the provision of health care
services and related activities during the enrollee's
office visits or contacts.
5.9.2 PCP CHANGES
A. Enrollee Request. Any enrollee or, where applicable, authorized
person dissatisfied with the PCP selected or assigned shall be
allowed to reselect or be assigned to another PCP. Such
reassignment shall become effective no later than the beginning of
the first month following a full month after the request to change
the enrollee's PCP. Except for DYFS enrollees, this reselection or
reassignment for any cause may be limited, at the contractor's
discretion, to two (2) times per year. However, in the event there
is reasonable cause following policies and procedures as
determined by the contractor and approved by the Department, the
enrollee or, where applicable, authorized person may reselect or
be reassigned at any time, regardless of the number of times the
enrollee has previously changed PCPs.
In the event an enrollee becomes non-eligible and then re-eligible
within six (6) months in the same region, said enrollee shall, if
at all possible, be assigned to the same PCP. In such a
circumstance, the contractor may count previous PCP changes toward
the annual two-change limit.
B. PCP Request. The contractor shall develop policies and procedures,
which shall be prior approved by the Department, for allowing a
PCP to request reassignment of an enrollee, e.g., for
irreconcilable differences, for when an enrollee has taken legal
action against the provider, or if an enrollee fails to comply
with health care instructions and such non-compliance prevents the
provider from safely and/or ethically proceeding with that
enrollee's health care services. The contractor shall approve any
reassignments and require documentation of the reasons for the
request for reassignment. For example, if a PCP requests
reassignment of an enrollee for failure to comply with health care
instructions, the contractor shall take into consideration whether
the enrollee has a physical or developmental disability that may
contribute to the noncompliance, and whether the provider has made
reasonable efforts to accommodate the enrollee's needs. In the
case of DYFS-eligible children, copies of such requests shall be
sent to the Division of Youth and Family Services, c/o Medicaid
Liaison, XX Xxx 000, Xxxxxxx, XX 00000-0000.
C. PCP Change Form. If a change form is used, by the contractor, the
contractor shall immediately provide the PCP Change Form to an
enrollee wishing a change, if such request is made in person, or
by mail if requested by telephone or in writing. The contractor
shall mail the form within three (3) business days of receiving a
telephone or written request for a form.
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D. Processing of PCP Change Forms. If a change form is used by the
contractor, enrollees shall submit the PCP change form to the
contractor for processing. The contractor shall process the form
and return the enrollee identification card or self- adhering
sticker to the enrollee within ten (10) calendar days of the
postmark date on the mailing envelope or, if not received by mail,
the date received by the contractor.
E. Verbal Requests for PCP Change. The contractor may accept verbal
requests from enrollees or authorized persons to change PCPs.
However, the contractor shall document the verbal request
including at a minimum name of caller, date of call, and selected
PCP. The contractor shall process the request and return the
enrollee identification card or self-adhering sticker to the
enrollee within ten (10) calendar days of the request for PCP
change.
5.10 DISENROLLMENT FROM CONTRACTOR'S PLAN
5.10.1 GENERAL PROVISIONS
A. Non-discrimination. Disenrollment from contractor's plan shall not
be based in whole or in part on an adverse change in the
enrollee's health, on any of the factors listed in Article 7.8, or
on amounts payable to the contractor related to the enrollee's
participation in the contractor's plan.
B. Coverage. The contractor shall not be responsible for the
provision and cost of care and services for an enrollee after the
effective date of disenrollment unless the enrollee is admitted to
a hospital prior to the expected effective date of disenrollment,
in which case the contractor is responsible for the provision and
cost of care and services covered under this contract until the
date on which the enrollee is discharged from the hospital,
including any charge for the enrollee readmitted within
forty-eight (48) hours of discharge for the same diagnosis.
C. Notification of Disenrollment Rights. The contractor shall notify
through personalized, written notification the enrollee or, where
applicable, authorized person of the enrollee's disenrollment
rights at least sixty (60) days prior to the end of his/her twelve
(12)-month enrollment period. The contractor shall notify the
enrollee of the effective disenrollment date
D. Release of Medical Records. The contractor shall transfer or
facilitate the transfer of the medical record (or copies of the
medical record), upon the enrollee's or, where applicable, an
authorized person's request, to either the enrollee, to the
receiving provider, or, in the case of a child eligible through
the Division of Youth and Family Services, to a representative of
the Division of Youth and Family Services or to an adoptive parent
receiving subsidy through DYFS, at no charge, in a timely fashion,
i.e., no later than ten days prior to the effective date of
transfer. The contractor shall release medical records of the
enrollee, and/or
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facilitate the release of medical records in the possession of
participating providers as may be directed by DMAHS authorized
personnel and other appropriate agencies of the State of New
Jersey, or the federal government. Release of medical records
shall be consistent with the provisions of confidentiality as
expressed in Article 7.40 of this contract and the provisions of
42 C.F.R.Section 431.300. For individuals being served through the
Division of Youth and Family Services, release of medical records
must be in accordance with the provisions under N.J.S.A. 9:6-8.10a
and 9:6-8.40 and consistent with the need to protect the
individual's confidentiality.
E. In the event the contract, or any portion thereof, is terminated,
or expires, the contractor shall assist DMAHS in the transition of
enrollees to other contractors. Such assistance and coordination
shall include, but not be limited to, the forwarding of medical
and other records and the facilitation and scheduling of medically
necessary appointments for care and services. The cost of
reproducing and forwarding medical charts and other materials
shall be borne by the contractor. The contractor shall be
responsible for providing all reports set forth in this contract.
The contractor shall make provision for continuing all management
and administrative services until the transition of enrollees is
completed and all other requirements of this contract are
satisfied. The contractor shall be responsible for the following:
1. Identification and transition of chronically ill, high risk
and hospitalized enrollees, and enrollees in their last
four weeks of pregnancy.
2. Transfer of requested medical records.
5.10.2 DISENROLLMENT FROM THE CONTRACTOR'S PLAN AT THE ENROLLEE'S REQUEST
A. An individual enrolled in a contractor's plan may be subject to
the enrollment Lock-In period provided for in this Article. The
enrollment Lock-In provision does not apply to SSI and NJ Care ABD
individuals, clients of DDD or to individuals eligible to
participate through the Division of Youth and Family Services.
1. An enrollee subject to the enrollment Lock-In period may
initiate disenrollment or transfer for any reason during
the first ninety (90) days after the latter of the date the
individual is enrolled or the date they receive notice of
enrollment with a new contractor and at least every twelve
(12) months thereafter without cause. NJ FamilyCare Plans
B, C, or D enrollees will be subject to a twelve (12)-month
Lock-In period.
a. The period during which an individual has the right
to disenroll from the contractor's plan without
cause applies to an individual's
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initial period of enrollment with the contractor. If
that individual chooses to re-enroll with the
contractor, his/her initial date of enrollment with
the contractor will apply.
2. An enrollee subject to the Lock-In period may initiate
disenrollment for good cause at any time.
a. Good cause reasons for disenrollment or transfer
shall include, unless otherwise defined by DMAHS:
i. Failure of the contractor to provide services
including physical access to the enrollee in
accordance with the terms of this contract;
ii. Enrollee has filed a grievance with the
contractor pursuant to the applicable
grievance procedure and has not received a
response within the specified time period
stated therein, or in a shorter time period
required by federal law;
iii. Documented grievance, by the enrollee against
the contractor's plan without satisfaction.
iv. Enrollee is subject to enrollment exemption
as set forth in Article 5.3.2. If an
exemption situation exists within the
contractor's plan but another contractor can
accommodate the individual's needs, a
transfer may be granted.
v. Enrollee has substantially more convenient
access to a primary care physician who
participates in another MCE in the same
enrollment area.
B. Voluntary Disenrollment. The contractor shall assure that
enrollees who disenroll voluntarily are provided with an
opportunity to identify, in writing, their reasons for
disenrollment. The contractor shall further:
1. Require the return, or invalidate the use of the
contractor's identification card; and
2. Forward a copy of the disenrollment request or refer the
beneficiary to DMAHS/HBC by the eighth (8th) day of the
month prior to the month in which disenrollment is to
become effective.
C. HBC Role. All enrollee requests to disenroll must be made through
the Health Benefits Coordinator. The contractor may not induce,
discuss or accept disenrollments. Any enrollee seeking to
disenroll should be directed to contact
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the HBC. This applies to both mandatory and voluntary enrollees.
Disenrollment shall be completed by the HBC at facilities and in a
manner so designated by DMAHS.
D. Effective Date. The effective date of disenrollment or transfer
shall be no later than the first day of the month immediately
following the full calendar month the disenrollment is initiated
by DMAHS. Notwithstanding anything herein to the contrary, the
remittance tape, along with any changes reflected in the weekly
register or agreed upon by DMAHS and the contractor in writing,
shall serve as official notice to the contractor of disenrollment
of an enrollee.
5.10.3 DISENROLLMENT FROM THE CONTRACTOR'S PLAN AT THE CONTRACTOR'S REQUEST
A. Criteria for Contractor Disenrollment Request. The contractor may
recommend, with written documentation to DMAHS, the disenrollment
of an enrollee. In no event may an enrollee be disenrolled due to
health status or need for health services. Enrollees may be
disenrolled in any of the following circumstances:
1. The contractor determines that the willful actions of the
enrollee are inconsistent with membership in the
contractor's plan, and the contractor has made and provides
DMAHS with documentation of at least three attempts to
reconcile the situation. Examples of inconsistent actions
include but are not limited to: persistent refusal to
cooperate with any participating provider regarding
procedures for consultations or obtaining appointments
(this does not preclude an enrollee's right to refuse
treatment), intentional misconduct, willful refusal to
receive prior approval for non-emergency care; willful
refusal to comply with reasonable administrative policies
of the contractor, fraud, or making a material
misrepresentation to the contractor. In no way can this
provision be applied to individuals on the basis of their
physical condition, utilization of services, age,
socio-economic status or mental disability.
2. The contractor becomes aware that the enrollee falls into
an aid category that is not set forth in Article 5.2 of
this contract, has become ineligible for enrollment
pursuant to Article 5.3.1 of this contract, or has moved to
a residence outside of the enrollment area covered by this
contract.
B. Reasonable Efforts Prior to Disenrollment. Prior to recommending
disenrollment of an enrollee, the contractor shall make a
reasonable effort to identify for the enrollee or, where
applicable, an authorized person those actions that have
interfered with effective provision of covered medical care and
services, and to explain what actions or procedures are
acceptable. The contractor must allow the enrollee or, where
applicable, an authorized person sufficient opportunity to comply
with acceptable procedures prior to recommending disenrollment.
The
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contractor shall provide at least one verbal and at least one
written warning to the enrollee regarding the implications of
his/her actions.
If the enrollee, or, where applicable, an authorized person fails
to comply with acceptable procedures, the contractor shall give at
least thirty (30) days prior written notice to the enrollee, or,
where applicable, an authorized person, of its intent to recommend
disenrollment. The notice shall include a written explanation of
the reason the contractor intends to request disenrollment, and
advise the enrollee or, where applicable, an authorized person of
his/her right to file a disenrollment grievance. The contractor
shall give DMAHS a copy of the notice and advise DMAHS immediately
if the enrollee or, where applicable, an authorized person files a
disenrollment grievance.
C. Disenrollment Appeals. The contractor shall notify DMAHS of
decisions related to all appeals filed by an enrollee or, where
applicable, an authorized person as a result of the contractor's
notice to an enrollee of its intent to recommend disenrollment. If
the enrollee has not filed an appeal or if the contractor
determines that the appeal is unfounded, the contractor may submit
to the Office of Managed Health Care of DMAHS a recommendation for
disenrollment of the enrollee. The contractor shall notify the
enrollee in writing of such request at the time it is filed with
DMAHS.
DMAHS will decide within ten (10) business days after receipt of
the contractor's recommendation whether to disenroll the enrollee
and will provide a written determination and notification of the
right to a Fair Hearing to the enrollee or, where applicable, an
authorized person and the contractor.
D. The DMAHS shall review each involuntary disenrollment and may
require an in- depth review by State staff, including but not
limited to patient and provider interviews, medical record review,
and home assessment to determine with the enrollee what plan of
action would serve the best interests of the enrollee (and family
as applicable.)
5.10.4 TERMINATION
A. Enrollees shall be terminated from the contractor's plan whenever:
1. The contract between the contractor and DMAHS is terminated
for any reason;
2. The enrollee loses Medicaid/NJ FamilyCare eligibility;
3. Nonpayment of premium for individuals eligible through the
NJ FamilyCare Program occurs;
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4. DMAHS is notified that the enrollee has moved outside of
the enrollment area that the contractor does not service;
5. The enrollee requires more than thirty (30) days of service
from a post- acute facility, in which case the contractor
shall provide health care services to the enrollee through
the last day of the month following the enrollee's
admission to the facility.
B. For enrollees covered by the contractor's plan who are eligible
through the Division of Youth and Family Services and who move to
a residence outside of the enrollment area covered by this
contract:
1. The DYFS representative will immediately contact the HBC.
2. The HBC will process the enrollee's disenrollment and
transfer the enrollee to a new contractor; or disenroll the
enrollee to the fee-for-service coverage under DMAHS.
3. The contractor shall continue to provide services to the
enrollee until the enrollee is disenrolled from the
contractor's plan.
C. Loss of Medicaid or NJ FamilyCare Eligibility. When an enrollee's
coverage is terminated due to a loss of Medicaid or NJ FamilyCare
eligibility, the contractor shall offer to the enrollee the
opportunity to convert the enrollee's membership to a non-group,
non-Medicaid enrollment, consistent with conversion privileges
offered to other groups enrolled in the contractor.
D. In no event shall an enrollee be disenrolled due to health status,
need for health services, or pre-existing medical conditions.
5.11 TELEPHONE ACCESS
A. Twenty-Four Hour Coverage. The contractor shall maintain a
twenty-four (24) hours per day, seven (7) days per week toll-free
telephone answering system that will respond in person (not voice
mail) and will include Telecommunication Device for the Deaf (TDD)
or Tech Telephone (TT) systems. Telephone staff shall be
adequately trained and staffed and able to promptly advise
enrollees of procedures for emergency and urgent care. The
telephone answering system must be available at no cost to the
enrollees for local and long-distance calls from within or
out-of-state.
B. The contractor shall maintain toll-free telephone access to the
contractor for the enrollees at a minimum from 8:00 a.m. to 5:00
p.m. on Monday through Friday, for calls concerning administrative
or routine care services.
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C. After Hours Response. The contractor shall have standards for PCP
and on-call medical/dental professional response to after hours
phone calls from enrollees or other medical/dental professionals
providing services to an enrollee (including, but not limited to
emergency department staff). The telephone response time shall not
exceed two (2) hours, except for emergencies which require
immediate response from the PCP.
D. Protocols.
1. Contractor. The contractor shall develop and use telephone
protocols for all of the following situations:
a. Answering the volume of enrollee telephone inquiries
on a timely basis.
i. Enrollees shall wait no more than five (5)
minutes on hold.
b. Identifying special enrollee needs e.g., wheelchair
and interpretive linguistic needs. (See also Article
4.5.)
c. Triage for medical and dental conditions and special
behavioral needs for non-compliant individuals who
are mentally deficient.
d. Response time for telephone call-back waiting times:
after hours telephone care for non-emergent,
symptomatic issues - within thirty (30) to
forty-five (45) minutes; same day for non-
symptomatic concerns; fifteen (15) minutes for
crisis situations.
2. Providers. The contractor shall monitor and require its
providers to develop and use telephone protocols for all of
the following situations:
a. Answering the enrollee telephone inquiries on a
timely basis.
b. Prioritizing appointments.
c. Scheduling a series of appointments and follow-up
appointments as needed by an enrollee.
d. Identifying and rescheduling broken and no-show
appointments.
e. Identifying special enrollee needs while scheduling
an appointment, e.g., wheelchair and interpretive
linguistic needs. (See also Article 4.5.)
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f. Triage for medical and dental conditions and special
behavioral needs for non-compliant individuals who
are mentally deficient.
g. Response time for telephone call-back waiting times:
after hours telephone care for non-emergent,
symptomatic issues - within thirty (30) to
forty-five (45) minutes; same day for
non-symptomatic concerns; fifteen (15) minutes for
crisis situations.
h. Scheduling continuous availability and accessibility
of professional, allied, and supportive
medical/dental personnel to provide covered services
within normal working hours. Protocols shall be in
place to provide coverage in the event of a
provider's absence.
E. The contractor shall maintain a P-Factor of P7 or less for calls
to Member Services and shall submit the P-Factor report in Section
A.5.1 of the Appendices.
5.12 APPOINTMENT AVAILABILITY
The contractor shall have policies and procedures to ensure the
availability of medical, mental health/substance abuse (for DDD clients)
and dental care appointments in accordance with the following standards:
A. Emergency Services. Immediately upon presentation at a service
delivery site.
B. Urgent Care. Within twenty-four (24) hours. An urgent, symptomatic
visit is an encounter with a health care provider associated with
the presentation of medical signs that require immediate
attention, but are not life-threatening.
C. Symptomatic Acute Care. Within seventy-two (72) hours. A
non-urgent, symptomatic office visit is an encounter with a health
care provider associated with the presentation of medical signs,
but not requiring immediate attention.
D. Routine Care. Within twenty-eight (28) days. Non-symptomatic
office visits shall include but shall not be limited to:
well/preventive care appointments such as annual gynecological
examinations or pediatric and adult immunization visits.
E. Specialist Referrals. Within four (4) weeks or shorter as
medically indicated. A specialty referral visit is an encounter
with a medical specialist that is required by the enrollee's
medical condition as determined by the enrollee's Primary Care
Provider (PCP). Emergency appointments must be provided within 24
hours of referral.
F. Urgent Specialty Care. Within twenty-four (24) hours of referral.
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G. Baseline Physicals for New Adult Enrollees. Within one hundred-eighty
(180) calendar days of initial enrollment.
H. Baseline Physicals for New Children Enrollees and Adult Clients of
DDD. Within ninety (90) days of initial enrollment, or in accordance
with EPSDT guidelines.
I. Prenatal Care. Enrollees shall be seen within the following
timeframes:
1. Three (3) weeks of a positive pregnancy test (home or laboratory)
2. Three (3) days of identification of high-risk
3. Seven (7) days of request in first and second trimester
4. Three (3) days of first request in third trimester
J. Routine Physicals. Within four (4) weeks for routine physicals needed
for school, camp, work or similar.
K. Lab and Radiology Services. Three (3) weeks for routine appointments;
forty-eight (48) hours for urgent care.
L. Waiting Time in Office. Less than forty-five (45) minutes.
M. Initial Pediatric Appointments. Within three (3) months of enrollment.
The contractor shall attempt to contact and coordinate initial
appointments for all pediatric enrollees.
N. For dental appointments, the contractor shall be able to provide:
1. Emergency dental treatment no later than forty-eight (48) hours,
or earlier as the condition warrants, of injury to sound natural
teeth and surrounding tissue and follow-up treatment by a dental
provider.
2. Urgent care appointments within three days of referral.
3. Routine non-symptomatic appointments within thirty (30) days of
referral.
O. For MH/SA appointments, the contractor shall provide:
1. Emergency services immediately upon presentation at a service
delivery site.
2. Urgent care appointments within twenty-four (24) hours of the
request.
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3. Routine care appointments within ten (10) days of the request.
P. Maximum Number of Intermediate/Limited Patient Encounters. Four (4)
per hour for adults and four (4) per hour for children.
Q. For SSI and New Jersey Care - ABD elderly and disabled enrollees, the
contractor shall ensure that each new enrollee or, as appropriate,
authorized person is contacted to offer an Initial Visit to the
enrollee's selected PCP. Each new enrollee shall be contacted within
forty-five (45) days of enrollment and offered an appointment date
according to the needs of the enrollee, except that each enrollee who
has been identified through the enrollment process as having special
needs shall be contacted within ten (10) business days of enrollment
and offered an expedited appointment.
5.13 APPOINTMENT MONITORING PROCEDURES
A. Contractor shall monitor the adequacy of its appointment processes and
reduce the unnecessary use of alternative methods such as emergency
room visits. Contractor shall monitor and institute policies that an
enrollee's waiting time at the PCP or specialist office is no more
than forty-five (45) minutes, except when the provider is unavailable
due to an emergency. Contractor shall have written policies and
procedures, about which it educates its provider network, about
appointment time requirements. Contractor shall have established
written procedures for disseminating its appointment standards to the
network, shall monitor compliance with appointment standards, and
shall have a corrective action plan when appointment standards are not
met.
B. The contractor shall have established policies and procedures for
monitoring and evaluating appointment scheduling for all PCPs which
shall include, but is not limited to, the following:
1. A methodology for monitoring:
a. Enrollee waiting time for receipt of both urgent and routine
appointments
b. Availability of appointments
c. Providers with whom enrollees regularly experience long
waiting times
d. Broken and no-show appointments
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0. A description of the policies and procedures for addressing
appointment problems that may occur and the plan for corrective
action if any of the above-referenced items are not met.
5.14 CULTURAL AND LINGUISTIC NEEDS
The contractor shall participate in the Department's Cultural and
Linguistic Competency Task Force, and cooperate in a study to review the
provision of culturally competent services.
The contractor shall address the relationship between culture, language,
and health care outcomes through, at a minimum, the following Cultural and
Linguistic Service requirements.
A. Physical and Communication Access. The contractor shall provide
documentation regarding the availability of and access procedures for
services which ensure physical and communication access to: providers
and any contractor related services (e.g. office visits, health
fairs); customer service or physician office telephone assistance;
and, interpreter, TDD/TT services for individuals who require them in
order to communicate. Document availability of interpreter, TDD/TT
services.
B. Twenty-four (24)-Hour Interpreter Access. The contractor shall provide
Twenty-four (24)-hour access to interpreter services for all
enrollees including the deaf or hard of hearing at provider sites
within the contractor's network, either through telephone language
services or in-person interpreters to ensure that enrollees are able
to communicate with the contractor and providers and receive covered
benefits. The contractor shall identify and report the linguistic
capability of interpreters or bilingual employed and contracted staff
(clinical and non-clinical). The contractor shall provide professional
interpreters when needed where technical, medical, or treatment
information is to be discussed, or where use of a family member or
friend as interpreter is inappropriate. Family members, especially
children, should not be used as interpreters in assessments, therapy
and other situations where impartiality is critical. The contractor
shall provide for training of its health care providers on the
utilization of interpreters.
C. Interpreter Listing. Throughout the term of this contract, the
contractor shall maintain a current list of interpreter
agencies/interpreters who are "on call" to provide interpreter
services.
D. Language Threshold. In addition to interpreter services, the
contractor will provide other linguistic services to a population of
enrollees if they exceed five (5) percent of those enrolled in the
contractor's Medicaid/NJ FamilyCare line of business or two hundred
(200) enrollees in the contractor's plan, whichever is greater.
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E. The contractor shall provide the following services to the enrollee
groups identified in D above.
1. Key Points of Contact
a. Medical/Dental: Advice and urgent care telephone, face to
face encounters with providers
b. Non-medical: Enrollee assistance, orientations, and
appointments
2. Types of Services
a. Translated signage
b. Translated written materials
c. Referrals to culturally and linguistically appropriate
community services programs
F. Community Advisory Committee. Contractor shall implement and maintain
community linkages through the formation of a Community Advisory
Committee (CAC) with demonstrated participation of consumers (with
representatives of each Medicaid/NJ FamilyCare eligibility category-
See Article 5.2), community advocates, and traditional and safety net
providers. The contractor shall ensure that the committee
responsibilities include advisement on educational and operational
issues affecting groups who speak a primary language other than
English and cultural competency.
G. Group Needs Assessment. Contractor shall assess the linguistic and
cultural needs of its enrollees who speak a primary language other
than English. The findings of the assessment shall be submitted to
DMAHS in the form of a plan entitled, "Cultural and Linguistic
Services Plan" at the end of year one of the contract. In the plan,
the contractor will summarize the methodology, findings, and outline
the proposed services to be implemented, the timeline for
implementation with milestones, and the responsible individual. The
contractor shall ensure implementation of the plan within six months
after the beginning of year two of the contract. The contractor shall
also identify the individual with overall responsibility for the
activities to be conducted under the plan. The DMAHS approval of the
plan is required prior to its implementation.
H. Policies and Procedures. The contractor shall address the special
health care needs of all enrollees. The contractor shall incorporate
in its policies and procedures the values of (1) honoring enrollees'
beliefs, (2) being sensitive to cultural diversity, and (3) fostering
respect for enrollees' cultural backgrounds.
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The contractor shall have specific policy statements on these topics
and communicate them to providers and subcontractors.
I. Mainstreaming. The contractor shall be responsible for ensuring that
its network providers do not intentionally segregate DMAHS enrollees
from other persons receiving services. Examples of prohibited
practices, based on race, color, creed, religion, sex, age, national
origin, ancestry, marital status, sexual preference, income status,
program membership or physical or mental disability, include, but may
not be limited to, the following:
1. Denying or not providing to an enrollee any covered service or
access to a facility.
2. Providing to an enrollee a similar covered service in a different
manner or at a different time from that provided to other
enrollees, other public or private patients or the public at
large.
3. Subjecting an enrollee to segregation or separate treatment in
any manner related to the receipt of any covered service.
4. Assigning times or places for the provision of services.
5. Closing a provider panel to DMAHS beneficiaries but not to other
patients.
J. Resolution of Cultural Issues. The contractor shall investigate and
resolve access and cultural sensitivity issues identified by
contractor staff, State staff, providers, advocate organizations, and
enrollees.
5.15 ENROLLEE COMPLAINTS AND GRIEVANCES
5.15.1 GENERAL REQUIREMENTS
A. DMAHS Approval. The contractor shall draft and disseminate a system
and procedure which has the prior written approval of DMAHS for the
receipt and adjudication of complaints and grievances by enrollees.
The grievance policies and procedures shall be in accordance with
N.J.A.C. 8:38 et seq. and with the modifications that are incorporated
in the contract. The contractor shall not modify the grievance
procedure without the prior approval of DMAHS, and shall provide DMAHS
with a copy of the modification. The contractor's grievance procedures
shall provide for expeditious resolution of grievances by contractor
personnel at a decision-making level with authority to require
corrective action, and will have separate tracks for administrative
and utilization management grievances. (For the utilization management
complaints/grievance process, see Article 4.6.4C.)
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The contractor shall review the grievance procedure at reasonable
intervals, but no less than annually, for the purpose of amending same
as needed, with the prior written approval of the DMAHS, in order to
improve said system and procedure.
The contractor's system and procedure shall be available to both
Medicaid beneficiaries and NJ FamilyCare beneficiaries. All enrollees
have available the complaint and grievance process under the
contractor's plan, the Department of Health and Senior Services and,
for Medicaid beneficiaries, the Medicaid Fair Hearing process.
Individuals eligible solely through NJ FamilyCare Plans B, C, and D do
not have the right to a Medicaid Fair Hearing.
B. Complaints. The contractor shall have procedures for receiving,
responding to, and documenting resolution of enrollee complaints that
are received orally and are of a less serious or formal nature.
Complaints that are resolved to the enrollee's satisfaction on the day
of receipt do not require a formal written response or notification.
The contractor shall call back an enrollee within twenty-four hours of
the initial contact if the contractor is unavailable for any reason or
the matter cannot be readily resolved during the initial contact. Any
complaint that is not resolved timely shall be treated as a grievance,
in accordance with requirements defined in Article 5.15.3.
C. HBC Coordination. The contractor shall coordinate its efforts with the
health benefits coordinator including referring the enrollee to the
HBC for assistance as needed in the management of the
complaint/grievance procedures.
D. DMAHS Intervention. DMAHS shall have the right to intercede on an
enrollee's behalf at any time during the contractor's
complaint/grievance process whenever there is an indication from the
enrollee, or, where applicable, authorized person, or the HBC that a
serious quality of care issue is not being addressed timely or
appropriately. Additionally, the enrollee may be accompanied by a
representative of the enrollee's choice to any proceedings and
grievances.
E. Legal Rights. Nothing in this Article shall be construed as removing
any legal rights of enrollees under State or federal law, including
the right to file judicial actions to enforce rights.
5.15.2 NOTIFICATION TO ENROLLEES OF GRIEVANCE PROCEDURE
A. The contractor shall provide all enrollees or, where applicable, an
authorized person, upon enrollment in the contractor's plan, and
annually thereafter, pursuant to this contract, with a concise
statement of the contractor's grievance procedure and the enrollees'
rights to a hearing by the Independent Utilization Review Organization
(IURO) per NJAC 8:38-8.7 as well as their right to pursue the Medicaid
Fair Hearing process described in N.J.A.C. 10:49-10.1 et seq. The
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information shall be provided through an annual mailing, a member
handbook, or any other method approved by DMAHS. The contractor shall
prepare the information orally and/or in writing in English, Spanish,
and other bilingual translations and a format accessible to the
visually impaired, such as Braille, large print, or audio tapes.
B. Written information to enrollees regarding the grievance process shall
include at a minimum:
1. Notification that copies of written grievances will be sent to
DMAHS for monitoring
2. Identification of who is responsible for processing and reviewing
grievances
3. Information to enrollees on how to file complaints/grievances
4. Local or toll-free telephone number for filing of
complaints/grievances
5. Information on obtaining grievance forms and copies of grievance
procedures for each primary medical/dental care site
6. Expected timeframes for acknowledgment of receipt of grievances
7. Expected timeframes for disposition of grievances
8. Extensions of the grievance process if needed and time frames
9. Fair hearing procedures including the Medicaid enrollee's right
to access the Medicaid Fair Hearing process at any time to
request resolution of a grievance
10. DHSS process for use of Independent Utilization Review
Organization (IURO)
C. A description of the process under which an enrollee may appeal
denials of authorization shall include at a minimum:
1. Title of person responsible for processing appeal
2. Title of person(s) responsible for resolution of appeal
3. Time deadlines for notifying enrollee of appeal resolution
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000
0. The right to request a Medicaid Fair Hearing/DHSS IURO processes
where applicable to specific enrollee eligibility categories
5.15.3 GRIEVANCE PROCEDURES
A. Availability. The contractor's grievance procedure shall be available
to all enrollees or, where applicable, an authorized person, or permit
a provider acting on behalf of an enrollee and with the enrollee's
consent, to challenge the denials of coverage of services or denials
of payment for services. The procedure shall assure that grievances
may be filed verbally directly with the contractor.
B. The grievance procedure shall be in accordance with N.J.A.C. 8:38 et
seq.
C. DMAHS shall have the right to submit comments to the contractor
regarding the merits or suggested resolution of any grievance.
By the first and the fifteenth of every month the contractor shall
mail/fax all enrollee grievance/appeal requests directly to the DMAHS.
DMAHS will log and monitor the grievance process through each stage.
In case of verbal filing, the contractor shall submit a written
statement of the grievance to DMAHS.
By the first and the fifteenth of every month the contractor shall
send a copy to DMAHS of the dates of each stage of the
grievance/appeal process as well as its findings at each stage of the
grievances/appeals process simultaneously with notification to the
enrollee. If the contractor finds against the enrollee, the denial
shall present the enrollee's appeal rights to the contractor, as well
as the right to a Medicaid Fair Hearing (except for NJ FamilyCare
Plans B, C and D) and the right to the DHSS' IURO process.
D. Time Limits to File. The contractor may provide reasonable time limits
within which enrollees must file grievances, but such time period
shall not be less than sixty (60) days from the date of the incident
giving rise to the grievance.
5.15.4 PROCESSING GRIEVANCES
A. Staffing. The contractor shall have an adequate number of staff to
receive and assist with enrollee grievances by phone, in person and by
mail. All staff involved in the receipt, investigation and resolution
of complaints shall be trained on the contractor's policies and
procedures and shall treat all enrollees with dignity and respect.
B. Grievance Forms. If the contractor uses a grievance form, the
contractor must make available written grievance forms in the
enrollee's primary language in accordance with the multilingual
definition. Such forms shall be readily available through the
contractor upon request by telephone or in writing. The contractor
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shall mail the form within five (5) work days of receiving a telephone
or written request for a form. The contractor shall permit grievances
to be filed in writing, either on the contractor's form or in any
other written format, by fax, or verbally. For purposes of this
section the contractor may use an approved translation service to
translate grievance forms in an enrollee's primary language in order
to meet the timeframes of this contract provision. A copy of the
translated form shall be sent to DMAHS for post review.
C. Confidentiality. The contractor shall have written policies and
procedures to assure enrollee confidentiality and reasonable privacy
throughout the complaint and grievance process.
D. Non-discrimination. The contractor shall have written policies and
procedures to assure that the contractor or any provider or agent of
the contractor shall not discriminate against an enrollee or attempt
to disenroll an enrollee for filing a complaint or grievance against
the contractor.
E. Documentation. Upon receipt of a grievance, the contractor's staff
shall record the date of receipt, a written summary of the problem,
the response given, the resolution effected, if any, and the
department or staff personnel to whom the grievance has been routed.
See Article 5.15.5 for further information on records maintenance.
F. Tracking System. The contractor shall maintain a separate complaint
log as well as a grievance tracking and resolution system for
Medicaid/NJ FamilyCare enrollees. The tracking system shall
categorize complaints or grievances according to type of issue,
standardize a system for routing complaints or grievances to
operational department(s) for the dual purpose of resolving specific
complaints or grievances and for improving the contractor's operating
procedures, indicate the status and focus of each open grievance, send
all requisite notices to enrollees within the appropriate timeframe,
and log in the final resolution of each grievance. The tracking system
shall differentiate between medical/dental and administrative
complaints and grievances.
5.15.5 RECORDS MAINTENANCE
A. The contractor shall develop and maintain a separate complaint log
tracking and resolution system for Medicaid and NJ FamilyCare
enrollees for issues not requiring a formal grievance hearing. The
system shall be made accessible to the State for review.
B. A grievance log to document all verbal (telephone or in person) and
written grievances and resolutions shall be maintained. The grievance
log shall be available in the office of the contractor. The grievance
log shall include the following information:
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000
0. A log number
2. The date and time the grievance is filed with the contractor or
provider
3. The name of the enrollee filing the grievance
4. The name of the contractor, provider or staff person receiving
the grievance
5. A description of the grievance or problem
6. A description of the action taken by the contractor or provider
to investigate and resolve the grievance
7. The proposed resolution by the contractor or provider
8. The name of the contractor, provider or staff person responsible
for resolving the grievance
9. The date of notification to the enrollee of the proposed
resolution
C. The contractor shall develop and maintain policies for the following:
1. Collection and analysis of grievance data
2. Frequency of review of the grievance system
3. File maintenance
4. Protecting the anonymity of the grievant.
5.16 MARKETING
5.16.1 GENERAL PROVISIONS - CONTRACTOR'S RESPONSIBILITIES
A. The DMAHS's enrollment agent, health benefits coordinator (HBC), will
outreach and educate Medicaid and NJ FamilyCare beneficiaries (or,
where applicable, an authorized person), and assist eligible
beneficiaries (or, where applicable, an authorized person), in
selection of a MCE. Direct marketing or discussion by the contractor
to a Medicaid or NJ FamilyCare beneficiary already enrolled in another
contractor shall not be permitted; direct marketing to non-enrolled
Medicaid beneficiaries will be limited and only allowed in locations
specified by DMAHS. The duties of the HBC will include, but are not
limited to, education, enrollment, disenrollment, transfers,
assistance through the contractor's
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grievance process and other problem resolutions with the contractor,
and communications. The contractor shall cooperate with the HBC in
developing information about its plan for dissemination to Medicaid/NJ
FamilyCare beneficiaries.
1. Active face-to-face marketing is prohibited:
a. To SSI-Aged, Blind, and Disabled individuals;
b. To New Jersey Care...Special Medicaid Programs for Pregnant
Women and Children, Aged, Blind, and Disabled;
c. To DYFS-supervised individuals;
d. At County Welfare Agency offices;
e. At open areas (other than designated events); and
f. To AFDC/TANF beneficiaries and AFDC/TANF-related
beneficiaries.
2. Active face-to-face marketing will be allowed:
a. Only at times, events, and locations specified and approved
by DMAHS. Examples of permissible venues include provider
sites, health fairs, and community centers.
b. To NJ FamilyCare populations.
B. Marketing activities that shall be permitted include:
1. Media advertising limited to billboards, bus and newspaper
advertisements, posters, literature display stands, radio and
television advertising.
2. Fulfillment of potential enrollee requests to the contractor for
general information, brochure and/or provider directories that
will be mailed to the beneficiary.
C. All marketing plans, procedures, presentations, and materials shall be
accurate and shall not mislead, confuse, or defraud either the
enrollee, providers or DMAHS. If such misrepresentation occurs, the
contractor shall hold harmless the State in accordance with Article
7.33 and shall be subject to damages described in Article 7.16.
D. The contractor shall be required to submit to DMAHS for prior written
approval a complete marketing plan that adheres to DMAHS's policies
and procedures. Written or audio-visual marketing materials, e.g.,
ads, flyers, posters, announcements, and letters, and marketing
scripts, public information releases to be distributed to or prepared
for the purpose of informing Medicaid beneficiaries,
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and subsequent revisions thereto, and promotional items shall be
approved by DMAHS prior to their use. If the contractor develops new
or revised marketing materials, it shall submit them to DMAHS for
review and approval prior to any dissemination. The contractor shall
not, under any circumstances, use marketing material that has not been
approved by DMAHS.
E. The DMAHS will consult with a medical care advisory committee in the
review of pertinent marketing materials and will respond within 45
days with either an approval, denial, or request for additional
information or modifications.
F. The contractor shall distribute all approved marketing materials
throughout all enrollment areas for which it is contracted to provide
services.
G. All marketing materials that will be used by marketing agents for
every type of marketing presentation shall be prior approved by DMAHS.
The contractor shall coordinate and submit, on a quarterly basis, to
DMAHS and its agents, all of its schedules, plans, activities by month
and informational materials for community education and outreach
programs. The contractor shall work in cooperation with
community-based groups and shall participate in such activities as
health fairs and other community events. The contractor shall make
every effort to ensure that all materials and outreach provided by
them provide both physical and communication accessibility. This
outreach should go beyond traditional venues and any health fairs or
community events should be held in accessible facilities.
1. For those instances where marketing is allowed, contractors shall
submit schedules to the DMAHSAT LEAST FIVE (5) DAYS PRIOR to the
activity taking place. The schedules can be submitted in any
format, but must include the full name of the marketing
representative, the name and full address of the location where
marketing is being conducted, the date(s) and beginning and
ending times of the activity. All schedules will be reviewed and
must be approved in writing by the DMAHS. PLANS MAY NOT COMMENCE
ANY MARKETING ACTIVITY WITHOUT PRIOR DMAHS APPROVAL.
H. With the exception allowed under Article 5.16.1I, neither the
contractor nor its marketing representatives may put into effect a
plan under which compensation, reward, gift, or opportunity are
offered to eligible enrollees as an inducement to enroll in the
contractor's plan other than to offer the health care benefits from
the contractor pursuant to this contract. The contractor is prohibited
from influencing an individual's enrollment with the contractor in
conjunction with the sale of any other insurance.
I. The contractor may offer promotional give-aways that shall not exceed
a combined total of $10 to any one individual or family for marketing
purposes. Giveaways and premiums that have DMAHS approval may be
distributed at approved events. These items shall be limited to items
that promote good health
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behavior (e.g., toothbrushes, immunization schedules). For NJ
FamilyCare, other promotional items shall be considered with prior
approval by DMAHS.
J. The contractor shall ensure that marketing representatives are
appropriately trained and capable of performing marketing activities
in accordance with terms of this contract, N.J.A.C. 11:17, 11:2-11,
11:4-17, 8:38-13.2, N.J.S.A. 17:22 A-1, 26:2J-16, and the marketing
standards described in Article 5.16.
K. The contractor shall ensure that marketing representatives are versed
in and adhere to Medicaid policy regarding beneficiary enrollment and
disenrollment as stated in 42 C.F.R. Section 434.27. This policy
includes, but is not limited to, requirements that enrollees do not
experience unreasonable barriers to disenroll, and that the contractor
shall not act to discriminate on the basis of adverse health status or
greater use or need for health care services.
L. Door-to-door canvassing, telephone, telemarketing, or "cold call"
marketing of enrollment activities, by the contractor itself or an
agent or independent contractor thereof, shall not be permitted. For
NJ FamilyCare (Plans B, C, D), telemarketing shall be permitted after
review and prior approval by DMAHS of the contractor's marketing plan,
scripts and methods to use this approach.
M. Contractor employees or agents shall not present themselves
unannounced at an enrollee's home for marketing or "educational"
purposes. This shall not limit such visits for medical emergencies,
urgent medical care, clinical outreach, and health promotion for known
enrollees.
N. Under no conditions shall a contractor use DMAHS's client/enrollee
data base or a provider's patient/customer database to identify and
market its plan to Medicaid or NJ FamilyCare beneficiaries. No lists
of Medicaid/NJ FamilyCare beneficiary names, addresses, telephone
numbers, or Medicaid/NJ FamilyCare numbers of potential Medicaid/NJ
FamilyCare enrollees shall be obtained by a contractor under any
circumstances. Neither shall the contractor violate confidentiality by
sharing or selling enrollee lists or enrollee/beneficiary data with
other persons or organizations for any purpose other than performance
of the contractor's obligations pursuant to this contract. For NJ
FamilyCare marketing only, general population lists such as census
tracts are permissible for marketing outreach after review and prior
approval by DMAHS.
O. The contractor shall allow unannounced, on-site monitoring by DMAHS of
its enrollment presentations to prospective enrollees, as well as to
attend scheduled, periodic meetings between DMAHS and contractor
marketing staff to review and discuss presentation content,
procedures, and technical issues.
P. For NJ FamilyCare the contractor shall explain that all health care
benefits as specified in Article 4.1 must be obtained through a PCP.
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Q. For NJ FamilyCare the contractor shall periodically review and assess
the knowledge and performance of its marketing representatives.
R. For NJ FamilyCare the contractor shall assure culturally competent
presentations by having alternative mechanisms for disseminating
information and must receive acknowledgment of the receipt of such
information by the beneficiary.
S. Individual Medicaid beneficiaries shall be able to contact the
contractor for information, and the contractor may respond to such a
request.
T. Incentives.
1. The contractor may provide an incentive program to its enrollees
based on health/educational activities or for compliance with
health related recommendations. The incentive program may
include, but is not limited to:
a. Health related gift items
b. Gift certificates in exchange for merchandise
Cash or redeemable coupons with a cash value are prohibited.
2. The contractor's incentive program shall be proposed in writing
and prior approved by DMAHS.
U. Periodic Survey of Enrollees.
1. The contractor shall quarterly survey and report results to DMAHS
of new enrollees, in person, by phone, or other means, on a
random basis to verify the enrollees' understanding of the
contractor's procedures and services availability.
2. The contractor shall quarterly survey enrollees on reasons for
disenrollment who voluntarily disenroll/transfer at time of
disenrollment/transfer from contractor's plan.
V. All marketing materials, plans and activities shall be prior approved
by DMAHS.
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5.16.2 STANDARDS FOR MARKETING REPRESENTATIVES
A. General Requirements
1. Only a trained marketing representative of the contractor's plan
who meets the DHS, DHSS, and DBI requirements shall be permitted
to market and to enroll prospective NJ FamilyCare enrollees. All
marketing representatives shall be registered with both the
Department of Banking and Insurance (DBI) and the Division of
Medical Assistance and Health Services (DMAHS). Delegation of
enrollment functions, such as to the office staff of a
subcontracting provider of service, shall not be permitted.
2. The contractor shall submit to DMAHS no less frequently than once
a month, a listing of the contractor's marketing representatives.
Marketing schedules shall be submitted at least five days in
advance of marketing activities. Information on each marketing
representative shall include the names, three digit
Identification Numbers, and marketing locations.
3. All marketing representatives shall wear an identification tag
that has been prior approved by DMAHS with a photo identification
that must be prominently displayed when the marketing
representative is performing marketing activities. The tag shall
be at least three inches (3") by five inches (5") and shall
display the marketing representative's name, the name of the
contractor, and a three-digit identification number.
4. In those counties where enrollment is in a voluntary stage,
marketing representatives shall not state or imply that
enrollment may be made mandatory in the future in an attempt to
coerce enrollment.
5. Canvassing shall not be permitted.
6. Outbound telemarketing shall not be permitted. For NJ FamilyCare
(Plans B, C, D), telemarketing shall be permitted after review
and prior approval by DMAHS of the contractor's marketing plan,
script, and methods to use this approach.
7. Marketing in or around a County Welfare Agency (CWA) office shall
not be permitted. The term "in and around the CWA" is defined as
being in an area where the marketing representative can be seen
from the CWA office and/or where the CWA facility can be seen.
The fact that an obstructed view prohibits the marketing
activities from being seen shall not mitigate this prohibition.
8. No more than two (2) marketing representatives shall approach a
Medicaid/NJ FamilyCare beneficiary at any one time.
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000
0. Marketing representatives shall not encourage clients to
disenroll from another contractor's plan or assist an enrollee of
another MCE in completing a disenrollment form from the other
MCE.
10. Marketing representatives shall ask the prospective enrollee
about existing relationships with physicians or other health care
providers. The prospective enrollees shall be clearly informed as
to whether they will be able to continue to go to those providers
as enrollees of the contractor's plan and/or if the Medicaid
program will pay for continued services with such providers.
11. Marketing representatives shall secure the signature of new
enrollees (head of household) on a statement indicating that an
explanation has been provided to them regarding the important
points of the contractor's plan and have understood its
procedures. A parent or, where applicable, an authorized person,
shall enroll minors and sign the statement of understanding.
However, the contractor may accept an application from pregnant
minors and minors living totally on their own who have their own
Medicaid ID numbers as head of their own household.
12. Prior to approval of this contract by HCFA, the contractor's
staff or agents are prohibited from marketing to, contacting
directly or indirectly, or enrolling Medicaid beneficiaries.
13. Marketing representatives shall not state or imply that
continuation of Medicaid benefits is contingent upon enrollment
in the contractor's plan.
14. Attendance by the contractor's marketing representatives at
State-sponsored training sessions is required at the
contractor's own expense.
B. Commissions/Incentive Payments
1. Commissions/incentive payments may not be based on enrollment
numbers alone but shall include other criteria, such as but not
limited to, the retention period of enrollees enrolled (at least
three (3) months), member satisfaction, and education by the
marketing representative.
a. The contractor shall also review disenrollment
information/surveys and all complaints/grievances
specifically referencing marketing staff.
2. Marketing commissions (including cash, prizes, contests, trips,
dinners, and other incentives) shall not exceed thirty (30)
percent of the representative's monthly salary.
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C. Enrollment Inducements
1. The contractor's marketing representatives and other contractor's
staff are prohibited from offering or giving cash or any other
form of compensation to a Medicaid beneficiary as an inducement
or reward for enrolling in the contractor's plan.
2. Promotional items, gifts, "give-aways" for marketing purposes
shall be permitted, but will be limited to items that promote
good health behavior (e.g., toothbrushes, immunization
schedules). However, the combined total of such gifts or gift
package shall not exceed an amount of $10 to any one individual
or family. Such items:
a. Shall be offered to the general public for marketing
purposes whether or not an individual chooses to enroll in
the contractor's plan.
b. Shall only be given at the time of marketing presentations
and may not be a continuous, periodic activity for the same
individual, e.g., monthly or quarterly give-aways, as an
inducement to remain enrolled.
c. Shall not be in the form of cash.
For NJ FamilyCare, other promotional items shall be considered
with prior approval by DMAHS.
3. Raffles shall not be allowed.
D. Sanctions
Violations of any of the above may result in any one or combination of
the following:
1. Cessation or reduction of enrollment including auto assignment.
2. Reduction or elimination of marketing and/or community event
participation.
3. Enforced special training/re-training of marketing
representatives including, but not limited to, business ethics,
marketing policies, effective sales practices, and State
marketing policies and regulations.
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4. Referral to the Department of Banking and Insurance for review
and suspension of commercial marketing activities.
5. Application of assessed damages by the State.
6. Referral to the Secretary of the United States Department of
Health and Human Services for civil money penalties.
7. Termination of contract.
8. Referral to the New Jersey Division of Criminal Justice
Department of Justice as warranted.
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ARTICLE SIX: PROVIDER INFORMATION
6.1 GENERAL
The contractor shall provide information to all contracted providers about
the Medicaid/NJ FamilyCare managed care program in order to operate in full
compliance with the contract and all applicable federal and State
regulations. The contractor shall monitor provider knowledge and
understanding of program requirements, and take corrective actions to
ensure compliance with such requirements.
6.2 PROVIDER PUBLICATIONS
A. Provider Manual. The contractor shall issue a Provider Manual and
Bulletins or other means of provider communication to the providers of
medical/dental services. The manual and bulletins shall serve as a
source of information to providers regarding Medicaid covered
services, policies and procedures, statutes, regulations, telephone
access and special requirements to ensure all contract requirements
are being met. Alternative to provider manuals shall be prior approved
by DMAHS.
The contractor shall provide all of its providers with, at a minimum,
the following information:
1. Description of the Medicaid/NJ FamilyCare managed care program
and covered populations
2. Scope of Benefits
3. Modifications to Scope of Benefits
4. Emergency Services Responsibilities, including responsibility to
educate enrollees regarding the appropriate use of emergency
services
5. EPSDT program services and standards
6. Grievance procedures for both enrollee and provider
7. Medical necessity standards as well as practice guidelines or
other criteria that will be used in making medical necessity
decisions. Medical necessity decisions must be in accordance with
the definition in Article 1 and based on peer-reviewed
publications, expert medical opinion, and medical community
acceptance.
8. Practice protocols/guidelines, including in particular guidelines
pertaining to treatment of chronic/complex conditions common to
the enrolled
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populations if utilized by the contractor to monitor and/or
evaluate provider performance. Practice guidelines may be
included in a separate document.
9. The contractor's policies and procedures
10. PCP responsibilities
11. Other provider/subcontractors' responsibilities
12. Prior authorization and referral procedures
13. Description of the mechanism by which a provider can appeal a
contractor's service decision through the DHSS' Independent
Utilization Review Organization process
14. Protocol for encounter data element reporting/records
15. Procedures for screening and referrals for the MH/SA services
16. Medical records standards
17. Payment policies
B. Bulletins. The contractor shall develop and disseminate bulletins as
needed to incorporate any and all changes to the Provider Manual. All
bulletins shall be mailed to the State at least three (3) calendar
days prior to publication or mailing to the providers or as soon as
feasible. The Department shall have the right to issue and/or modify
the bulletins at any time. If the DHS determines that there are
factual errors or misleading information, the contractor shall be
required to issue corrected information in the manner determined by
the DHS.
C. Timeframes. Within twenty (20) calendar days after the contractor
places a newly enrolled provider in an active status, the contractor
shall furnish the provider with a current Provider Manual, all related
bulletins and the contractor's methodology for supplying encounter
data.
D. The contractor shall provide a Provider Manual to the Department. All
updates of the manual shall also be provided to the Department on a
timely basis.
E. The Provider Manual and all policies and procedures shall be reviewed
at least annually to ensure that the contractor's current practices
and contract requirements are reflected in the written policies and
procedures.
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6.3 PROVIDER EDUCATION AND TRAINING
A. Initial Training. The contractor shall ensure that all providers
receive sufficient training regarding the managed care program in
order to operate in full compliance with program standards and all
applicable federal and State regulations. At a minimum, all providers
shall receive initial training in managed care services, the
contractor's policies and procedures, and information about the needs
of enrollees with special needs. Ongoing training shall be provided as
deemed necessary by either the contractor or the State in order to
ensure compliance with program standards.
Subjects for provider training shall be tailored to the needs of the
contractor's plan's target groups. Listed below are some examples of
topics for training:
1. Identification and management of polypharmacy.
2. Identification and treatment of depression among elderly people
and people with disabilities.
3. Identification and treatment of alcohol/substance abuse.
4. Identification of abuse and neglect.
5. Coordination of care with long-term services, mental health and
substance abuse providers, including instruction regarding
policies and procedures for maintaining the centralized member
record.
6. Skills to assist elderly people and people with disabilities in
coping with loss.
7. Cultural sensitivity to providing health care to various ethnic
groups.
B. Ongoing Training. The contractor shall continue to provide
communications and guidance for PCPs, specialty providers, and others
about the health care needs of enrollees with special needs and xxxxxx
cultural sensitivity to the diverse populations enrolled with the
contractor.
6.4 PROVIDER TELEPHONE ACCESS
A. The contractor shall maintain a mechanism by which providers can
access the contractor by telephone. The contractor shall maintain
policies and procedures for staffing and training the allocated
personnel, including the hours of operation, days of the week and
numbers of personnel available, and the telephone number to the
providers. Telephone access to the contractor shall be available to
providers, at a minimum, from 8:00 a.m. to 5:00 p.m., Monday through
Friday.
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B. Response time. The contractor shall respond to after hours telephone
calls regarding medical care within the following timeframes: fifteen
(15) minutes for crisis situations; forty-five (45) minutes for
non-emergent, symptomatic issues; same day for non-symptomatic
concerns.
C. At no time shall providers wait more than five (5) minutes on hold.
6.5 PROVIDER GRIEVANCES AND APPEALS
A. Payment Disputes. The contractor shall establish and utilize a
procedure to resolve billing, payment, and other administrative
disputes between health care providers and the contractor for any
reason including, but not limited to: lost or incomplete claim forms
or electronic submissions; requests for additional explanation as to
services or treatment rendered by a health care provider;
inappropriate or unapproved referrals initiated by the providers; or
any other reason for billing disputes. The procedure shall include an
appeal process and require direct communication between the provider
and the contractor and shall not require any action by the enrollee.
B. Complaint, Grievances and Appeal. The contractor shall establish and
maintain provider complaint, grievance and appeals procedures for any
provider who is not satisfied with the contractor's policies and
procedures, or with a decision made by the contractor, or disagrees
with the contractor as to whether a service, supply, or procedure is a
covered benefit, is medically necessary, or is performed in the
appropriate setting. The contractor procedure shall satisfy the
following minimum standards:
1. The contractor shall have in place an informal complaint process
which network providers can use to make verbal complaints, to ask
questions, and get problems resolved without going through the
formal, written grievance process.
2. The contractor shall have in place a formal grievance and appeal
process which network providers and non-participating providers
can use to complain in writing.
3. Such procedures shall not be applicable to any disputes that may
arise between the contractor and any provider regarding the
terms, conditions, or termination or any other matter arising
under contract between the provider and contractor.
C. The contractor shall log, track and respond to provider complaints and
grievances.
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D. The contractor shall submit quarterly a Provider Grievances/Complaints
Report. All provider grievances shall be summarized, with actions and
recommendations of the Medical or Dental Director and QA Committee (if
involved) clearly stated. The summary report shall include, but not be
limited to, the following data elements:
1. Total number of all provider grievances and complaints received
2. Number of unresolved (pending) grievances and complaints
3. Category of the grievance or complaint, including, but not
limited to:
a. Denials of requested services prior authorizations
b. Denials of specialty referrals
c. Enrollee allocation inequities
E. The contractor shall notify providers of the mechanism to appeal a
contractor service decision on behalf of an enrollee, with the
enrollee's consent, through the DHSS' Independent Utilization Review
Organization process and that the provider is not entitled to request
a Medicaid administrative law hearing.
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ARTICLE SEVEN: TERMS AND CONDITIONS (ENTIRE CONTRACT)
7.1 CONTRACT COMPONENTS
The Contract, Attachments, Schedules, Appendices, Exhibits, and any
amendments determine the work required of the contractor and the terms and
conditions under which said work shall be performed.
No other contract, oral or otherwise, regarding the subject matter of this
contract shall be deemed to exist or to bind any of the parties or vary any
of the terms contained in this contract.
7.2 GENERAL PROVISIONS
A. HCFA Approval. This contract is subject to approval by the Health Care
Financing Administration (HCFA) and shall not be effective absent such
approval. In addition, this contract is subject to HCFA's grant of a
1915(b) waiver to mandate enrollment of children with special health
care needs.
B. General. The contractor agrees that it shall carry out its obligations
as herein provided in a manner prescribed under applicable federal and
State laws, regulations, codes, and guidelines including New Jersey
licensing regulations, the Medicaid, NJ KidCare and NJ FamilyCare
State Plans, and in accordance with procedures and requirements as may
from time to time be promulgated by the United States Department of
Health and Human Services. These include:
1. 42 U.S.C. -> 1396 et seq.
2. 42 C.F.R., Parts 417, 434, 440, 455, 1000
3. 45 C.F.R., Part 74
4. N.J.S.A. 30:4D-1 et seq.
5. N.J.S.A. 30:4I-1 et seq.
6. N.J.S.A. 30:4J-1 et seq.
7. N.J.S.A. 26:2J-1 et seq.
8. N.J.A.C. 10:74 et seq.
9. N.J.A.C. 10:49 et seq.
10. N.J.A.C. 10:79 et seq.
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11. New Jersey Medicaid, NJ KidCare, and NJ FamilyCare State Plans
12. 1915(b) Waiver
13. N.J.A.C. 8:38 et seq. and amendments thereof, and the contractor
shall comply with the higher standard contained in N.J.A.C. 8:38
et seq. or this contract.
14. N.J.S.A. 59:13 et seq.
15. The federal and State laws and regulations above have been cited
for reader ease. They are available for review at the New Jersey
State Library, 000 Xxxx Xxxxx Xxxxxx, Xxxxxxx, Xxx Xxxxxx 00000.
However, whether cited or not, the contractor is obligated to
comply with all applicable laws and regulations and, in turn, is
responsible for ensuring that its providers and subcontractors
comply with all laws and regulations.
16. Neither the contractor nor its employees, providers, or
subcontractors shall violate, or induce others to violate, any
federal or state laws or regulations, or professional licensing
board regulations.
C. Applicable Law and Venue. This contract and any and all litigation
arising there from or related thereto shall be governed by the
applicable laws, regulations, and rules of evidence of the State of
New Jersey without reference to conflict of laws principles. The
contractor shall agree and submit to the jurisdiction of the courts of
the State of New Jersey should any dispute concerning this contract
arise, and shall agree that venue for any legal proceeding against the
State shall be in Xxxxxx County.
D. Medicaid Provider. The contractor shall be a Medicaid provider and a
health maintenance organization with a Certificate of Authority to
operate government programs in New Jersey.
E. Significant Changes. The contractor shall report to the Contracting
Officer(See Article 7.5) immediately all significant changes that may
affect the contractor's performance under this contract.
F. Provider Enrollment Process. The contractor shall comply with the
Medicaid provider enrollment process including the submission of the
HCFA 1513 Form.
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G. Conflicts in Provisions. The contractor shall advise DMAHS of any
conflict of any provision of this contract with any federal or State
law or regulation. The contractor is required to comply with the
provisions of the federal or State law or regulation until such time
as the contract may be amended. (See also Article 7.11.)
Any provision of this contract that is in conflict with the above
laws, regulations, or federal Medicaid statutes, regulations, or HCFA
policy guidance is hereby amended to conform to the provisions of
those laws, regulations, and federal policy. Such amendment of the
contract shall be effective on the effective date of the statutes or
regulations necessitating it and will be binding on the parties even
though such amendment may not have been reduced to writing and
formally agreed upon and executed by the parties.
H. Compliance with Codes. The contractor shall comply with the
requirements of the New Jersey Uniform Commercial Code, the latest
National Electrical Code, the Building Officials & Code Administrators
International, Inc. (B.O.C.A.) Basic Building Code, and the
Occupational Safety and Health Administration to the extent applicable
to the contract.
I. Corporate Authority. All New Jersey corporations shall obtain a
Certificate of Incorporation from the Office of the New Jersey
Secretary of State prior to conducting business in the State of New
Jersey.
If a contractor is a corporation incorporated in a state other than
New Jersey, the contractor shall obtain a Certificate of Authority to
do business from the Office of the Secretary of State of New Jersey
prior to execution of the contract. The contractor shall provide
either a certification or notification of filing with the Secretary of
State.
If the contractor is an individual, partnership or joint venture not
residing in this State or a partnership organized under the laws of
another state, then the contractor shall execute a power of attorney
designating the Secretary of State as his true and lawful attorney for
the sole purpose of receiving process in any civil action which may
arise out of the performance of this contract or agreement. This
appointment of the Secretary of State shall be irrevocable and binding
upon the contractor, his heirs, executors, administrators, successors
or assigns. Within ten (10) days of receipt of this service, the
Secretary of State shall forward same to the contractor at the address
designated in the contract.
J. Contractor's Warranty. By signing this contract, the contractor
warrants and represents that no person or selling agency has been
employed or retained to solicit or secure the contract upon an
agreement or understanding for a commission, percentage, brokerage or
contingent fee, except bona fide employees or bona fide established
commercial or selling agencies maintained by the
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contractor for the purpose of securing business. The penalty for
breach or violation of this provision may result in termination of the
contract without the State being liable for damages, costs and/or
attorney fees or, in the Department's discretion, a deduction from the
contract price or consideration the full amount of such commission,
percentage, brokerage or contingent fee.
X. XxxXxxxx Principles. The contractor shall comply with the XxxXxxxx
principles of nondiscrimination in employment and have no business
operations in Northern Ireland as set forth in N.J.S.A. 52:34-12.1.
L. Ownership of Documents. All documents and records, regardless of form,
prepared by the contractor in fulfillment of the contract shall be
submitted to the State and shall become the property of the State.
M. Publicity. Publicity and/or public announcements pertaining to the
project shall be approved by the State prior to release. See Article
5.16 regarding Marketing.
N. Taxes. Contractor shall maintain, and produce to the Department upon
request, proof that all appropriate federal and State taxes are paid.
7.3 STAFFING
In addition to complying with the specific administrative requirements
specified in Articles Two through Six and Eight, the contractor shall
adhere to the standards delineated below.
A. The contractor shall have in place the organization, management and
administrative systems necessary to fulfill all contractual
arrangements. The contractor shall demonstrate to DMAHS' satisfaction
that it has the necessary staffing, by function and qualifications, to
fulfill its obligations under this contract which include at a
minimum:
- A designated administrative liaison for the Medicaid contract who
shall be the main point of contact responsible for coordinating
all administrative activities for this contract ("Contractor's
Representative"; See also Article 7.5 below)
- A medical director who shall be a New Jersey licensed physician
(M.D. or D.O.)
- Financial officer(s) or accounting and budgeting officer
- QM/UR coordinator who is a New Jersey-licensed registered nurse
or physician
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- Prior authorization staff sufficient to authorize medical care
twenty-four (24) hours per day/seven (7) days per week
- Designated Medicaid care manager(s) who shall be available to
DMAHS medical staff to respond to medically related problems,
complaints, and emergent or urgent situations
- A full-time Care Management Supervisor who is a New
Jersey-licensed physician or has a Bachelor's degree in nursing
and has a minimum of four (4) years of experience serving
enrollees with special needs. The Care Management Supervisor
shall be responsible for the management and supervision of the
Care Management staff.
- Member services staff
- Provider services staff
- Encounter reporting staff/claims processors
- Grievance coordinator
- Adequate administrative and support staff
B. Staff Changes. The contractor shall inform the DMAHS, in writing,
within seven (7) days of key administrative staffing changes (listed
in A) in any of the positions noted in this Article.
C. Training. The contractor shall ensure that all staff have appropriate
training, education, experience, and orientation to fulfill the
requirements of the positions they hold and shall verify and document
that it has met this requirement.
D. DMAHS Meetings. The contractor's CEO, president, or DHS-approved
representative shall be required to attend DHS-sponsored contractor
CEO dinners. No substitutes will be permitted. The Contractor's
Representative, as hereinafter defined, shall be required to attend
DHS-sponsored contractor Roundtable sessions.
7.4 RELATIONSHIPS WITH DEBARRED OR SUSPENDED PERSONS PROHIBITED
Pursuant to Section 1932(d)(a) of the Social Security Act (42
U.S.C.->1396u-2(d)(a)):
A. The contractor shall not have a director, officer, partner, or person
with beneficial ownership of more than five (5) percent of the
contractor's equity who has been debarred or suspended from
participating in procurement activities under the
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Federal Acquisition Regulation or from participating in nonprocurement
activities under regulations issued pursuant to Executive Order No.
12549 or under guidelines implementing such order.
B. The contractor shall not have an employment, consulting, or any other
agreement with a debarred or suspended person (as defined in Article
7.4A above) for the provision of items or services that are
significant and material to the contractor's contractual obligation
with the State.
C. The contractor shall certify to DMAHS that it meets the requirements
of this Article prior to initial contracting with the Department and
at any time there is a changed circumstance from the last such
certification. The contractor shall, among other sources, consult with
the Excluded Parties List, which can be obtained from the General
Services Administration.
D. If the contractor is found to be non-compliant with the provisions
concerning affiliation with suspended or debarred individuals, DMAHS:
1. Shall notify the Secretary of the US Department of Health and
Human Services of such non-compliance;
2. May continue the existing contract with the contractor unless the
Secretary (in consultation with the Inspector General of the US
Department of Health and Human Services [DHHS]) directs
otherwise; and
3. May not renew or otherwise extend the duration of an existing
contract with the contractor unless the Secretary (in
consultation with the Inspector General of the DHHS) provides to
DMAHS and to Congress a written statement describing compelling
reasons that exist for renewing or extending the contract.
E. The contractor shall agree and certify it does not employ or contract,
directly or indirectly, with:
1. Any individual or entity excluded from Medicaid participation
under Sections 1128 (42 U.S.C.->1320a-7) or 1128A (42
U.S.C.->1320a-7a) of the Social Security Act 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 as being controlled by a
sanctioned individual;
2. Any entity for the provision of such services (directly or
indirectly) through an excluded individual or entity;
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3. Any individual or entity excluded from Medicaid or NJ FamilyCare
participation by DMAHS;
4. Any individual or entity discharged or suspended from doing
business with the State of New Jersey; or
5. Any entity that has a contractual relationship (direct or
indirect) with an individual convicted of certain crimes as
described in Section 1128(b)(8) of the Social Security Act.
F. The contractor shall obtain, whenever issued, available State listings
and notices of providers, their contractors, subcontractors, or any of
the aforementioned individuals or entities, or their owners, officers,
employees, or associates who are suspended, debarred, disqualified,
terminated, or otherwise excluded from practice and/or participation
in the fee-for-service Medicaid program. Upon verification of such
suspension, debarment, disqualification, termination, or other
exclusion, the contractor shall immediately act to terminate the
provider from participation in this program. Termination for loss of
licensure, criminal convictions, or any other reason shall coincide
with the effective date of termination of licensure or the Medicaid
program's termination effective date whichever is earlier.
7.5 CONTRACTING OFFICER AND CONTRACTOR'S REPRESENTATIVE
A. The Department shall designate a single administrator, hereafter
called the "Contracting Officer." The Contracting Officer shall be
appointed by the Commissioner of DHS. The Contracting Officer shall
make all determinations and take all actions as are appropriate under
this contract, subject to the limitations of applicable federal and
New Jersey laws and regulations. The Contracting Officer may delegate
his/her authority to act to an authorized representative through
written notice to the contractor.
B. The contractor shall designate a single administrator, hereafter
called the Contractor's Representative, who shall be an employee of
the contractor. The Contractor's Representative shall make all
determinations and take all actions as are appropriate to implement
this contract, subject to the limitations of the contract, and to
federal and New Jersey laws and regulations. The Contractor's
Representative may delegate his or her authority to act to an
authorized representative through written notice to the Contracting
Officer. The Contractor's Representative shall have direct managerial
and administrative responsibility and control over all aspects of the
contract and shall be empowered to legally bind the contractor to all
agreements reached with the Department.
C. The Contractor's Representative shall be designated in writing by the
contractor no later than the first day on which the contract becomes
effective.
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D. The Department shall have the right to approve or disapprove the
Contractor's Representative.
7.6 AUTHORITY OF THE STATE
The State is the ultimate authority under this contract to:
A. Establish, define, or determine the reasonableness, the necessity and
the level and scope of covered benefits under the managed care program
administered in this contract or coverage for such benefits, or the
eligibility of enrollees or providers to participate in the managed
care program, or any aspect of reimbursement to providers, or of
operations.
B. Establish or interpret policy and its application related to the
above.
7.7 EQUAL OPPORTUNITY EMPLOYER
The contractor shall, in all solicitations or advertisements for employees
placed by or on behalf of the contractor, state that it is an equal
opportunity employer, and shall send to each labor union or representative
of workers with which it has a collective bargaining agreement or other
contract or understanding, a notice to be provided by the Department
advising the labor union or workers' representative of the contractor's
commitments as an equal opportunity employer and shall post copies of the
notice in conspicuous places available to employees and applicants for
employment.
7.8 NONDISCRIMINATION REQUIREMENTS
The contractor shall comply with the following requirements regarding
nondiscrimination:
A. The contractor shall and shall require its providers and
subcontractors to accept assignment of an enrollee and not
discriminate against eligible enrollees because of race, color, creed,
religion, ancestry, marital status, sexual orientation, national
origin, age, sex, physical or mental handicap in accordance with Title
VI of the Civil Rights Act of 1964, 42 U.S.C.->2000d, Section 504 of
the Rehabilitation Act of 1973, 29 U.S.C. ->794, the Americans with
Disabilities Act of 1990 (ADA), 42 U.S.C.->12131 and rules and
regulations promulgated pursuant thereto, or as otherwise provided by
law or regulation.
B. ADA Compliance. The contractor shall and shall require its providers
or subcontractor to comply with the requirements of the Americans with
Disabilities Act (ADA). In providing health care benefits, the
contractor shall not directly or indirectly, through contractual,
licensing, or other arrangements, discriminate against Medicaid/NJ
FamilyCare beneficiaries who are qualified disabled
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individuals covered by the provisions of the ADA (See also Article
4.5.2 for a description of the contractor's ADA compliance plan).
A "qualified individual with a disability" defined pursuant to 42
U.S.C.->12131 is an individual with a disability who, with or without
reasonable modifications to rules, policies, or practices, the removal
of architectural, communication, or transportation barriers, or the
provision of auxiliary aids and services, meets the essential
eligibility requirements for the receipt of services or the
participation in programs or activities provided by a public entity
(42 U.S.C.->12131).
The contractor shall submit to DMAHS a written certification that it
is conversant with the requirements of the ADA, that it is in
compliance with the law, and that it has assessed its provider network
and certifies that the providers meet ADA requirements to the best of
the contractor's knowledge. The contractor shall survey its providers
of their compliance with the ADA using a standard survey document that
will be developed by the State. Survey attestation shall be kept on
file by the contractor and shall be available for inspection by the
DMAHS. The contractor warrants that it will hold the State harmless
and indemnify the State from any liability which may be imposed upon
the State as a result of any failure of the contractor to be in
compliance with the ADA. Where applicable, the contractor shall abide
by the provisions of Section 504 of the federal Rehabilitation Act of
1973, as amended, 29 U.S.C.->794, regarding access to programs and
facilities by people with disabilities.
C. The contractor shall and shall require its providers and
subcontractors to not discriminate against eligible persons or
enrollees on the basis of their health or mental health history,
health or mental health status, their need for health care services,
amount payable to the contractor on the basis of the eligible person's
actuarial class, or pre-existing medical/health conditions.
D. The contractor shall and shall require its providers and
subcontractors to comply with the Civil Rights Act of 1964 (42
U.S.C.->2000d), the regulations (45 C.F.R. Parts 80 & 84) pursuant to
that Act, and the provisions of Executive Order 11246, Equal
Opportunity, dated September 24, 1965, the New Jersey
anti-discrimination laws including those contained within N.J.S.A.
10:2-1 through N.J.S.A. 10:2-4, N.J.S.A. 10:5-1 et seq. and N.J.S.A.
10:5-38, and all rules and regulations issued thereunder, and any
other laws, regulations, or orders which prohibit discrimination on
grounds of age, race, ethnicity, mental or physical disability, sexual
or affectional orientation or preference, marital status, genetic
information, source of payment, sex, color, creed, religion, or
national origin or ancestry. The contractor shall not discriminate
against any employee engaged in the work required to produce the
services covered by this contract, or against any applicant for such
employment because of race, creed, color, national origin, age,
ancestry, sex, marital status, religion, disability or sexual or
affectional orientation or preference.
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E. The contractor shall not discriminate with respect to participation,
reimbursement, or indemnification as to any provider who is acting
within the scope of the provider's license or certification under
applicable State law, solely on the basis of such license or
certification. This paragraph shall not be construed to prohibit an
organization from including providers only to the extent necessary to
meet the needs of the organization's enrollees or from establishing
any measure designed to maintain quality and control costs consistent
with the responsibilities of the organization.
F. Scope. This non-discrimination provision shall apply to but not be
limited to the following: recruitment or recruitment advertising,
hiring, employment upgrading, demotion, or transfer, lay-off or
termination, rates of pay or other forms of compensation, and
selection for training, including apprenticeship included in PL 1975,
Chapter 127 as attached hereto and made a part hereof.
G. Grievances. The contractor shall forward to the Department copies of
all grievances alleging discrimination against enrollees because of
race, color, creed, sex, religion, age, national origin, ancestry,
marital status, sexual or affectional orientation, physical or mental
handicap for review and appropriate action within three (3) business
days of receipt by the contractor.
7.9 INSPECTION RIGHTS
The contractor shall allow the New Jersey Department of Human Services, the
US Department of Health and Human Services (DHHS), and other authorized
State agencies, or their duly authorized representatives, to inspect or
otherwise evaluate the quality, appropriateness, and timeliness of services
performed under the contract, and to inspect, evaluate, and audit any and
all books, records, and facilities maintained by the contractor and its
providers and subcontractors, pertaining to such services, at any time
during normal business hours (and after business hours when deemed
necessary by DHS or DHHS) at a New Jersey site designated by the
Contracting Officer. Pursuant to N.J.S.A. 10:49-9.8m inspections of
contractors may be unannounced with or without cause, and inspections of
providers and subcontractors may be unannounced for cause. Books and
records include, but are not limited to, all physical records originated or
prepared pursuant to the performance under this contract, including working
papers, reports, financial records and books of account, medical records,
dental records, prescription files, provider contracts and subcontracts,
credentialing files, and any other documentation pertaining to medical,
dental, and nonmedical services to enrollees. Upon request, at any time
during the period of this contract, the contractor shall furnish any such
record, or copy thereof, to the Department or the Department's External
Review Organization within thirty (30) days of the request. If the
Department determines, however, that there is an urgent need to obtain a
record, the Department shall have the right to demand the record in less
than thirty (30) days, but no less than twenty-four (24) hours.
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Access shall be undertaken in such a manner as to not unduly delay the work
of the contractor and/or its provider(s) or subcontractor(s). The right of
access herein shall include onsite visits by authorized designees of the
State.
The contractor shall also permit the State, at its sole discretion, to
conduct onsite inspections of facilities maintained by the contractor, its
providers and subcontractors, prior to approval of their use for providing
services to enrollees.
7.10 NOTICES/CONTRACT COMMUNICATION
All notices or contract communication under this contract shall be in
writing and shall be validly and sufficiently served by the State upon the
contractor, and vice versa, if addressed and mailed by certified mail,
delivered by overnight courier or hand-delivered to the following
addresses:
For DHS:
Contracting Officer
Division of Medical Assistance and Health Services
X.X. Xxx 000
Xxxxxxx, XX 00000-0000
The contractor shall specify the name of the Contractor's Representative
and official mailing address for all formal communications. The name and
address of the individual appears in Appendix D.6 and is incorporated
herein by reference.
7.11 TERM
7.11.1 CONTRACT DURATION AND EFFECTIVE DATE
The performance, duties, and obligations of the parties hereto shall
commence on the effective date, provided that at the effective date the
Director and the contractor agree that all procedures necessary to
implement this contract are ready and shall continue for a period of nine
(9) months thereafter unless suspended or terminated in accordance with the
provisions of this contract. The initial nine (9) month period shall be
known as the "original term" of the contract. The effective date of the
contract shall be October 1, 2000.
7.11.2 AMENDMENT, EXTENSION, AND MODIFICATION
A. The contract may be amended, extended, or modified by written contract
duly executed by the Director and the contractor. Any such amendment,
extension or modification shall be in writing and executed by the
parties hereto. It is mutually understood and agreed that no amendment
of the terms of the contract shall be valid unless reduced to writing
and executed by the parties hereto, and that no oral
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understandings, representations or contracts not incorporated herein
nor any oral alteration or variations of the terms hereof, shall be
binding on the parties hereto. Every such amendment, extension, or
modification shall specify the date its provisions shall be effective
as agreed to by the Department and the contractor. Any amendment,
extension, or modification is not effective or binding unless
approved, in writing, by duly authorized officials of DHS, HCFA, and
any other entity, as required by law or regulation.
B. This contract may be extended for successive twelve (12) month periods
beyond the original term of the contract whenever the Division
supplies the contractor with at least ninety (90) days advance notice
of such intent and if a written amendment to extend the contract is
obtained from both parties. This successive twelve (12) month period
shall be known as an "extension period" of the contract. In addition,
ninety (90) days prior to the contract expiration, the Director shall
provide the contractor with the proposed capitation rates for the
extension period.
C. In the event that the capitation rates for the extension period are
not provided ninety (90) days prior to the contract expiration, the
contract will be extended at the existing rate which shall be an
interim rate. After the execution of the succeeding rate amendment, a
retroactive rate adjustment will be made to bring the interim rate to
the level established by that amendment.
D. The contractor shall begin providing services to all populations
covered under this contract on October 1, 2000. The State shall pay
the contractor the capitation rates set forth in Appendix C, except
for the following premium groups:
1. DDD With Medicare
2. DDD Without Medicare (ABD)
3. DDD Without Medicare (non-ABD)
4. AIDS - ABD With Medicare
5. AIDS & DDD - ABD With Medicare
6. AFDC - AIDS
7. AFDC - AIDS & DDD
8. Blind/Disabled With Medicare, less than 45 M & F
9. Blind/Disabled With Medicare, 45+ M & F
For those enrollees who are members of the contractor's plan as of
October 1, 2000 and who are subsequently identified by the State as
members of one of the above premium groups, the State may initially
pay the contractor the following capitation rates:
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PREMIUM GROUP INTERIM RATE
------------- ------------
DDD With Medicare Aged with Medicare
DDD Without Medicare (ABD) ABD (including AIDS) Without Medicare
DDD Without Medicare (non-ABD) ABD (including AIDS) Without Medicare
AIDS - ABD With Medicare ABD (including AIDS) Without Medicare
AIDS & DDD - ABD With ABD (including AIDS) Without
Medicare Medicare
AFDC - AIDS ABD (including AIDS) Without Medicare
AFDC - AIDS & DDD ABD (including AIDS) Without Medicare
Blind/Disabled With Medicare, Aged With Medicare
less than 45 M & F
Blind/Disabled With Medicare, 45+ Aged With Medicare
M & F
The State shall retroactively adjust these payments to reflect the
premium rate for these enrollees.
E. Nothing in this Article shall be construed to prevent the Director by
amendment to the contract from extending the contract on a month to
month basis under the existing rates until such a time that the
Director provides revised capitation rates pursuant to Article
7.11.2B.
7.12 TERMINATION
A. Change of Circumstances. Where circumstances and/or the needs of the
State significantly change or the contract is otherwise deemed by the
Director to no longer be in the public interest, the DMAHS may
terminate this contract upon no less than thirty (30) days notice to
the contractor.
B. Emergency Situations. In cases of emergency the Department may shorten
the time periods of notification.
C. For Cause. DMAHS shall have the right to terminate this contract,
without liability to the State, in whole or in part if the contractor:
1. Takes any action or fails to prevent an action that threatens the
health, safety or welfare of any enrollee, including significant
marketing abuses;
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2. Takes any action that threatens the fiscal integrity of the
Medicaid program;
3. Has its certification suspended or revoked by DOBI, DHSS, and/or
any federal agency or is federally debarred or excluded from
federal procurement and non-procurement contracts;
4. Materially breaches this contract or fails to comply with any
term or condition of this contract that is not cured within
twenty (20) working days of DMAHS' request for compliance;
5. Violates state or federal law;
6. Becomes insolvent; or
7. Brings a proceeding voluntarily, or has a proceeding brought
against it involuntarily, under the Bankruptcy Act.
D. Notice and Hearing. Except as provided in A and B above, DMAHS shall
give the contractor ninety (90) days advance, written notice of
termination of this contract, with an opportunity to protest said
termination and/or request an informal hearing. This notice shall
specify the applicable provisions of this contract and the effective
date of termination, which shall not be less than will permit an
orderly disenrollment of enrollees to the Medicaid fee-for-service
program or transfer to another managed care program.
E. Contractor's Right to Terminate for Material Breach. The contractor
shall have the right to terminate this contract in the event that
DMAHS materially breaches this contract or fails to comply with any
material term or condition of this contract that is not cured within
twenty (20) working days of the contractor's request for compliance.
In such event, the contractor shall give DMAHS written notice
specifying the reason for and the effective date of the termination,
which shall not be less than will permit an orderly disenrollment of
enrollees to the Medicaid fee-for-service program or transfer to
another managed care program and in no event shall be less than ninety
(90) days from the end of the twenty (20) day working day cure period.
The effective date of termination is subject to DMAHS concurrence and
approval.
F. Contractor's Right to Terminate for Act of God. The contractor shall
have the right to terminate this contract if the contractor is unable
to provide services pursuant to this contract because of a natural
disaster and/or an Act of God to such a degree that enrollees cannot
obtain reasonable access to services within the contractor's
organization, and, after diligent efforts, the contractor cannot make
other provisions for the delivery of such services. The contractor
shall give
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DMAHS, within forty-five (45) days after the disaster, written notice
of any such termination that specifies:
1. The reasons for the termination, with appropriate documentation
of the circumstances arising from a natural disaster or Act of
God that precludes reasonable access to services;
2. The contractor's attempts to make other provisions for the
delivery of services; and
3. The requested effective date of the termination, which shall not
be less time than will permit an orderly disenrollment of
enrollees to the Medicaid fee-for-service program or transfer to
another managed care program. The effective date of termination
is subject to DMAHS concurrence and approval.
G. Reduction in Funding. In the event that State and federal funding for
the payment of services under this contract is reduced so that
payments to the contractor cannot be made in full, this contract shall
terminate, without liability to the State, unless both parties agree
to a modification of the obligations under this contract. The
effective date of such termination shall be ninety (90) days after the
contractor receives written notice of the reduction in payment, unless
available funds are insufficient to continue payments in full during
the ninety (90) day period, in which case the Department shall give
the contractor written notice of the earlier date upon which the
contract shall terminate.
H. It is hereby understood and agreed by both parties that this contract
shall be effective and payments by DMAHS made to the contractor
subject to the availability of State and federal funds. It is further
agreed by both parties that this contract can be renegotiated or
terminated, without liability to the State in order to comply with
state and federal requirements for the purpose of maximizing federal
financial participation.
I. Upon termination of this contract, the contractor shall comply with
the closeout procedures in Article 7.13.
J. Rights and Remedies. The rights and remedies of the Department
provided in this Article shall not be exclusive and are in addition to
all other rights and remedies provided by law or under this contract.
7.13 CLOSEOUT REQUIREMENTS
A. A closeout period shall begin one hundred-twenty (120) days prior to
the last day the contractor is responsible for operating under this
contract. During the closeout period, the contractor shall work
cooperatively with, and supply program
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information to, any subsequent contractor and DMAHS. Both the program
information and the working relationships between the two contractors
shall be defined by DMAHS.
B. The contractor shall be responsible for the provision of necessary
information and records, whether a part of the MCMIS or compiled
and/or stored elsewhere, to the new contractor and/or DMAHS during the
closeout period to ensure a smooth transition of responsibility. The
new contractor and/or DMAHS shall define the information required
during this period and the time frames for submission. Information
that shall be required includes but is not limited to:
1. Numbers and status of complaints and grievances in process;
2. Numbers and status of hospital authorizations in process, listed
by hospital;
3. Daily hospital logs;
4. Prior authorizations approved and disapproved;
5. Program exceptions approved;
6. Medical cost ratio data;
7. Payment of all outstanding obligations for medical care rendered
to enrollees;
8. All encounter data required by this contract; and
9. Information on beneficiaries in treatment plans who will require
continuity of care consideration.
C. All data and information provided by the contractor shall be
accompanied by letters, signed by the responsible authority,
certifying to the accuracy and completeness of the materials supplied.
The contractor shall transmit the information and records required
under this Article within the time frames required by the Department.
The Department shall have the right, in its sole discretion, to
require updates to these data at regular intervals.
D. The new contractor shall reimburse any reasonable costs associated
with the contractor providing the required information or as mutually
agreed upon by the two contractors. The contractor shall not charge
more than a cost mutually agreed upon by the contractor and DMAHS or
as mutually agreed upon by the two contractors. If program operations
are transferred to DMAHS, no such fees shall
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be charged by the contractor nor paid by DMAHS. Under no circumstances
shall a Medicaid beneficiary be billed for any record transfer.
E. The contractor shall continue to be responsible for provider and
enrollee toll free numbers and after-hours calls until the last day of
the closeout period. The new contractor shall bear financial
responsibility for costs incurred in modifying the toll free number
telephone system. The contractor shall, in good faith, negotiate a
contract with the new contractor to coordinate/transfer the toll free
number responsibilities, and will provide space at the contractor's
current business address including access to necessary records, and
information for the new contractor during a due diligence review
period.
F. Effective two (2) weeks prior to the last day of the closeout period,
the contractor shall work cooperatively with the new contractor to
process service authorization requests received. The contractor shall
be financially responsible for approved requests when the service is
provided on or before the last day of the closeout period or if the
service is provided through the data of discharge or thirty-one (31)
days after the cancellation or termination of this contract for
enrollees who remain hospitalized after the last day of the transition
period. Disputes between the contractor and the new contractor
regarding service authorizations shall be resolved by DMAHS.
G. The contractor shall continue to provide all required reports during
the closeout period.
H. Runout Requirements - General. Runout for this Managed Care Contract
shall consist of the processing, payment and monetary
reconciliation(s) necessary regarding all enrollees, claims for
payment from the contractor's provider network, appeals by both
providers and/or enrollees, and final reports which identify all
expenditures, up to and including the last month of capitated payment
made to the contractor.
I. The contractor shall complete the processing and payment of claims
generated during the life of the contract.
J. Runout Requirements - Items of Concern.
1. Information and documentation that the Department deems necessary
under this Article, to effect a smooth Turnover to a successor
contractor, shall be required to be submitted on a monthly basis.
The Department shall have the right to require updates to this
data at regular intervals.
2. Any other information or data, within the parameters of this
Managed Care Contract, deemed necessary by the Department to
assist in the reprocurement of the contract including where
applicable, but not limited
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to, duplicate copies of x-rays, charting and lab reports, and
copies of actual documents and supporting documentation, etc.,
relevant to access, quality of care, and enrollee history shall
be provided to DMAHS.
K. Runout Requirements - Final Transition. During the final forty-five
(45) days before the end of the closeout period, the terminating and
successor contractors shall share operational responsibilities, as
delineated below:
1. Record Sharing. The contractor shall make available and/or
require its providers to make available to the Department copies
of medical/dental records, patient files, and any other pertinent
information, including information maintained by any
subcontractor or sub-subcontractor, necessary for efficient care
management of enrollees, as determined by the Director. Under no
circumstances shall a Medicaid enrollee be billed for this
service.
2. Enrollee Notification. The terminating and successor contractors
shall notify enrollees of the pending transition, with all
notices to be submitted to DMAHS for review and approval before
mail out.
L. Post-Operations Period. The post-operations period shall begin at
12:00 a.m. the day after the last day of the closeout period. During
the post-operations period, the contractor shall no longer be
responsible for the operation of the program. Obligations of the
contractor under this contract that are applicable to the post-
operations period will apply whether or not they are enumerated in
this Article.
1. The contractor shall maintain local telephone access for
providers during the first six (6) months of the post-operations
period.
2. The contractor shall be financially responsible for the
resolution of beneficiary complaints and grievances timely filed
prior to the last day of the post-operations period.
3. The contractor shall have a continuing obligation to provide any
required reports during the closeout and post-operations periods.
4. The contractor shall refill prescriptions to cover a minimum of
ten (10) days beyond the contract termination date, unless other
arrangements are made with the receiving contractor and approved
by DMAHS.
5. The contractor shall provide DME for a minimum of the first
thirty (30) days of the post-operations period, unless other
arrangements are made with the receiving contractor and approved
by DMAHS.
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a. Customized DME is considered to belong to the enrollee and
stays with the enrollee when there is a change of
contractors.
b. Non-customized DME may be reclaimed by the contractor when
the enrollee no longer requires the equipment if a system is
in place for refurbishing and reissuing the equipment. If no
such system is in place, the non-customized DME shall be
considered the property of the enrollee.
6. The contractor shall, within sixty days after the end of the
closeout period, account for and return any and all funds
advanced by the Department for coverage of enrollees for periods
subsequent to the effective date of post-operations.
7. The contractor shall submit to the Department within ninety (90)
days after the end of the closeout period an annual report for
the period through which services are rendered, and a final
financial statement and audit report including at a minimum,
revenue and expense statements relating to this contract, and a
complete financial statement relating to the overall lines of
business of the contractor prepared by a Certified Public
Accountant or a licensed public accountant.
M. In the event of termination of the contract by DMAHS, such termination
shall not affect the obligation of contractor to indemnify DMAHS for
any claim by any third party against the State or DMAHS arising from
contractor's performance of this contract and for which contractor
would otherwise be liable under this contract.
7.14 MERGER/ACQUISITION REQUIREMENTS
A. General Information. In addition to any other information otherwise
required by the State, a contractor that intends to merge with or be
acquired by another entity ("non-surviving contractor") shall provide
the following information and documents to DHS, and copies to DHSS and
DOBI, one hundred-twenty (120) days prior to the effective date of the
merger/acquisition:
1. The basic details of the sale, including the name of the
acquiring legal entity, the date of the sale and a list of all
owners with five (5) percent or more ownership.
2. The source of funds for the purchase.
3. A Certificate of Authority modification.
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4. Any changes in the provider network, including but not limited to
a comparison of hospitals that no longer will be available under
the new network, and comparison of PCPs and specialists
participating and not participating in both HMOs.
5. Submit a draft of the asset purchase agreement to DHS, DHSS, and
DOBI for prior approval prior to execution of the document.
6. The closing date for the merger/acquisition, which shall occur
prior to the required notification to enrollees, i.e. no later
than forty-five (45) days prior to effective date of transition
of enrollees.
7. Submit a copy of all information, including all financials, sent
to/required by DHSS and DOBI.
B. General Requirements. The non-surviving contractor shall:
1. Comply with the provisions of Article 7.13, Closeout; and
2. Meet and complete all outstanding issues, reporting requirements
(including but not limited to encounter data reporting, quality
assurance studies, financial reports, etc.)
C. Medicaid Beneficiary Notification. By no later than sixty (60) days,
the non-surviving contractor shall prepare and submit, in English and
Spanish, to the DMAHS, letters and other materials which shall be
mailed to its enrollees no later than forty-five (45) days prior to
the effective date of transfer in order to assist them in making an
informed decision about their health and needs. Separate notices shall
be prepared for mandatory populations and voluntary populations. The
letter should contain the following, at a minimum:
1. From the non-surviving contractor:
a. The basic details of the sale, including the name of the
acquiring legal entity, and the date of the sale.
b. Any major changes in the provider network, including at
minimum a comparison of hospitals that no longer will be
available under the network, if that is the case.
c. For each enrollee, a representation whether that
individual's primary care provider under the non-surviving
contractor's plan will be available under the acquiring
contractor's plan. When the PCP is no longer available under
the acquiring contractor's plan,
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the enrollee shall be advised to call the HBC to see what
other MCE the PCP participates in.
d. In those cases where a primary dentist is selected under the
non-surviving contractor's plan, a representation whether
each individual's primary dentist under the non-surviving
contractor's plan will be available under the acquiring
contractor's plan.
e. Information on beneficiaries in treatment plans and the
status of any continuing medical care being rendered under
the non-surviving contractor's plan, how that treatment
will continue, and time frames for transition from the
non-surviving contractor's plan to the acquiring
contractor's plan.
f. Any changes in the benefits/procedures between the
non-surviving contractor's plan and the acquiring
contractor's plan, including for example, eye care and
glasses benefits, over-the-counter drugs, and referral
procedures, etc.
g. Toll free telephone numbers for the HBC and the acquiring
entity where enrollees' questions can be answered.
h. A time frame of not less than two weeks (fourteen days) for
the beneficiary to make a decision about staying in the
acquiring contractor's plan, or switching to another MCE
(for mandatory beneficiaries). The time frame should
incorporate the monthly cut-off dates established by the
DMAHS and the HBC for the timely and accurate production of
Medicaid identification cards.
i. For voluntary populations, the letter should indicate the
option to revert to the fee-for-service system.
2. From the acquiring contractor:
a. If the acquiring contractor wishes to send welcoming
letters, it shall submit for prior approval to DMAHS, all
welcoming letters and information it will send to the new
enrollees no later than thirty (30) days prior to the
effective date of transfer.
b. The acquiring contractor may not, either directly or
indirectly, contact the enrollees of the non-surviving
contractor, prior to the enrollees conversion (approximately
ten (10) days prior to the effective date of transfer).
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Any returned mail should be re-sent two additional times. If
the mail to a beneficiary is returned three times, the name,
the Medicaid identification number and last know address
should be submitted to the DMAHS for research to determine a
more current address.
D. Provider Notification. By no later than ninety (90) days prior to the
effective date of transfer, the non-surviving contractor shall notify
its providers of the pending sale or merger, and of hospitals,
specialists and laboratories that will no longer be participating as a
result of the merger/acquisition.
E. Marketing/Outreach.
1. The acquiring contractor may not make any unsolicited home visits
or telephone calls to enrollees of the non-surviving contractor,
before the effective date of coverage under the acquiring
contractor's plan.
2. Coincident with the date that enrollee notification letters are
sent to those enrollees affected by the merger/acquisition, the
non-surviving contractor shall no longer be offered as an option
to either new enrollees or to those seeking to transfer from
other plans. DMAHS shall approve all enrollee notification
letters, and they shall be mailed by the non-surviving
contractor. Marketing by the non-surviving contractor shall also
cease on that date.
F. Provider Network. The acquiring contractor shall supply the DMAHS and
the HBC with an updated provider network fifty (50) days prior to the
effective date of transfer on a diskette formatted in accordance with
the procedures set forth in Section A.4.1 of the Appendices.
Additionally, the acquiring contractor shall furnish to the DMAHS
individual provider capacity analyses and how the provider/enrollee
ratio limits will be maintained in the new entity. This network
information shall be furnished before the enrollee notification
letters are to be sent. Such letters shall not be mailed until there
is a clear written notification by the DMAHS that the provider network
information meets all of the DMAHS requirements. The network
submission shall include all required provider types listed in Article
4, shall be formatted in accordance with specifications in Article 4
and Section A.4.1 of the Appendices, and shall include a list of all
providers who decline participation with the acquiring contractor and
new providers who will participate with the acquiring contractor. The
acquiring contractor shall submit weekly updates through the ninety
(90) day period following the effective date of transfer.
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G. Administrative.
1. The non-surviving contractor shall inform DMAHS of the corporate
structure it will assume once all enrollees are transitioned to
the acquiring contractor. Additionally, an indication of the time
frame that this entity will continue to exist shall be provided.
2. The contract of the non-surviving contractor is not terminated
until the transaction (acquisition or merger) is approved,
enrollees are placed, and all outstanding issues with DOBI, DHSS,
and DHS are resolved. Some infrastructure shall exist for up to
one year beyond the last date of services to enrollees in order
to fulfill remaining contractual requirements.
3. The acquiring contractor and the non-surviving contractor shall
maintain their own separate administrative structure and staff
until the effective date of transfer.
7.15 SANCTIONS
In the event DMAHS finds the contractor to be out-of-compliance with
program standards, performance standards or the terms or conditions of this
contract, the Department shall issue a written notice of deficiency,
request a corrective action plan and/or specify the manner and timeframe in
which the deficiency is to be cured. If the contractor fails to cure the
deficiency as ordered, the Department shall have the right to exercise any
of the administrative sanction options described below, in addition to any
other rights and remedies that may be available to the Department. The type
of action taken shall be in relation to the nature and severity of the
deficiency:
A. Suspend enrollment of beneficiaries in contractor's plan.
B. Notify enrollees of contractor non-performance and permit enrollees to
transfer to another MCE.
C. Reduce or eliminate marketing and/or community event participation.
D. Terminate the contract, under the provisions of the preceding Article.
E. Cease auto-assignment of new enrollees.
F. Refuse to renew the contract.
G. Impose and maintain temporary management in accordance with
Section 1932(e)(2) of the Social Security Act during the period in
which improvements are made to correct violations.
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H. In the case of inappropriate marketing activities, referral may also
be made to the Department of Banking and Insurance for review and
appropriate enforcement action.
I. Require special training or retraining of marketing representatives
including, but not limited to, business ethics, marketing policies,
effective sales practices, and State marketing policies and
regulations, at the contractor's expense.
J. In the event the contractor becomes financially impaired to the point
of threatening the ability of the State to obtain the services
provided for under the contract, ceases to conduct business in the
normal course, makes a general assignment for the benefit of
creditors, or suffers or permits the appointment of a receiver for its
business or its assets, the State may, at its option, immediately
terminate this contract effective the close of business on the date
specified.
K. Refuse to consider for future contracting a contractor that fails to
submit encounter data on a timely and accurate basis.
L. Refer the matter to the US Department of Justice, the US Attorney's
Office, the New Jersey Division of Criminal Justice, and/or the New
Jersey Division of Law as warranted.
M. Refer the matter to the applicable federal agencies for civil money
penalties.
N. Refer the matter to the New Jersey Division of Civil Rights where
applicable.
O. Exclude the contractor from participation in the Medicaid program.
P. Refer the matter to the New Jersey Division of Consumer Affairs.
The contractor may appeal the imposition of sanctions or damages in
accordance with Article 7.18.
7.16 LIQUIDATED DAMAGES PROVISIONS
7.16.1 GENERAL PROVISIONS
It is agreed by the contractor that:
A. If contractor does not provide or perform the requirements referred to
or listed in this provision, damage to the State may result.
B. Proving such damages shall be costly, difficult, and time-consuming.
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C. Should the State choose to impose liquidated damages, the contractor
shall pay the State those damages for not providing or performing the
specified requirements; if damages are imposed, collection shall be
from the date the State placed the contractor on notice or as may be
specified in the written notice.
D. Additional damages may occur in specified areas by prolonged periods
in which contractor does not provide or perform requirements.
E. The damage figures listed below represent a good faith effort to
quantify the range of harm that could reasonably be anticipated at the
time of the making of the contract.
F. The Department may, at its discretion, withhold capitation payments in
whole or in part, or offset with advanced notice liquidated damages
from capitation payments owed to the contractor.
G. The DHS shall have the right to deny payment or recover reimbursement
for those services or deliverables which have not been performed and
which due to circumstances caused by the contractor cannot be
performed or if performed would be of no value to the State. Denial of
the amount of payment shall be reasonably related to the amount of
work or deliverable lost to the State.
H. The DHS shall have the right to recover incorrect payments to the
contractor due to omission, error, fraud or abuse, or defalcation by
the contractor. Recovery to be made by deduction from subsequent
payments under this contract or other contracts between the State and
the contractor, or by the State as a debt due to the State or
otherwise as provided by law.
I. Whenever the State determines that the contractor failed to provide
one (1) or more of the medically necessary covered contract services,
the State shall have the right to withhold a portion of the
contractor's capitation payments for the following month or subsequent
months, such portion withheld to be equal to the amount of money the
State shall pay to provide such services along with administrative
costs of making such payment. Any other harm to the State or the
beneficiary/enrollee shall be calculated and applied as a damage. The
contractor shall be given written notice prior to the withholding of
any capitation payment.
J. The contractor shall submit a written corrective action plan for any
deficiency identified by the Department in writing within five (5)
business days from the date of receipt of the Department's
notification or within a time determined by the Department depending
on the nature of the issue. For each day beyond that time that the
Department has not received an acceptable corrective action plan,
monetary damages in the amount of one hundred dollars ($100) per day
for five (5) days and two hundred fifty ($250) per day thereafter will
be deducted from the capitation payment to the contractor. The
contractor shall implement the
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corrective action plan immediately from time of Department
notification of the original problem pending approval of the final
corrective action plan. The damages shall be applied for failure to
implement the corrective action plan from the date of original State
notification of the problem. Corrective action plans apply to each of
the areas in this Article for potential liquidated damages and the
time period allowed shall be at the sole discretion of the DMAHS.
K. Self-Reporting of Failures and Noncompliance. Any monetary damages
that otherwise would be assessed pursuant to this Article of this
contract, may be reduced, at the State's option, if the contractor
reports the failure or noncompliance in written detail to DMAHS prior
to notice of the noncompliance from the Department. The amount of the
reduction shall be no more than ninety (90) percent of the total value
of the monetary damages.
L. Nothing in this provision shall be construed as relieving the
contractor from performing any other contract duty not listed herein,
nor is the State's right to enforce or to seek other remedies for
failure to perform any other contract duty hereby diminished.
7.16.2 MANAGED CARE OPERATIONS, TERMS AND CONDITIONS, AND PAYMENT PROVISIONS
During the life of the contract, the contractor shall provide or perform
each of the requirements as stated in the contract.
Except as provided for elsewhere in this Article (i.e., the other
liquidated damages provisions in this Article take precedence), for each
and every contractor requirement not provided or performed as scheduled, or
if a requirement is provided or performed inaccurately or incompletely, the
Department, if it intends to impose liquidated damages, shall notify the
contractor in writing that the requirement was not provided or performed as
specified and that liquidated damages will be assessed accordingly.
The contractor shall have fifteen (15) business days from the date of such
written notice from the Department, or longer if the Department so allows,
or through a corrective action plan approved by DHS to provide or perform
the requirement as specified.
Liquidated Damages:
If the contractor does not provide or perform the requirement within
fifteen (15) business days of the written notice, or longer if allowed by
the Department, or through an approved corrective action plan, the
Department may impose liquidated damages of $250 per requirement per day
for each day the requirement continues not to be provided or performed. If
after fifteen (15) additional days from the date the Department imposes
liquidated damages, the requirement still has not been provided or
performed, the
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Department, after written notice to the contractor, may increase the
liquidated damages to $500 per requirement per day for each day the
requirement continues to be unprovided or unperformed.
7.16.3 TIMELY REPORTING REQUIREMENTS
The contractor shall produce and deliver timely reports within the
specified timeframes and descriptions in the contract including information
required by the ERO. Reports shall be produced and delivered on both a
scheduled and mutually agreed upon on-request basis according to the
schedule established by DMAHS.
Liquidated Damages:
For each late report, the Department shall have the right to impose
liquidated damages of $250 per day per report until the report is provided.
For any late report that is not delivered after thirty (30) days or such
longer period as the Department shall allow, the Department, after written
notice, shall have the right to increase the liquidated damages assessment
to $500 per day per report until the report is provided.
7.16.4 ACCURATE REPORTING REQUIREMENTS
Every report due the State shall contain sufficient and accurate
information and in the approved media format to fulfill the State's purpose
for which the report was generated.
If the Department imposes liquidated damages, it shall give the contractor
written notice of a report that is either insufficient or inaccurate and
that liquidated damages will be assessed accordingly. After such notice,
the contractor shall have fifteen (15) business days, or such longer period
as the Department may allow, to correct the report.
Encounter data shall be accurate and complete, i.e., have no missing
encounters or required data elements.
Liquidated Damages:
If the contractor fails to correct the report within the fifteen (15)
business days, or such longer period as the Department may allow, the
Department shall have the right to impose liquidated damages of $250 per
day per report until the corrected report is delivered. If the report
remains uncorrected for more than thirty (30) days from the date liquidated
damages are imposed, the Department, after written notice, shall have the
right to increase the liquidated damages assessment to $500 per day per
report until the report is corrected.
An amount of $1 may be assessed for each missing or omitted encounter. In
addition, $1 per encounter or encounter data element may be assessed for
any pending encounter or error that is not corrected and returned to DMAHS
within thirty (30) days after
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notification by DMAHS that the data are incomplete or incorrect. The
Department shall have the right to calculate the total number of missing or
omitted encounters and encounter data by extrapolating from a sample of
missing or omitted encounters and encounter data.
7.16.5 TIMELY PAYMENTS TO MEDICAL PROVIDERS
The contractor shall process claims in accordance with New Jersey laws and
regulations and shall be subject to damages pursuant to such laws and
regulations. In addition, pursuant to this contract the Department may
assess liquidated damages if the contractor does not process (pay or deny)
claims within the following timeframes: ninety (90) percent of all claims
(the totality of claims received whether contested or uncontested)
submitted electronically by medical providers within thirty (30) days of
receipt; ninety (90) percent of all claims filed manually within forty (40)
days of receipt; ninety-nine (99) percent of all claims, whether submitted
electronically or manually, within sixty (60) days of receipt; and one
hundred (100) percent of all claims within ninety (90) days of receipt.
Claims processed for providers under investigation for fraud or abuse and
claims suppressed pursuant to Article 8.9 (regarding PIPs) are not subject
to these requirements.
The amount of time required to process a paid claim shall be computed in
days by comparing the initial date of receipt with the check mailing date.
The amount of time required to process a denied claim (whether all or part
of the claim is denied) shall be computed in days by comparing the date of
initial receipt with the denial notice mailing date. Claims processed
during the quarter shall be reported in required categories through the
Claims Lag report (See Section A.7.6 of the Appendices (Table 4A and B)).
Table 4A shall be used to report claims submitted manually and Table 4B
shall be used to report claims submitted electronically.
Liquidated Damages:
Liquidated damages may be assessed if the contractor does not meet the
above requirements on a quarterly basis. Based on the contractor-reported
information on the claims lag reports, the Department shall determine for
each time period (thirty (30)/forty (40), sixty (60), and ninety (90) days)
the actual percentage of claims processed (electronic and manual claims
shall be added together). This number shall be subtracted from the
percentage of claims the contractor should have processed in the particular
time period. The difference shall be expressed in points. For example, if
the contractor only processed eighty-eight (88) percent of electronic
claims within thirty (30) days and eighty-eight (88) percent of manual
claims within forty (40) days, it shall be considered to be two (2) points
short for that time period. The points that the contractor is short for
each of the three time periods shall be added together. This sum shall then
be multiplied times .0004 times the Medicaid capitation payments received
by the contractor during the quarter at issue to arrive at the liquidated
damages amount.
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No offset shall be given if a criterion is exceeded. DMAHS reserves the
right to audit and/or request detail and validation of reported
information. DMAHS shall have the right to accept or reject the
contractor's report and may substitute reports created by DMAHS if
contractor fails to submit reports or the contractor's reports are
found to be unacceptable.
7.16.6 CONDITIONS FOR TERMINATION OF LIQUIDATED DAMAGES
Except as waived by the Contracting Officer, no liquidated damages
imposed on the contractor shall be terminated or suspended until the
contractor issues a written notice of correction to the Contracting
Officer certifying the correction of condition(s) for which liquidated
damages were imposed and until all contractor corrections have been
subjected to system testing or other verification at the discretion of
the Contracting Officer. Liquidated damages shall cease on the day of
the contractor's certification only if subsequent testing of the
correction establishes that, indeed, the correction has been made in
the manner and at the time certified to by the contractor.
A. The contractor shall provide the necessary system time to
system test any correction the Contracting Officer deems
necessary.
B. The Contracting Officer shall determine whether the necessary
level of documentation has been submitted to verify
corrections. The Contracting Officer shall be the sole judge
of the sufficiency and accuracy of any documentation.
C. System corrections shall be sustained for a reasonable period
of at least ninety (90) days from State acceptance; otherwise,
liquidated damages may be reimposed without a succeeding grace
period within which to correct.
D. Contractor use of resources to correct deficiencies shall not
be allowed to cause other system problems.
7.16.7 EPSDT PERFORMANCE STANDARDS
A. The contractor shall ensure that it has achieved a fifty (50)
percent participation rate for the first twelve (12)-month
contract period. Participation rates for subsequent years
shall be established and incorporated into the contract for
future years. "Participation" is defined as one initial or
periodicity visit and will be measured using encounter data.
If the contractor has not achieved the fifty (50) percent
participation rate by the end of the first contract year, it
shall submit a corrective action plan to DMAHS within thirty
(30) days of notification by DMAHS of its actual participation
rate. DMAHS shall have the right to conduct a follow-up onsite
review and/or impose financial damages for non-compliance.
Failure of the contractor to achieve the minimum screening
rate shall require the following refund of capitation paid:
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1. Achievement of a 25 percent to less than 50 percent
EPSDT and lead screenings, dental visits and
immunization rate (the lowest measured rate of each
of the components of EPSDT screening, i.e., periodic
exam, immunization rate, lead screening rate, and
dental screening rate, shall be considered to be the
rate for EPSDT participation and the basis for the
sanction): refund of $10 per enrollee for all
enrollees under age 21 times the most current average
length of enrollment in years of enrollees under age
21.
2. Achievement of less than 25 percent: refund of $25
per enrollee for all enrollees under age 21 times the
most current average length of enrollment in years of
enrollees under 21.
B. Failure to achieve and maintain the required screening rate
shall result in the Local Health Departments being permitted
to screen the contractor's pediatric members. The cost of
these screenings shall be paid by the DMAHS to the LHD, and
the screening cost shall be deducted from the contractor's
capitation rate in addition to the damages imposed as a result
of failure to achieve EPSDT performance standards.
7.16.8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CIVIL MONEY PENALTIES
7.16.8.1 FEDERAL STATUTES
Pursuant to 42 U.S.C. Section 1396b(m)(5)(A), the Secretary of the
Department of Health and Human Services may impose substantial monetary
and/or criminal penalties on the contractor when the contractor:
A. Fails to substantially provide an enrollee with required
medically necessary items and services, required under law or
under contract to be provided to an enrolled beneficiary, and
the failure has adversely affected the enrollee or has
substantial likelihood of adversely affecting the enrollees.
B. Imposes premiums or charges on enrollees in violation of this
contract, which provides that no premiums, deductibles,
co-payments or fees of any kind may be charged to Medicaid
enrollees.
C. Engages in any practice that discriminates among enrollees on
the basis of their health status or requirements for health
care services by expulsion or refusal to re-enroll an
individual or engaging in any practice that would reasonably
be expected to have the effect of denying or discouraging
enrollment by eligible persons whose medical condition or
history indicates a need for substantial future medical
services.
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D. Misrepresents or falsifies information that is furnished to 1)
the Secretary, 2) the State, or 3) to any person or entity.
E. Fails to comply with the requirements for physician incentive
plans found in 42 U.S.C. Section 1876(i)(8), Section B.7.1 of
the Appendices, and at 42 C.F.R. Section 417.479, or fails to
submit to the Division its physician incentive plans as
required or requested in 42 C.F.R. Section 434.70.
7.16.8.2 FEDERAL PENALTIES
A. The Secretary may provide, in addition to any other remedies
available under the law, for any of the following remedies:
1. Civil money penalties of not more than $25,000 for
each determination above; or,
with respect to a determination under Article
7.16.8.1C or 1D, above, of not more than $100,000 for
each such determination; plus,
with respect to a determination under Article
7.16.8.1B above, double the amount charged in
violation of such Article (and the excess amount
charged shall be deducted from the penalty and
returned to the individual concerned); and the
Secretary may seek criminal penalties; and plus,
with respect to a determination under Article
7.16.8.1C above, $15,000 for each individual not
enrolled as a result of a practice described in such
Article.
2. Suspension of enrollment of individuals after the
date the Secretary notifies the Division of a
determination to assess damages as described in
Article 7.16.8.2A above, and until the Secretary is
satisfied that the basis for such determination has
been corrected and is not likely to recur, or
3. Suspension of payment to the contractor for
individuals enrolled after the date the Secretary
notifies the Division of a determination under
Article 7.16.8.2A above and until the Secretary is
satisfied that the basis for such determination has
been corrected and is not likely to recur.
B. The contractor shall be responsible to pay any costs incurred
by the State as a result of the Secretary denying payment to
the State under 42 U.S.C. Section 1396(m)(5)(B)(ii). The State
shall have the right to offset such costs from amounts
otherwise due to the contractor.
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C. Determination by the Division/Secretary regarding the amount
of the penalty and assessment for failure to comply with
physician incentive plans shall be in accordance with 42
C.F.R. Section 1003.106, i.e., the extent to which the failure
to provide medically necessary services could be attributed to
a prohibited inducement to reduce or limit services under a
physician incentive plan and the harm to the enrollee which
resulted or could have resulted from such failure. It would be
considered an aggravating factor if the contracting
organization knowingly or routinely engaged in any prohibited
practice which acted as an inducement to reduce or limit
medically necessary services provided with respect to a
specific enrollee in the contractor's plan.
7.17 STATE SANCTIONS
DMAHS shall have the right to impose any of the sanctions and damages
authorized or required by N.J.S.A. 30:4D-1 et seq., N.J.A.C. 10:49-1 et
seq., or federal statute or regulation against the contractor or its
providers or subcontractors pursuant to this contract. The DMAHS shall
have the right to withhold and/or offset any payments otherwise due to
the contractor pursuant to such sanctions and damages.
7.18 APPEAL PROCESS
In order to appeal the DMAHS imposition of any sanctions or damages,
the contractor shall request review by and submit supporting
documentation first to the Executive Director, Office of Managed Health
Care (OMHC), within twenty (20) days of receipt of notice. The
Executive Director, OMHC, shall issue a response within thirty (30)
days of receipt of the contractor's submissions. Thereafter, the
contractor may obtain a second review by the Director by filing the
request for review with supporting documentation and copy of the
Executive Director's decision within twenty (20) days of the
contractor's receipt of the Executive Director's decision. The
imposition of sanctions and damages is not automatically stayed pending
appeal. Pending final determination of any dispute hereunder, the
contractor shall proceed diligently with the performance of this
contract and in accordance with the Contracting Officer's direction.
7.19 ASSIGNMENTS
The contractor shall not, without the Department's prior written
approval, assign, delegate, transfer, convey, sublet, or otherwise
dispose of this contract; of the contractor's administrative or
management operations/service under this contract; of the contractor's
right, title, interest, obligations or duties under this contract; of
the contractor's power to execute the contract; or, by power of
attorney or otherwise, of any of the contractor's rights to receive
monies due or to become due under this contract. The contractor shall
retain obligations and responsibilities as stated under this contract
or under state or federal law or regulations.
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All requests shall be submitted in writing, including all
documentation, contracts, agreements, etc., at least 90 days prior to
the anticipated implementation date, to DMAHS for prior approval. DMAHS
approval shall also be contingent on regulatory agency review and
approval. Any assignment, transfer, conveyance, sublease, or other
disposition without the Department's consent shall be void and subject
this contract to immediate termination by the Department without
liability to the State of New Jersey.
7.20 CONTRACTOR CERTIFICATIONS
7.20.1 GENERAL PROVISIONS
With respect to any report, invoice, record, papers, documents, books
of account, or other contract-required data submitted to the Department
in support of an invoice or documents submitted to meet contract
requirements, including, but not limited to, proofs of insurance and
bonding, Lobbying Certifications and Disclosures, Conflict of Interest
Disclosure Statements and/or Conflict of Interest Avoidance Plans,
pursuant to the requirements of this contract, the Contractor's
Representative or his/her designee shall certify that the report,
invoice, record, papers, documents, books of account or other contract
required data is current, accurate, complete and in full compliance
with legal and contractual requirements to the best of that
individual's knowledge and belief.
7.20.2 CERTIFICATION SUBMISSIONS
Where in this contract there is a requirement that the contractor
"certify" or submit a "certification," such certification shall be in
the form of an affidavit or declaration under penalty of perjury dated
and signed by the Contractor's Representative or his/her designee.
7.20.3 ENVIRONMENTAL COMPLIANCE
The contractor shall comply with all applicable environmental laws,
rules, directives, standards, orders, or requirements, including but
not limited to, Section 306 of the Clean Air Act (42 U.S.C. Section
1857(h)), Section 508 of the Clean Water Act (33 U.S.C. Section 1368),
Executive Order 11738, and the Environmental Protection Agency (EPA)
regulations (40 C.F.R., Part 15) that prohibit the use of the
facilities included on the EPA List of Violating Facilities.
7.20.4 ENERGY CONSERVATION
The contractor shall comply with any applicable mandatory standards and
policies relating to energy efficiency that are contained in the state
energy conservation plan issued in compliance with the Energy Policy
and Conservation Act of 1975 (Public L. 94-165) and any amendments to
the Act.
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7.20.5 INDEPENDENT CAPACITY OF CONTRACTOR
The parties agree that the contractor is an independent contractor, and
that the contractor, its agents, officers, and employees act in an
independent capacity and not as officers or employees or agents of the
State, the Department or any other government entity.
7.20.6 NO THIRD PARTY BENEFICIARIES
Nothing in this contract is intended or shall confer upon anyone, other
than the parties hereto, any legal or equitable right, remedy or claim
against any of the parties hereto.
7.20.7 PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING
A. The contractor agrees, pursuant to 31 U.S.C. Section 1352 and
45 C.F.R. Part 93, that no federal appropriated funds have
been paid or will be paid to any person by or on behalf of the
contractor for the purpose of influencing or attempting to
influence an officer or employee of any agency, a member of
Congress, an officer or employee of Congress, or an employee
of a member of Congress in connection with the award of any
federal contract, the making of any federal grant, the making
of any federal loan, the entering into of any cooperative
contract, or the extension, continuation, renewal, amendment,
or modification of any federal contract, grant loan, or
cooperative contract. The contractor shall complete and submit
the "Certification Regarding Lobbying", as attached in Section
A.7.1 of the Appendices.
B. If any funds other than federal appropriated funds have been
paid or will be paid by the contractor to any person for the
purpose of influencing or attempting to influence an officer
or employee of any agency, a member of Congress, an officer or
employee of Congress, or an employee of a member of Congress
in connection with the award of any federal contract, the
making of any federal grant, the making of any federal loan,
the entering into of any cooperative contract, or the
extension, continuation, renewal, amendment, or modification
of any federal contract, grant, loan, or cooperative contract,
and the contract exceeds $100,000, the contractor shall
complete and submit Standard Form LLL-"Disclosure of Lobbying
Activities" in accordance with its instructions.
C. The contractor shall include the provisions of this Article in
all provider and subcontractor contracts under this contract
and require all participating providers or subcontractors
whose contracts exceed $100,000 to certify and disclose
accordingly to the contractor.
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7.21 REQUIRED CERTIFICATE OF AUTHORITY
During the term of the contract, the contractor shall maintain a
Certificate of Authority (COA) from the Department of Health and Senior
Services and the Department of Banking and Insurance and function as a
Health Maintenance Organization in each of the counties in the
region(s) it is contracted to serve or for each of the counties as
approved in accordance with Article 2.H.
7.22 SUBCONTRACTS
In carrying out the terms of the contract, the contractor may elect to
enter into subcontracts with other entities for the provision of health
care services and/or administrative services as defined in Article 1.
In doing so, the contractor shall, at a minimum, be responsible for
adhering to the following criteria and procedures.
A. All subcontracts shall be in writing and shall be submitted to
DMAHS for prior approval at least 90 days prior to the
anticipated implementation date. DMAHS approval shall also be
contingent on regulatory agency review and approval.
B. The Department shall prior approve all provider contracts and
all subcontracts.
C. All provider contracts and all subcontracts shall include
the terms in Section B.7.2 of the Appendices, Provider/
Subcontractor Contract Provisions.
D. The contractor shall monitor the performance of its
subcontractors on an ongoing basis and ensure that performance
is consistent with the contract between the contractor and the
Department.
E. Unless otherwise provided by law, contractor shall not cede or
otherwise transfer some or all financial risk of the
contractor to a subcontractor.
7.23 SET-OFF FOR STATE TAXES AND CHILD SUPPORT
Pursuant to N.J.S.A 54:49-19, if the contractor is entitled to payment
under the contract at the same time as it is indebted for any State tax
(or is otherwise indebted to the State) or child support, the State
Treasurer may set off payment by the amount of the indebtedness.
7.24 CLAIMS
The contractor shall have the right to request an informal hearing
regarding disputes under this contract by the Director, or the designee
thereof. This shall not in any way limit the contractor's or State's
right to any remedy pursuant to New Jersey law.
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7.25 MEDICARE RISK CONTRACTOR
To maximize coordination of care for dual eligibles while promoting the
efficient use of public funds, the contractor:
A. Is recommended to be a Medicare+Choice contractor.
B. Shall serve all eligible populations.
7.26 TRACKING AND REPORTING
As a condition of acceptance of a managed care contract, the contractor
shall be held to the following reporting requirements:
A. The contractor shall develop, implement, and maintain a system
of records and reports which include those described below and
shall make available to DMAHS for inspection and audit any
reports, financial or otherwise, of the contractor and require
its providers or subcontractors to do the same relating to
their capacity to bear the risk of potential financial losses
in accordance with 42 C.F.R. Section 434.38. Except where
otherwise specified, the contractor shall provide reports on
hard copy, computer diskette or via electronic media using a
format and commonly-available software as specified by DMAHS
for each report.
B. The contractor shall maintain a uniform accounting system that
adheres to generally accepted accounting principles for
charging and allocating to all funding resources the
contractor's costs incurred hereunder including, but not
limited to, the American Institute of Certified Public
Accountants (AICPA) Statement of Position 89-5 "Financial
Accounting and Reporting by Providers of Prepaid Health Care
Services".
C. The contractor shall submit financial reports in accordance
with the timeframes and formats contained in Section A of the
Appendices.
D. The contractor shall provide its primary care practitioners
with quarterly utilization data within forty-five (45) days of
the end of the program quarter comparing the average medical
care utilization data of their enrollees to the average
medical care utilization data of other managed care enrollees.
These data shall include, but not be limited to, utilization
information on enrollee encounters with PCPs, specialty
claims, prescriptions, inpatient stays, and emergency room
use.
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E. The contractor shall collect and analyze data to implement
effective quality assurance, utilization review, and peer
review programs in which physicians and other health care
practitioners participate. The contractor shall review and
assess data using statistically valid sampling techniques
including, but not limited to, the following:
Primary care practitioner audits; specialty audits; inpatient
mortality audits; quality of care and provider performance
assessments; quality assurance referrals; credentialing and
recredentialing; verification of encounter reporting rates;
quality assurance committee and subcommittee meeting agendas
and minutes; enrollee complaints, grievances, and follow-up
actions; providers identified for trending and sanctioning;
special quality assurance studies or projects; prospective,
concurrent, and retrospective utilization reviews of inpatient
hospital stays; and denials of off-formulary drug requests.
F. The contractor shall prepare and submit to DMAHS quarterly
reports to be reported by hard copy and diskette in a format
and software application system determined by DMAHS,
containing summary information on the contractor's operations
for each quarter of the program (See Section A.7 of the
Appendices, Tables 1 through 18). These reports shall be
received by DMAHS no later than forty-five (45) calendar days
after the end of the quarter. After a grace period of five (5)
calendar days, for each calendar day after a due date that
DMAHS has not yet received at a prescribed location a report
that fulfills the requirements of any one item, assessment for
damages equal to one half month's negotiated blended
capitation rate that would normally be owed by DMAHS to the
contractor for one recipient shall be applied. The damages
shall be applied as an offset to subsequent payments to the
contractor.
The contractor shall be responsible for continued reporting
beyond the term of the contract because of lag time in
submitting source documents by providers.
G. The contractor may submit encounter reports daily but must
submit encounter reports at least quarterly. However,
encounter reports will be processed by DMAHS' fiscal agent no
more frequently than monthly. All encounters shall be reported
to DMAHS within seventy-five (75) days of the end of the
quarter in which they are received by the contractor and
within one year plus seventy-five (75) days from the date of
service.
H. The contractor shall semi-annually report its staffing
positions including the names of supervisory personnel
(Director level and above and the QM/UR personnel),
organizational chart, and any position vacancies in these
major areas.
I. The contractor shall report, semi-annually, number of appeals
received from hospitals, physicians, other providers and
enrollees and, for enrollees, average call waiting times, and
number of abandoned calls.
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J. The contractor shall submit, quarterly, information pertaining
to the obstetrical HealthStart programs, as specified by the
Department of Health and Senior Services.
K. DMAHS shall have the right to create additional reporting
requirements at any time as required by applicable federal or
State laws and regulations, as they exist or may hereafter be
amended and incorporated into this contract.
L. Reports that shall be submitted on an annual or semi-annual
basis, as specified in this contract, shall be due within
sixty (60) days of the close of the reporting period, unless
specified otherwise.
7.27 FINANCIAL STATEMENTS
7.27.1 AUDITED FINANCIAL STATEMENTS (GAAP BASIS)
The contractor shall submit audited annual financial statements
prepared in accordance with Generally Accepted Accounting Principles
(GAAP) certified by an independent public accountant, no later than
June 1, for the immediately preceding calendar year for the contractor
and any company that is a financial guarantor for the contractor
completed in accordance with N.J.S.A. 8:38-11.6, "Financial Reporting
Requirements." In addition to meeting requirements as stated in
N.J.S.A. 8:38-11.6, the audited financial statements of the contractor
shall include an opinion supported by adequate testing by the
independent public accountant as to the accuracy and accounting
principles used in reporting Medicaid specific financial information
required by this contract. This includes but is not limited to
quarterly expense statements, Medical Cost Ratio information, cost
allocations made to the Medicaid contract, and claims processing
information reported to the DMAHS. The contractor shall authorize the
independent accountant to allow representatives of the Department, upon
written request, to inspect any and all working papers related to the
preparation of the audit report.
7.27.2 FINANCIAL STATEMENTS (SAP)
Contractor shall submit to DMAHS all quarterly and annual financial
statements and annual supplements in accordance with Statutory
Accounting Principles (SAP) required in N.J.A.C. 8:38-11.6. Submissions
to DMAHS shall be on the same time frame described in N.J.A.C. 8:38-14,
i.e., quarterly reports are due the fifteenth (15th)day of the second
month following the quarter end and statutory unaudited statement and
the annual supplemental are due March 1 covering the preceding calendar
year. Such information shall be subject to the confidentiality
provisions in Article 7.40.
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7.28 FEDERAL APPROVAL AND FUNDING
This managed care contract shall not be implemented until and unless
all necessary federal approval and funding have been obtained.
7.29 CONFLICT OF INTEREST
A. No contractor shall pay, offer to pay, or agree to pay, either
directly or indirectly, any fee, commission, compensation,
gift, gratuity, or other thing of value of any kind to any
State officer or employee or special State officer or
employee, as defined by N.J.S.A. 52:13D-13b and e, in the
Department or any other agency with which such contractor
transacts or offers or proposes to transact business, or to
any member of the immediate family, as defined by N.J.S.A.
52:13D-13i, of any such officer or employee, or partnership,
firm or corporation with which they are employed or
associated, or in which such officer or employee has an
interest within the meaning of N.J.S.A. 52:13D-13g.
B. The solicitation of any fee, commission, compensation, gift,
gratuity or other thing of value by any State officer or
employee or special State officer or employee from any State
contractor shall be reported in writing forthwith by the
contractor to the Attorney General and the Executive
Commission on Ethical Standards.
C. No contractor may, directly or indirectly, undertake any
private business, commercial or entrepreneurial relationship
with, whether or not pursuant to employment, contract or other
agreement, express or implied, or sell any interest in such
contractor to any State officer or employee or special State
officer or employee having any duties or responsibilities in
connection with the purchase, acquisition or sale of any
property or services by or to any State agency or any
instrumentality thereof, or with any person, firm or entity
with which he is employed or associated or in which he has an
interest within the meaning of N.J.S.A. 52:13D-13g. Any
relationships subject to this provision shall be reported in
writing forthwith to the Executive Commission on Ethical
Standards which may grant a waiver of this restriction upon
application of the State officer or employee or special State
officer or employee upon a finding that the present or
proposed relationship does not present the potential, actual
or appearance, of a conflict of interest.
D. No contractor shall influence, or attempt to influence or
cause to be influenced, any State officer or employee or
special State officer or employee in his official capacity in
any manner which might tend to impair the objectivity or
independence of judgment of said officer or employee.
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E. No contractor shall cause or influence, or attempt to cause or
influence, any State officer or employee or special State
officer or employee to use, or attempt to use, his official
position to secure unwarranted privileges or advantages for
the contractor or any other person.
F. The provisions cited above in this Article shall not be
construed to prohibit a State officer or employee or special
State officer or employee from receiving gifts from or
contracting with the contractor under the same terms and
conditions as are offered or made available to members of the
general public subject to any guidelines the Executive
Commission on Ethical Standards may promulgate.
7.30 RECORDS RETENTION
A. The contractor hereby agrees to maintain an appropriate
recordkeeping system (See Section B.4.14 of the Appendices)
for services to enrollees and further require its providers
and subcontractors to do so. Such system shall collect all
pertinent information relating to the medical management of
each enrolled beneficiary; and make that information readily
available to appropriate health professionals and the
Department. Records shall be retained for the later of
1. Five (5) years from the date of service, or
2. Three (3) years after final payment is made under the
contract or subcontract and all pending matters are
closed.
B. If an audit, investigation, litigation, or other action
involving the records is started before the end of the
retention period, the records shall be retained until all
issues arising out of the action are resolved or until the end
of the retention period, whichever is later. Records shall be
made accessible at a New Jersey site, and on request to
agencies of the State of New Jersey and the federal
government. For enrollees covered by the contractor's plan who
are eligible through the Division of Youth and Family
Services, records shall be kept in accordance with the
provisions under N.J.S.A. 9:6-8.10a and 9:6-8:40 and
consistent with need to protect the enrollee's
confidentiality. All providers and subcontractors shall comply
with, and all provider contracts and subcontracts shall
contain the requirements stated in this paragraph. (See also
Article 7.40, "Confidentiality".)
C. If contractor's enrollees disenroll from the contractor's
plan, the contractor shall require participating providers to
release medical records of enrollees as may be directed by the
enrollee, authorized representatives of the Department and
appropriate agencies of the State of New Jersey and of the
federal government. Release of records shall be consistent
with the provision of confidentiality expressed in Article
7.40 and at no cost to the enrollee.
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7.31 WAIVERS
Nothing in the contract shall be construed to be a waiver by the State
of any warranty, expressed or implied, except as specifically and
expressly stated in writing executed by the Director. Further, nothing
in the contract shall be construed to be a waiver by the State of any
remedy available to the State under the contract, at law or equity
except as specifically and expressly stated in writing executed by the
Director. A waiver by the State of any default or breach shall not
constitute a waiver of any subsequent default or breach.
7.32 CHANGE BY THE CONTRACTOR
The contractor shall not make any enhancements, limitations, or changes
in benefits or benefits coverage; any changes in definition or
interpretation of benefits; or any changes in the administration of the
managed care program related to the scope of benefits, allowable
coverage for those benefits, eligibility of enrollees or providers to
participate in the program, reimbursement methods and/or schedules to
providers, or substantial changes to contractor operations without the
express, written direction or approval of the State. The State shall
have the sole discretion for determining whether an amendment is
required to effect a change (e.g., to provide additional services).
7.33 INDEMNIFICATION
A. The contractor agrees to indemnify and hold harmless the
State, its officers, agents and employees, and the enrollees
and their eligible dependents from any and all claims or
losses accruing or resulting from contractor's negligence to
any participating provider or any other person, firm, or
corporation furnishing or supplying work, services, materials,
or supplies in connection with the performance of this
contract.
B. The contractor agrees to indemnify and hold harmless the
State, its officers, agents, and employees, and the enrollees
and their eligible dependents from liability deriving or
resulting from the contractor's insolvency or inability or
failure to pay or reimburse participating providers or any
other person, firm, or corporation furnishing or supplying
work, services, materials, or supplies in connection with the
performance of this contract.
C. The contractor agrees further that it shall require under all
provider contracts that, in the event the contractor becomes
insolvent or unable to pay the participating provider, the
participating provider shall not seek compensation for
services rendered from the State, its officers, agents, or
employees, or the enrollees or their eligible dependents.
D. The contractor agrees further that it shall indemnify and hold
harmless the State, its officers, agents, and employees, and
the enrollees and their eligible dependents
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from any and all claims for services for which the contractor
receives monthly capitation payments, and shall not seek
payments other than the capitation payments from the State,
its officers, agents, and/or employees, and/or the enrollees
and/or their eligible dependents for such services, either
during or subsequent to the term of the contract.
E. The contractor agrees further to indemnify and hold harmless
the State, its officers, agents and employees, and the
enrollees and their eligible dependents, from all claims,
damages, and liability, including costs and expenses, for
violation of any proprietary rights, copyrights, or rights of
privacy arising out of the contractor's or any participating
provider's publication, translation, reproduction, delivery,
performance, use, or disposition of any data furnished to it
under this contract, or for any libelous or otherwise unlawful
matter contained in such data that the contractor or any
participating provider inserts.
F. The contractor shall indemnify the State, its officers, agents
and employees, and the enrollees and their eligible dependents
from any injury, death, losses, damages, suits, liabilities
judgments, costs and expenses and claim of negligence or
willful acts or omissions of the contractor, its officers,
agents and employees, subcontractors, participating providers,
their officers, agents or employees, or any other person for
any claims arising out of alleged violation of any State or
federal law or regulation. The contractor shall also indemnify
and hold the State harmless from any claims of alleged
violations of the Americans with Disabilities Act by the
contractor, its subcontractors or providers.
G. The contractor agrees to pay all losses, liabilities, and
expenses under the following conditions:
1. The parties who shall be entitled to enforce this
indemnity of the contractor shall be the State, its
officials, agents, employees, and representatives,
including attorneys or the State Attorney General,
other public officials, Commissioner and DHS
employees, any successor in office to any of the
foregoing individuals, and their respective legal
representatives, heirs, and beneficiaries.
2. The losses, liabilities and expenses that are
indemnified shall include but not be limited to the
following examples: judgments, court costs, legal
fees, the costs of expert testimony, amounts paid in
settlement, and all other costs of any type whether
or not litigation is commenced. Also covered are
investigation expenses, including but not limited to,
the costs of utilizing the services of the
contracting agency and other State entities incurred
in the defense and handling of said suits, claims,
judgments, and the like, and in enforcing and
obtaining compliance with the provisions of this
paragraph whether or not litigation is commenced.
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3. Nothing in this contract shall be considered to
preclude an indemnified party from receiving the
benefits of any insurance the contractor may carry
that provides for indemnification for any loss,
liability, or expense that is described in this
contract.
4. The contractor shall do nothing to prejudice the
State's right to recover against third parties for
any loss, destruction of, or damage to the
contracting agency's property. Upon the request of
the DHS or its officials, the contractor shall
furnish the DHS all reasonable assistance and
cooperation, including assistance in the prosecution
of suits and the execution of instruments of
assignment in favor of the contracting agency in
obtaining recovery.
5. Indemnification includes but is not limited to, any
claims or losses arising from the promulgation or
implementation of the contractor's policies and
procedures, whether or not said policies and
procedures have been approved by the State, and any
claims of the contractor's wrong doing in
implementing DHS policies.
7.34 INVENTIONS
Inventions, discoveries, or improvements of computer programs developed
pursuant to this contract by the contractor, and paid for by DMAHS in
whole or in part, shall be the property of DMAHS.
7.35 USE OF CONCEPTS
The ideas, knowledge, or techniques developed and utilized through the
course of this contract by the contractor, or jointly by the contractor
and DMAHS, for the performance under the contract, may be used by
either party in any way they may deem appropriate. However, such use
shall not extend to pre-existing intellectual property of the
contractor or DMAHS that is patented, copyrighted, trademarked or
service marked, which shall not be used by another party unless a
license is granted.
7.36 PREVAILING WAGE
The New Jersey Prevailing Wage Act, PL 1963, Chapter 150, is hereby
made a part of this contract, unless it is not within the contemplation
of the Act. The contractor's signature on the contract is a guarantee
that neither the contractor nor any providers or subcontractors it
might employ to perform the work covered by this contract is listed or
is on record in the Office of the Commissioner of the New Jersey
Department of Labor and Industry as one who has failed to pay
prevailing wages in accordance with the provisions of this Act.
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7.37 DISCLOSURE STATEMENT
The contractor shall report ownership and related information to DMAHS
at the time of initial contracting, and yearly thereafter, and upon
request, to the Secretary of DHHS and the Inspector General of the
United States in accordance with federal and state law.
A. The contractor shall include full and complete information as
to the name and address of each person or corporation with a
five (5) percent or more ownership or controlling interest in
the contractor's plan, or any provider or subcontractor in
which the contractor has a five (5) percent or more ownership
interest (Section 1903(m)(2)(A) of the Social Security Act and
N.J.A.C. 10:49-19.2)
The contractor shall comply with this disclosure requirement
through submission of the HCFA-1513 Form whether federally
qualified or not.
B. If the contractor is not federally qualified, it shall
disclose to DMAHS at the time of contracting (and within ten
days of any change) information on types of transactions with
a "party in interest" as defined in Section 1318(b) of the
Public Health Service Act (Section 1903(m)(4)(A) of the Social
Security Act).
1. All contractor business transactions shall be
reported. This requirement shall not be limited to
transactions related only to serving the Medicaid
enrollees and applies at least to the following
transactions:
a. Any sale, exchange, or leasing of property
between the contractor and a "party in
interest";
b. Any furnishing for consideration of goods,
services or facilities between the
contractor and a "party in interest" (not
including salaries paid to employees for
services provided in the normal course of
their employment);
c. Any lending of money or other extension of
credit between the contractor and a "party
in interest"; and
d. Transactions or series of transactions
during any one fiscal year that are expected
to exceed the lesser of $25,000 or five (5)
percent of the total operating expenses of
the contractor.
2. The information that shall be disclosed regarding
transactions listed in B.1 above between the
contractor and a "party in interest" includes:
a. The name of the "party in interest" for each
transaction;
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b. A description of each transaction and the
quantity or units involved;
c. The accrued dollar value of each transaction
during the fiscal year; and
d. The justification of the reasonableness of
each transaction.
3. This information shall be reported annually to DMAHS
and shall also be made available, upon request, to
the Office of the Inspector General, the Comptroller
General and to the contractor's enrollees. DMAHS may
request that the information be in the form of a
consolidated financial statement for the organization
and entity (N.J.A.C. 10:49-19.2).
C. The contractor shall disclose the identity of any person who
has been convicted of certain offenses, as defined in Section
1126 of the Social Security Act. This includes any person who
has ownership or control interest in the contractor, or is an
agent or managing employee of the contractor and:
1. Has been convicted of a criminal offense related to
the delivery of an item or service under Medicare,
Medicaid, or title XXI;
2. Has been convicted of a criminal offense relating to
neglect or abuse of patients in connection with the
delivery of a health care item or service;
3. Has been convicted for an offense that occurred after
the date of the enactment of the Health Insurance
Portability and Accountability Act of 1996, in
connection with the delivery of a health care item or
service or omission in a health care program operated
by or financed in whole or in part by any Federal,
State, or local government agency, of a criminal
offense consisting of a felony relating to fraud,
theft, embezzlement, breach of fiduciary
responsibility, or other financial misconduct; or
4. Has been convicted for an offense that occurred after
the date of the enactment of the Health Insurance
Portability and Accountability Act of 1996 of a
criminal offense consisting of a felony relating to
the unlawful manufacture, distribution, prescription,
or dispensing of a controlled substance.
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7.38 FRAUD AND ABUSE
7.38.1 ENROLLEES
A. Policies and Procedures. The contractor shall establish
written policies and procedures for identifying potential
enrollee fraud and abuse. Proven cases are to be referred to
the Department for screening for advice and/or assistance on
follow-up actions to be taken. Referrals are to be
accompanied by all supporting case documentation.
B. Typical Cases. The most typical cases of fraud or abuse
include but are not limited to: the alteration of an
identification card for possible expansion of benefits; the
loaning of an identification card to others; use of forged or
altered prescriptions; and mis-utilization of services.
7.38.2 PROVIDERS
A. Policies and Procedures. The contractor shall establish
written policies and procedures for identifying,
investigating, and taking appropriate corrective action
against fraud and abuse (as defined in 42 C.F.R. Section
455.2) in the provision of health care services. The policies
and procedures will include, at a minimum:
1. Written notification to DMAHS within five (5)
business days of intent to conduct an investigation
or to recover funds, and approval from DMAHS prior to
conducting the investigation or attempting to recover
funds. Details of potential investigations shall be
provided to DMAHS and include the data elements in
Section A.7.2.B of the Appendices. Representatives of
the contractor may be required to present the case to
DMAHS. DMAHS, in consultation with the contractor,
will then determine the appropriate course of action
to be taken.
2. Incorporation of the use of claims and encounter data
for detecting potential fraud and abuse of services.
3. Reporting investigation results within twenty (20)
business days to DMAHS.
4. Specifications of, and reports generated by, the
contractor's prepayment and postpayment surveillance
and utilization review systems, including prepayment
and postpayment edits.
B. Distinct Unit. The contractor shall establish a distinct fraud
and abuse unit, separate from the contractor's utilization
review and quality of care functions. The unit can either be
part of the contractor's corporate structure, or operate under
contract with the contractor. The unit shall be staffed with
individuals with the
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qualifications and an investigator-to-beneficiary ratio
consistent, at a minimum, with the Department of Banking and
Insurance requirements for fraud units within health insurance
carriers or greater ratio as needed to meet the demands.
C. Prepayment Monitoring. The contractor shall conduct prepayment
monitoring of its own network providers and subcontractors
when it believes fraud or abuse may be occurring.
D. It shall be the responsibility of the contractor to report in
writing to DMAHS' Office of Program Integrity Administration
the following:
1. All cases of suspected fraud and abuse, using the
format described in Section A.7.2 of the Appendices;
2. Inappropriate or inconsistent practices by providers,
subcontractors, enrollees or employees or anyone who
can order or refer services, and related parties; and
3. Prepayment monitoring of a provider or a
subcontractor by the contractor.
E. DMAHS shall have the right to withhold from a contractor's
capitation payments an appropriate amount if DMAHS determines
that evidence of fraud or abuse exists relating to the
contractor, its providers, subcontractors, enrollees,
employees, or anyone who can order or refer services, and
related parties.
F. When DMAHS has withheld payment and/or initiated a recovery
action against one of the contractor's providers or
subcontractors or a withholding of payments action pursuant to
42 C.F.R. Section 455.23, DMAHS may require the contractor to
withhold payments to that provider or subcontractor and/or
forward those payments to DMAHS.
G. DMAHS may direct the contractor to monitor one of its
providers or subcontractors, or take such corrective action
with respect to that provider or subcontractor as DMAHS deems
appropriate, when, in the opinion of DMAHS, good cause exists.
H. Sanctions. Failure of the contractor to investigate and
correct fraud and abuse problems relating to its enrollees,
network providers or subcontractors, and to notify DMAHS
timely of same, may result in sanctions. Timely notification
is defined as within five (5) business days of identification
of the fraud and/or abuse and within twenty (20) business days
of the completion of an investigation. For purposes of this
subsection, the term "investigation" shall include prepayment
monitoring as described above.
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DMAHS shall have the right to also impose sanctions and/or
withhold payments to the contractor (in accordance with
provisions of 42 C.F.R. Section 455.23) if it has reliable
evidence of fraud or willful misrepresentation relating to the
contractor's participation in the New Jersey Medicaid or NJ
FamilyCare program or if the contractor fails to initiate its
investigation of an identified fraud and/or abuse within one
year of identification.
7.38.3 NOTIFICATION TO DMAHS
The contractor shall submit quarterly the report in Section A.7.2 of
the Appendices, Fraud & Abuse.
7.39 EQUALITY OF ACCESS AND TREATMENT/DUE PROCESS
A. Unless a higher standard is required by this contract, the
contractor shall provide and require its subcontractors and
its providers to provide the same level of medical care and
health services to DMAHS enrollees as to enrollees in the
contractor's plan under private or group contracts unless
otherwise required in this contract.
B. Enrollees shall be given equitable access, i.e., equal
opportunity and consideration for needed services without
exclusionary practices of providers or system design because
of gender, age, race, ethnicity, color, creed, religion,
ancestry, national origin, marital status, sexual or
affectional orientation or preference, mental or physical
disability, genetic information, or source of payment.
C. DMAHS shall assure that all due process safeguards that are
otherwise available to Medicaid beneficiaries remain available
to enrollees under this contract.
D. The contractor shall assure the provision of services,
notifications, preparation of educational materials in
appropriate alternative formats, for enrollees including the
blind, hearing impaired, people with cognitive or
communication impairments, and individuals who do not speak
English.
7.40 CONFIDENTIALITY
A. General. The contractor hereby agrees and understands that all
information, records, data, and data elements collected and
maintained for the operation of the contractor and the
Department and pertaining to enrolled persons, shall be
protected from unauthorized disclosure in accordance with the
provisions of 42 U.S.C. Section 1396(a)(7)(Section 1902(a)(7)
of the Social Security Act), 42 C.F.R. Part 431, subpart F,
N.J.S.A. 30:4D-7 (g) and N.J.A.C. 10:49-9.4. Access to such
information, records, data and data elements shall be
physically secured and safeguarded and shall be limited to
those who perform their duties in accordance with provisions
of this contract including the Department of Health and Human
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Services and to such others as may be authorized by DMAHS in accordance
with applicable law. For enrollees covered by the contractor's plan
that are eligible through the Division of Youth and Family Services,
records shall be kept in accordance with the provisions under N.J.S.A.
9:6-8.10a and 9:6-8:40 and consistent with the need to protect the
enrollee's confidentiality.
B. Enrollee-Specific Information. With respect to any
identifiable information concerning an enrollee under the
contract that is obtained by the contractor or its providers
or subcontractors, the contractor: (1) shall not use any such
information for any purpose other than carrying out the
express terms of this contract; (2) shall promptly transmit to
the Department all requests for disclosure of such
information; (3) shall not disclose except as otherwise
specifically permitted by the contract, any such information
to any party other than the Department without the
Department's prior written authorization specifying that the
information is releasable under 42 C.F.R. Section 431.300 et
seq., and (4) shall, at the expiration or termination of the
contract, return all such information to the Department or
maintain such information according to written procedures
sent the contractor by the Department for this purpose.
C. Employees. The contractor shall instruct its employees to keep
confidential information concerning the business of DMAHS, its
financial affairs, its relations with its enrollees and its
employees, as well as any other information which may be
specifically classified as confidential by law.
D. Medical records and management information data concerning
Medicaid beneficiaries enrolled pursuant to this contract
shall be confidential and shall be disclosed to other persons
within the contractor's organization only as necessary to
provide medical care and quality, peer, or grievance review of
medical care under the terms of this contract.
E. The provisions of this Article shall survive the termination
of this contract and shall bind the contractor so long as the
contractor maintains any individually identifiable information
relating to Medicaid/NJ FamilyCare beneficiaries.
F. If DMAHS receives a request pursuant to the Right To Know Law
for release of information concerning the contractor, DMAHS
shall determine what information is required by law to be
released and retain authority over the release of that
information. Prior to release of information that was
previously labeled by the contractor as "confidential" or
"proprietary," DMAHS shall notify the contractor, who may
apply to the Superior Court of New Jersey for a protective
order if the contractor opposes the release of information.
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7.41 SEVERABILITY
If this contract contains any unlawful provision that is not an
essential part of the contract and that was not a controlling or
material inducement to enter into the contract, the provision shall
have no effect and, upon notice by either party, shall be deemed
stricken from the contract without affecting the binding force of the
remainder of the contract.
7.42 CONTRACTING OFFICER AND CONTRACTOR'S REPRESENTATIVE
It is agreed that___________________, Director of DMAHS, or her
representative, shall serve as the Contracting Officer for the State
and that___________________shall serve as the Contractor's
Representative. The Contracting Officer and the Contractor's
Representative each reserve the right to delegate such duties as may be
appropriate to others in the DMAHS's or contractor's employ.
Each party shall provide timely written notification of any change in
Contracting Officer or Contractor's Representative.
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ARTICLE EIGHT: FINANCIAL PROVISIONS
8.1 GENERAL INFORMATION
This Article includes financial requirements (including solvency and
insurance), medical cost ratio requirements, information on rates set
by the State, third party liability (TPL) requirements, general
capitation requirements, and provider payment requirements.
8.2 FINANCIAL REQUIREMENTS
8.2.1 COMPLIANCE WITH CERTAIN CONDITIONS
The contractor shall remain in compliance with the following conditions
which shall satisfy the Departments of Human Services, Banking and
Insurance (DOBI) and Health and Senior Services prior to this contract
becoming effective:
A. Provider Contracts Executed. The contractor has entered into
written contracts with providers in accordance with Article
Four of this contract.
B. No Judgment Preventing Implementation. No court order,
administrative decision, or action by any other
instrumentality of the United States government or the State
of New Jersey or any other state which prevents implementation
of this contract is outstanding.
C. Approved Certificate of Authority. The contractor has and
maintains an approved certificate of authority to operate as a
health maintenance organization in New Jersey from the DOBI
and the Department of Health and Senior Services for the
Medicaid population.
D. Compliance with All Solvency Requirements. The contractor
shall comply with and remain in compliance with minimum net
worth and fiscal solvency and reporting requirements of the
DOBI and the Department of Human Services, the federal
government, and this contract.
8.2.2 SOLVENCY REQUIREMENTS
The contractor shall maintain a minimum net worth in accordance with
N.J.A.C. 8:38-11 et seq.
The Department shall have the right to conduct targeted financial
audits of the contractor's Medicaid line of business. The contractor
shall provide the Department with financial data, as requested by the
Department, within a timeframe specified by the Department.
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8.2.3 GENERAL PROVISIONS AND CONTRACTOR COMPLIANCE
The contractor shall comply with the following financial operations
requirements:
A. The contractor must establish and maintain (1) an office in
New Jersey, and (2) premium and claims accounts in a bank with
a principal office in New Jersey.
B. The contractor shall have a fiscally sound operation as
demonstrated by:
1. Maintenance of minimum net worth in accordance with
DOBI requirements (total line of business) and the
requirements outlined in Article 8.2.2.
2. Maintenance of a net operating surplus for Medicaid
line of business. If the contractor fails to earn a
net operating surplus during the most recent calendar
year, or does not maintain minimum net worth
requirements on a quarterly basis, it shall submit a
corrective plan of action within the time specified
by the Department. The plan is subject to the
approval of DMAHS. It must demonstrate how and when
minimum net worth requirements will be replenished
and present marketing and financial projections.
These must be supported by suitable back-up material.
The discussion must include possible alternative
funding sources, including the invoking of a parental
guarantee.
This plan shall include:
a. A detailed marketing plan with enrollment
projections for the next two years.
b. A projected balance sheet for the next two
years.
c. A projected statement of revenue and
expenses on an accrual basis for the next
two years.
d. A statement of cash flow projected for the
next two years.
e. A description of how to maintain capital
requirements and replenish net worth.
f. Sources and timing of new capital must be
specifically identified.
3. The contractor shall demonstrate it has sufficient
cash and adequate liquidity set aside (i.e.,
restricted) but accessible to the DOBI to meet
obligations as they become due, and which are
acceptable to DMAHS. The
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contractor shall comply with DOBI requirements
regarding cash reserves and where restricted funds
will be held (See N.J.A.C. 8:38-11.3, Reserve
Requirements).
8.3 INSURANCE REQUIREMENTS
The contractor shall maintain general comprehensive liability
insurance, products/completed operations insurance, premises/operations
insurance, unemployment compensation coverage, workmen's compensation
insurance, reinsurance, and malpractice insurance in such amounts as
determined necessary in accordance with state and federal statutes and
regulations, insuring all claims which may arise out of contractor
operations under the terms of this contract. The DMAHS shall be an
additional named insured with sixty (60) days prior written notice in
event of default and/or non-renewal of the policy. Proof of such
insurance shall be provided to and approved by DMAHS prior to the
provision of services under this contract and annually thereafter. No
policy of insurance provided or maintained under this Article shall
provide for an exclusion for the acts of officers.
8.3.1 INSURANCE CANCELLATION AND/OR CHANGES
In the event that any carrier of any insurance described in 8.4 or
8.4.2 exercises cancellation and/or changes, or cancellation or change
is initiated by the contractor, notice of such cancellation and/or
change shall be sent immediately to DMAHS for approval. At State's
option upon cancellation and/or change or lapse of such insurance(s),
DMAHS may withhold all or part of payments for services under this
contract until such insurance is reinstated or comparable insurance
purchased. The contractor is obligated to provide any services during
the period of such lapse or termination.
8.3.2 STOP-LOSS INSURANCE
At the discretion of the Departments of Banking and Insurance, Human
Services, and Health and Senior Services and notwithstanding the
requirements of N.J.A.C. 8:38-11.5 (b), the contractor may be required
to obtain, prior to this contract, and maintain "stop-loss" insurance
from a reinsurance company authorized to do business in New Jersey that
will cover medical costs that exceed a threshold per case for the
duration of the contract period. Any coverage other than stipulated
must be based on an actuarial review, taking into account geographic
and demographic factors, the nature of the clients, and state solvency
safeguard requirements.
All "stop-loss" insurance arrangements, including modifications, shall
be reviewed and prior approved by the Departments of Banking and
Insurance, Human Services, and Health and Senior Services. The
"stop-loss" insurance underwriter must meet the standards of financial
stability as set forth by the DOBI.
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Contractors with sufficient reserves may choose self-insurance, subject
to approval by the Department of Human Services and the DOBI where
appropriate.
8.4 MEDICAL COST RATIO
8.4.1 MEDICAL COST RATIO STANDARD
The contractor shall maintain direct medical expenditures for enrollees
equal to or greater than eighty (80) percent of premiums paid in all
forms from the State. This medical cost ratio (MCR) shall apply to
annual periods from the contract effective date (if the contract ends
before the completion of an annual period, the MCR shall apply to that
shorter period). The MCR shall be based on reports completed by the
contractor and acceptable to the Department.
A. Direct Medical Expenditures. Direct medical expenditures are
the incurred costs of providing direct care to enrollees for
covered health care services as stated in Article 4.1.
Education and outreach costs and/or administrative costs are
not considered direct medical expenditures.
B. Calculation of MCR. The calculation of MCR will be made using
information submitted by each contractor on the quarterly
reports - Statement of Revenues and Expenses (Section A.7.8 of
the Appendices (Table 6)). The sum of all applicable quarters
for Total Medical and Hospital Expenses (line 28) less
Coordination of Benefits (COB) (line 6) and less reinsurance
recoveries (line 7) will be divided by the sum of all
applicable quarters of Medicaid/NJ FamilyCare premiums (line
4) to arrive at the ratio.
8.4.2 EXEMPTIONS
An exemption may be granted to reduce the eighty (80) percent MCR
requirement to no lower than seventy-five (75) percent. Under no
circumstances will an exemption be granted to a contractor for MCR
below seventy-five (75) percent. An exemption may be granted if the
contractor meets all of the following established criteria:
A. Has no unresolved quality of care issues;
B. Has not received any pending or imposed sanctions;
C. Is in compliance with all reporting requirements;
D. Had no vacancies in key administrative positions for longer
than sixty (60) days;
E. Is in compliance with all corrective plans of action relating
to Medicaid activity imposed by the Departments of Human
Services, Banking and Insurance, or Health and Senior
Services;
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F. Has demonstrated timely processing of claims over the term of
the contract and has had no substantiated pattern of
complaints from providers for late payments; and
G. Has produced evidence to demonstrate compliance with education
and outreach provisions of the contract.
8.4.3 DAMAGES
The Department shall have the right to impose damages on a contractor
that has failed to maintain an appropriate MCR. The formula for
imposing damages follows:
ACTUAL MCR 1ST OFFENSE 2ND OFFENSE
---------- ----------- -----------
80% or above NONE NONE
78.00-79.99% .15 times .15 times
underexpenditure underexpenditure
75.00-77.99% .50 times .50 times
underexpenditure underexpenditure
74.99 or below .90 times 1.00 times
underexpenditure underexpenditure
If the contractor fails to meet the MCR requirement and a penalty is
applied, a plan of corrective action will be required.
8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS
8.5.1 REGIONS
Rates for DYFS, NJ FamilyCare Plan A Parents/caretaker relatives with
children and adults without dependent children under the age of 19, NJ
FamilyCare Plans B, C and D, and the non risk-adjusted rates for AIDS
and clients of DDD are statewide. All other rates for each premium
group have been set for each of the following regions:
- Region 1: Bergen, Hudson, Hunterdon, Xxxxxx, Passaic,
Somerset, Sussex, and Xxxxxx counties
- Region 2: Essex, Union, Middlesex, and Xxxxxx counties
- Region 3: Atlantic, Burlington, Camden, Cape May, Cumberland,
Gloucester, Monmouth, Ocean, and Salem counties
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Contractors may contract for one or more regions but, except as
provided in Article 2, may not contract for part of a region.
8.5.2 AFDC/TANF AND NJ FAMILYCARE PLAN A CHILDREN
The capitation rates for Aid to Families with Dependent Children
(AFDC)/Temporary Assistance for Needy Families (TANF) includes New
Jersey Care Pregnant Women and NJ FamilyCare Plan A children (age less
than 19) but excludes individuals who have AIDS or are clients of DDD.
Rates have been set for the following premium groups:
A. Males and females less than 1 year
B. Males and females 1 year to 1.99 years
C. Males 2 to 20.99 years and females 2 to 14.99 years
D. Females 15 to 44.99 years
E. Males 21 to 44.99 years
F. Males and females 45 years and older
8.5.3 NJ FAMILYCARE PLAN A PARENTS/CARETAKERS
The capitation rates for NJ FamilyCare Plan A parents/caretakers,
excluding individuals with AIDS and clients of DDD, are in the
following premium groups:
A. Males 19 to 44.99 years
B. Females 19 to 44.99 years
C. Males and females 45 years and older
8.5.4 NJ FAMLYCARE PLAN A ADULTS WITHOUT DEPENDENT CHILDREN
UNDER 19 YEARS OF AGE
The capitation rates for NJ FamilyCare Plan A adults without dependent
children under 19 years of age, excluding individuals with AIDS and
clients of DDD, are in the following premium groups:
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A. Males 19 to 44.99 years
B. Females 19 to 44.99 years
C. Males and females 45 years and older
8.5.5 NJ FAMILYCARE PLANS B & C
The capitation rates for NJ FamilyCare Plans B and C enrollees,
excluding individuals with AIDS are in the following premium groups:
A. Males and females less than 1 year
B. Males and females 1 year to 1.99 years
C. Males and females 2 to 18.99 years
8.5.6 NJ FAMILYCARE PLAN D CHILDREN
The capitation rates for NJ FamilyCare Plan D children, excluding
individuals with AIDS, are in the following premium groups:
A. Males and females less than 1 year
B. Males and females 1 year to 1.99 years
C. Males and females 2 to 18.99 years
8.5.7 NJ FAMILYCARE PLAN D PARENTS/CARETAKERS
The capitation rates for NJ FamilyCare Plan D parents/caretakers,
excluding individuals with AIDS, are in the following premium groups:
A. Males 19 to 44.99 years
B. Females 19 to 44.99 years
C. Males and Females 45 years and older
8.5.8 NJ FAMILYCARE PLAN D ADULTS WITHOUT DEPENDENT CHILDREN
UNDER 19 YEARS OLD
The capitation rates for NJ FamilyCare Plan D adults without dependent
children under 19 years old, excluding individuals with AIDS, are in
the following premium groups:
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A. Males 19 to 44.99 years
B. Females 19 to 44.99 years
C. Males and Females 45 years and older
8.5.9 PREMIUM GROUPS FOR DYFS AND AGING OUT XXXXXX CHILDREN
The capitation rates for Division of Youth and Family Services,
excluding individuals with AIDS and clients of DDD, are in the
following premium groups:
A. Males and females less than 1 year
B. Males and females 1 year to 1.99 years
C. Males and females 2 to 20.99 years
8.5.10 ABD WITHOUT MEDICARE
Compensation to the contractor for the ABD without Medicare will be
risk-adjusted using the Health Based Payments System (HBPS), which is
described in Article 8.6. Since the HBPS adjusts for regional
variations, a separate rate for each region is not necessary. In
addition, the HBPS adjusts for the diagnosis of AIDS; therefore,
separate AIDS rates are not necessary for this population. Finally, the
HBPS adjusts for age and sex so separate rates for age and sex within
this population are not necessary. Accordingly, the base rates to be
used for this population are as follows:
A. ABD without Medicare (non-DDD)
B. ABD-DDD without Medicare
8.5.11 ABD WITH MEDICARE
The capitation rates for the ABD with Medicare population, excluding
individuals with AIDS and clients of DDD, are in the following premium
groups:
A. Aged
B. Blind/Disabled less than 45
C. Blind/Disabled 45+
These rates are set by region and will not be risk-adjusted using the
HBPS.
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8.5.12 CLIENTS OF DDD
The contractor shall be paid separate, statewide rates for subgroups of
the DDD population, excluding individuals with AIDS. These rates
include MH/SA services for the following premium groups:
A. ABD-DDD with Medicare
B. AFDC-DDD (includes DYFS, New Jersey Care Pregnant Women, and
NJ FamilyCare Plan A)
These rates will not be risk-adjusted using the HBPS.
8.5.13 PREMIUM GROUPS FOR ENROLLEES WITH AIDS
A. In an effort to more appropriately match payment to risk, the
contractor shall be paid capitation rates according to the
following statewide premium groups for enrollees with AIDS:
1. AFDC-AIDS (includes DYFS, New Jersey Care Pregnant
Women, and NJ FamilyCare Plans A (children and
parents/caretakers), B, and C individuals, NJ
FamilyCare Plan D children)
2. NJ FamilyCare AIDS Plan D parents/caretakers and
adults without dependent children under 19 years old
and Plan A adults without dependent children under 19
years old
3. ABD-AIDS with Medicare
4. ABD-DDD-AIDS with Medicare (includes a MH/SA add on
to the ABD-AIDS rate)
5. AFDC-DDD-AIDS (includes a MH/SA add on to the
AFDC-AIDS rate) Other eligible groups include DYFS,
New Jersey Care Pregnant Women and NJ FamilyCare Plan
A (children and parents/caretakers).
6. NJ FamilyCare Plan A adults without dependent
children under 19 years old, DDD-AIDS (includes MH/SA
add on to the NJ FamilyCare AIDS rate).
B. The contractor will be reimbursed double the AIDS rate, once
in a member lifetime, in the first month of payment for a
recorded diagnosis of AIDS, prospective and newly diagnosed.
This is a one-time-only-per-member payment, regardless of MCE.
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8.5.14 SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME
Because costs for pregnancy outcomes were not included in the
capitation rates, the contractor shall be paid supplemental payments
for pregnancy outcomes for all eligibility categories.
Payment for pregnancy outcome shall be a single, predetermined lump sum
payment. This amount shall supplement the existing capitation rate
paid. The Department will make a supplemental payment to contractors
following pregnancy outcome. For purposes of this Article, pregnancy
outcome shall mean each live birth, still birth or miscarriage
occurring at the thirteenth (13th) or greater week of gestation. This
supplemental payment shall reimburse the contractor for its inpatient
hospital, antepartum, and postpartum costs incurred in connection with
delivery. Costs for care of the baby are not included. Payment shall be
made by the State to the contractor based on submission of appropriate
encounter data and use of a special indicator on the claim as specified
by DMAHS.
8.5.15 PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS
The contractor shall be paid separately for factor VIII and IX blood
clotting factors. Payment will be made by DMAHS to the contractor based
on: 1) submission of appropriate encounter data; and 2) prior
notification from the contractor to DMAHS of identification of
individuals with factor VIII or IX hemophilia.
8.5.16 PAYMENT FOR HIV/AIDS DRUGS
The contractor shall be paid separately for protease inhibitors for all
eligibility groups with the exception of NJ FamilyCare Plan A adults
without dependent children under the age of 19 and NJ Family Care Plan
D parents/caretakers and adults without dependent children under the
age of 19. Payment for protease inhibitors shall be made by DMAHS to
the contractor based on: 1) submission of appropriate encounter data;
and 2) prior notification from the contractor to DMAHS of
identification of individuals with HIV/AIDS.
Individuals eligible through NJ FamilyCare with a program status code
of 380 and all children groups shall receive protease inhibitors and
other anti-retroviral agents under the contractor's plan. All other
individuals eligible through NJ FamilyCare with program status codes of
497-498, and 761-763 shall receive protease inhibitors (First Data Bank
Specific Therapeutic Class Code W5C) and other anti-retrovirals (First
Data Bank Specific Therapeutic Class Code W5B) through Medicaid
fee-for-service and the AIDS Drug Distribution Program (ADDP).
8.5.17 EPSDT INCENTIVE PAYMENT
The contractor shall be paid separately, $10 for every documented
encounter record for an EPSDT screening examination. The contractor
shall be required to pass the $10 amount directly to the screening
provider.
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The incentive payment shall be reimbursed for EPSDT encounter records
submitted in accordance with 1) procedure codes specified by DMAHS, and
2) EPSDT periodicity schedule.
8.6 HEALTH BASED PAYMENT SYSTEM (HBPS) FOR THE ABD WITHOUT
MEDICARE POPULATION
A. The capitation rates for the ABD without Medicare population
account for the potential of the contractor receiving a
disproportionate number of higher cost beneficiaries. If a
traditional age and sex capitation model were used, the rates
may not adequately account for the difference in risk assumed
by each contractor. In order to account for this problem
diagnostic information, as well as age, sex, and
regional/geographic information, will be used to adjust the
capitation payments. This process is known as health based
capitation. By using this additional information, capitation
rates can more adequately match the payment with the risk of
the enrolled population.
In order to incorporate diagnostic information into the
analysis, a health based system categorizes beneficiaries into
different diagnostic groups. The Disability Payment System
(DPS) grouper will be used to categorize the beneficiaries.
This information is then used to create a unique case mix rate
for each individual. This individual information is then
aggregated to measure the health risk for the contractor.
B. The following narrative describes the implementation plan for
a health based capitation model in New Jersey:
1. Develop demographic capitation rates.
2. Develop payment weights for the diagnostic
categories. In order to estimate the prospective
medical cost for each beneficiary, a payment weight
for each diagnostic category is developed. These
payment weights identify how much an individual will
cost relative to an average beneficiary. For example,
an average cost beneficiary will have a case mix rate
of 1.0, while a higher cost beneficiary - for
example, a beneficiary with a high cost pulmonary
condition - will have a score of 1.26.
Separate payment weights will be developed for the
following populations:
- ABD without Medicare (non-DDD)
- ABD-DDD without Medicare
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3. Compile a case mix value for each beneficiary. Using the most
recent historical FFS and managed care encounter information,
a look-up file will be created that links each eligible
beneficiary with a unique case mix score. In order to develop
this unique case mix score historical claims information will
be run through the DPS grouper. The output from this process
will identify the beneficiaries' diagnostic categories. Using
this information and the payment weights estimated in step 2,
a case mix weight is then computed for each beneficiary. The
following example describes the process for an ABD beneficiary
who is not a client of DDD, is a forty-five (45) to sixty-four
(64) year old male beneficiary, and lives in Region 3, with a
medium-cost central nervous system disorder and a high-cost
pulmonary condition:
.45 Baseline (costs assigned to all beneficiaries -
including those in no diagnostic group)
.08 Male 45 - 64
.78 Medium Cost Central Nervous System Disorder
-.10 Region 3
1.26 High Cost Pulmonary Condition
----
2.47 Total Case Mix Rate
In this case, the beneficiary would have projected medical
costs 2.47 times the cost of an average beneficiary.
4. Compute case mix values for each contractor and the FFS
program. After completing the preceding task, the individual
case mix rates are used to compute an aggregate case rate for
each contractor. This is done by matching the individuals in
the eligibility file for each contractor with individuals'
case mix weights. In matching the eligibility files, some
beneficiaries may have either been eligible for an incomplete
time period or have not been eligible during the most recent
time period. Beneficiaries with incomplete eligibility will be
assigned a case mix of the contractor's average. Individuals
without FFS information will not be included in the analysis.
These individuals will be assigned the contractor's case mix
average.
After matching the eligibility file for the contractor and the
FFS program with the individual case mix weights, an average
case rate for the contractor and the FFS program will be
calculated. These aggregate case rates are then normalized to
ensure the program will be budget neutral. The following chart
describes the normalization process:
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CONTRACTOR CASE MIX POPULATION NORMALIZED
SCORE CASE MIX RATE
---------- -------- ---------- -------------
Contractor A 1.3 1,000 1.3/1.07 = 1.21
Contractor B 1.1 4,000 1.1/1.07 = 1.03
Contractor C .9 4,000 .90/1.07 = .84
FFS 1.4 1,000 1.4/1.07 = 1.31
Total 1.07 (weighted 10,000
average)
By normalizing the case mix scores, the State can
ensure the average cost for each beneficiary will not
exceed the average prospective cost estimated in step
1.
In order to determine the payment for the contractor,
the case mix rates for the contractor will be
multiplied by the base rate calculated in step 1. The
case mix rates will be updated periodically, as
deemed necessary.
5. Credibility adjustment. If the contractor has few
enrollees, there may not be complete confidence in
the contractor's relative case mix produced by the
limited number of enrollees. In this case, a
credibility rating can be used to blend the
contractor's case rate with the State's average case
rate. For example, if the State assigns a contractor
a case mix credibility of fifty (50) percent, the
following formula is used to develop a case mix rate
for the contractor:
(.5)*(the contractor's relative case mix) +
(.5)*(State's average case rate)
The credibility factor will be based primarily on the
number of beneficiaries enrolled with the contractor.
6. Collect and validate contractor encounter data. The
following encounter information will be required to
develop individual case mix scores for each enrollee:
- Unique identifier code for each enrollee
- ICD-9 diagnosis code(s) for each encounter
8.7 THIRD PARTY LIABILITY
A. General. The contractor, and by extension its providers and
subcontractors, hereby agree to utilize, whenever available,
other public or private sources of payment for services
rendered to enrollees in the contractor's plan. "Third party",
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for the purposes of this Article, shall mean any person or
entity who is or may be liable to pay for the care and
services rendered to a Medicaid beneficiary (See N.J.S.A.
30:4D-3m). Examples of a third party include a beneficiary's
health insurer, casualty insurer, a managed care organization,
Medicare, or an employer-administered ERISA plan. Federal and
State law requires that Medicaid payments be last dollar
coverage and should be utilized only after all other sources
of third party liability (TPL) are exhausted, subject to the
exceptions in Section F below.
B. Third Party Coverage Unknown. If coverage through health or
casualty insurance is not known or is unavailable at the time
the claim is filed, then the claim must be paid and
postpayment recovery must be initiated within six months from
the date of service.
C. Capitation Rates. The State has taken into account historical
and/or anticipated cost avoidance and recovery due to the
existence of liable third parties in setting capitation rates
and determining the payment amounts. These factors do not
include any reductions due to tort recoveries, or to
recoveries made by the State from the estates of deceased
Medicaid beneficiaries. In addition, future rates may be based
upon the contractor's actual or expected performance involving
TPL. Consequently, it is in the interests of both the State
and the contractor for the contractor to maximize its revenue
by fully exhausting all sources of available third party
coverage.
D. Categories. Third party resources are categorized as 1) health
insurance, 2) casualty insurance, 3) legal causes of action
for damages, and 4) estate recoveries.
1. Health Insurance. The contractor shall pursue and
collect payments from health insurers when health
insurance coverage is available, unless prior
approval to take other action is obtained from the
State. "Health insurance" shall include, but not be
limited to, coverage by any health care insurer, HMO,
Medicare, or an employer-administered ERISA plan.
Funds so collected shall be retained by the
contractor. In pursuing such recoveries, the
contractor may utilize the State's assignment and
subrogation authority to the extent permitted by
State law.
a. The State shall have the right to pursue,
collect, and retain payments from liable
health insurers if the contractor has failed
to initiate collection from the health
insurer within six (6) months from the date
of service. The contractor shall cooperate
with the State in all such collection
efforts, and shall also direct its providers
to do so.
2. Casualty Insurance. The contractor shall pursue and collect
payment from casualty insurance available to the enrollee,
unless prior approval to take other action is obtained from
the State. "Casualty insurance" shall
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include, but not be limited to, no fault auto insurance
benefits, worker's compensation benefits, and medical payments
coverage through a homeowner's insurance policy. Funds so
collected shall be retained by the contractor. In pursuing
such recoveries, the contractor may utilize the State's
assignment and subrogation authority to the extent permitted
by State law.
a. The State shall have the right to pursue, collect,
and retain casualty insurance payments where the
contractor has failed to initiate collection within
six (6) months from the date of service.
3. Legal Causes of Action for Damages. The State shall have the
sole and exclusive right to pursue and collect payments made
by the contractor when a legal cause of action for damages is
instituted on behalf of a Medicaid enrollee against a third
party or when the State receives notice that legal counsel has
been retained by or on behalf of any enrollee. The contractor
shall cooperate with the State in all collection efforts, and
shall also direct its providers to do so. State collections
identified as contractor-related resulting from such legal
actions will be retained by the State.
4. Estate Recoveries. The State shall have the sole and exclusive
right to pursue and recover correctly paid benefits from the
estate of a deceased Medicaid enrollee in accordance with
federal and State law. Such recoveries will be retained by the
State.
E. Cost Avoidance.
1. When the contractor is aware of health or casualty insurance
coverage prior to paying for a health care service, it shall
avoid payment by rejecting a provider's claim and directing
that the claim be submitted first to the appropriate third
party, or by directing its provider to withhold payments to a
subcontractor.
2. If insurance coverage is not available, or if one of the
exceptions to the cost avoidance rule discussed below applies,
then payment must be made and a claim made against the third
party, if it is determined that the third party is or may be
liable.
F. Exceptions to the Cost Avoidance Rule.
1. In the following situations, the contractor must first pay its
providers and then coordinate with the liable third party,
unless prior approval to take other action is obtained from
the State.
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a. The coverage is derived from a parent whose
obligation to pay support is being enforced by the
Department of Human Services.
b. The claim is for prenatal care for a pregnant woman
or for preventive pediatric services (including EPSDT
services) that are covered by the Medicaid program.
c. The claim is for labor, delivery, and post-partum
care and does not involve hospital costs associated
with the inpatient hospital stay.
d. The claim is for a child who is in a DYFS supported
out of home placement.
e. The claim involves coverage or services mentioned in
1.a, 1.b, 1.c, or 1.d, above in combination with
another service.
2. If the contractor knows that the third party will neither pay
for nor provide the covered service, and the service is
medically necessary, the contractor shall neither deny payment
for the service nor require a written denial from the third
party.
3. If the contractor does not know whether a particular service
is covered by the third party, and the service is medically
necessary, the contractor shall contact the third party and
determine whether or not such service is covered rather than
requiring the enrollee to do so. Further, the contractor shall
require the provider or subcontractor to xxxx the third party
if coverage is available.
4. Postpayment recovery rather than cost avoidance is necessary
in cases where the contractor was not aware of third party
coverage at the time that services were rendered or paid for,
or was unable to cost avoid, in accordance with the provisions
of this Article as applicable. Under these circumstances, the
contractor shall identify all potentially liable third parties
and pursue reimbursement from them, unless prior approval to
take other action is obtained from the State. In pursuing such
recoveries, the contractor may utilize the State's assignment
and subrogation authority to the extent permitted by State
law. This provision shall not apply in the case of any tort
matter but rather the provisions of Article 8.7D.3 shall be
applicable.
G. Sharing of TPL Information by the State.
1. By the fifteenth (15th) day of every month, the State may
provide the contractor with a list of all known health
insurance coverage information for the purpose of updating the
contractor's files.
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2. Additionally, the State may provide a quarterly health insurer
file to the contractor that will contain all of the health
insurers that the State has on file and related information
that is needed in order to file TPL claims.
H. Sharing of TPL Information by the Contractor.
1. The contractor shall notify the State within thirty (30) days
after it learns that an enrollee has health insurance coverage
not reflected in the State's health insurance coverage file,
or casualty insurance coverage, or of any change in an
enrollee's health insurance coverage. (See Section A.8.1 of
the Appendices.) The contractor shall impose a corresponding
requirement upon its servicing providers to notify it of any
newly discovered coverage, or of any changes in an enrollee's
health insurance coverage.
2. When the contractor becomes aware that an enrollee has
retained counsel, who either may institute or has instituted a
legal cause of action for damages against a third party, the
contractor shall notify the State in writing, including the
enrollee's name and Medicaid identification number, date of
accident/incident, nature of injury, name and address of
enrollee's legal representative, copies of pleadings, and any
other documents related to the action in the contractor's
possession or control. This shall include, but not be limited
to (for each service date on or subsequent to the date of the
accident/incident), the name of the provider, practitioner or
subcontractor, the enrollee's diagnosis, the nature of the
service provided to the enrollee, and the amount paid to the
provider (or to a provider's authorized subcontractor) by the
contractor for each service. A form is available for this
purpose and is included in Section A.8.2 of the Appendices.
3. The contractor shall notify the State within thirty (30) days
of the date it becomes aware of the death of one of its
Medicaid enrollees age fifty-five (55) or older, giving the
enrollee's full name, Social Security Number, Medicaid
identification number, and date of death. The State will then
determine whether it can recover correctly paid Medicaid
benefits from the enrollee's estate.
4. The contractor agrees to cooperate with the State's efforts to
maximize the collection of third party payments by providing
to the State updates to the information required by this
Article.
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I. Enrollment Exclusions and Contractor Liability for the Costs of Care.
1. Any Medicaid beneficiary enrolled in or covered by either a
Medicare or commercial HMO will not be enrolled by the
contractor. The only exception to this exclusion from
enrollment is when the contractor and the beneficiary's
Medicare/commercial HMO are the same. When beneficiaries are
enrolled under this exception, appropriate reductions will be
made in the State's capitation payments to the contractor.
2. If the contractor and the Medicaid beneficiary's Medicare or
commercial HMO are the same, the contractor will be
responsible for either:
a. Paying all cost-sharing expenses of the Medicaid
beneficiary; or
b. Addressing cost sharing in the contracts with its
providers in such a way that the Medicaid beneficiary
is not liable for any cost-sharing expenses, subject
to subarticle 3 below.
3. If a Medicaid beneficiary otherwise covered by the provisions
of subarticle 2 above wishes to utilize a provider outside of
the Medicare or commercial HMO's network, the HMO's rules
apply. Failure to follow the HMO's rules relieves both the
contractor and the State of any liability for the cost of the
care and services rendered to the beneficiary, subject to
subarticle 4 below.
4. The only exception to subarticle 3 above is if the HMO's rules
cannot be followed solely because emergency services were
provided by a non-participating provider, practitioner, or
subcontractor because the services were immediately required
due to sudden or unexpected onset of a medical condition. In
this circumstance, the contractor remains responsible for the
cost of the care and services rendered to the beneficiary.
5. If a Medicaid beneficiary enrolled with the contractor is also
enrolled in or covered by a health or casualty insurer other
than a Medicare or commercial HMO, the contractor is fully
responsible for coordinating benefits so as to maximize the
utilization of third party coverage in accordance with the
provisions of this Article. The contractor shall be
responsible for payment of the enrollee's coinsurance,
deductibles, copayments, and other cost-sharing expenses, but
the contractor's total liability shall not exceed what it
would have paid in the absence of TPL. The contractor shall
coordinate benefits and payments with the health or casualty
insurer for services authorized by the contractor, but
provided outside the contractor's plan. The contractor remains
responsible for the costs incurred by the beneficiary with
respect to care and services which
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are included in the contractor's capitation rate, but which
are not covered or payable under the health or casualty
insurer's plan.
6. The State will continue to pay Medicare Part A and
Part B premiums for Medicare/Medicaid dual eligibles
and Qualified Medicare Beneficiaries.
7. Any references to Medicare coverage in this Article
shall apply to both Medicare/Medicaid dual eligibles
and Qualified Medicare Beneficiaries.
J. Other Protections for Medicaid Enrollees.
1. The contractor shall not impose, or allow its
participating providers or subcontractors to impose,
cost-sharing charges of any kind upon Medicaid
beneficiaries enrolled in the contractor's plan
pursuant to this contract. This Article does not
apply to individuals eligible solely through the NJ
FamilyCare Program Plan C or D, for whom providers
will be required to collect cost-sharing for certain
services.
2. The contractor's obligations under this Article shall
not be imposed upon the enrollees, although the
contractor shall require enrollees to cooperate in
the identification of any and all other potential
sources of payment for services. Instances of
non-cooperation shall be referred to the State.
3. The contractor shall neither encourage nor require a
Medicaid enrollee to reduce or terminate TPL
coverage.
4. Unless otherwise permitted or required by federal and
State law, health care services cannot be denied to a
Medicaid enrollee because of a third party's
potential liability to pay for the services, and the
contractor shall ensure that its cost avoidance
efforts do not prevent an enrollee from receiving
medically necessary services.
8.8 COMPENSATION/CAPITATION CONTRACTUAL REQUIREMENTS
A. Contractor Compensation. Compensation to the contractor shall
consist of monthly capitation payments, supplemental payments
per pregnancy outcome/delivery, certain blood products for
hemophilia factors VIII & IX disorders, and payment for
certain HIV/AIDS drugs. Contractors must agree to enroll all
non-exempt Aged, Blind and Disabled and NJ FamilyCare
beneficiaries to qualify to serve AFDC/TANF beneficiaries.
B. Capitation Payment Schedule. DMAHS hereby agrees to pay the
capitation by the fifteenth (15th) day of any month during
which health care services will be available to an enrollee;
provided that information pertaining to enrollment and
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eligibility, which is necessary to determine the amount of
said payment, is received by DMAHS within the time limitation
contained in Article 5 of this contract.
C. Upper Payment Limit and Cost-Effectiveness. The contractor
shall receive monthly capitation payments, for a defined scope
of services to be furnished to a defined number of enrollees,
for providing the services contained in the Benefits Package
described in Article 4.1 of this contract. Such payments will
not exceed the upper payment limit, established by DMAHS,
pursuant to 42 C.F.R. Part 447, which is the cost of providing
those services on a fee-for-service basis to an actuarially
equivalent, non-enrolled population group. The contractor is
not entitled to receive payments that exceed the upper payment
limit. In addition, the contractor is not entitled to payments
that would cause the State to exceed the cost-effectiveness
established in its 1915(b) waiver.
D. Adjustments and Renegotiation of Capitation Rates. Capitation
rates are prospective in nature and will not be adjusted
retroactively or subject to renegotiation during the contract
period except as explicitly noted in the contract. Capitation
rates will be paid only for eligible beneficiaries enrolled
during the period for which the adjusted capitation payments
are being made. Payments provided for under the contract will
be denied for new enrollees when, and for so long as, payments
for those enrollees is denied by HCFA under 42 C.F.R.
434.67(e).
E. Payment by State Fiscal Agent. The State fiscal agent will
make payments to the contractor.
F. Payment in Full. The monthly capitation payments plus
supplemental payments for pregnancy outcomes and payment for
certain HIV/AIDS drugs and blood clotting factors VIII and IX
to the contractor shall constitute full and complete payment
to the contractor and full discharge of any and all
responsibility by the Division for the costs of all services
that the contractor provides pursuant to this contract.
G. Payments to Providers. Payments shall not be made on behalf of
an enrollee to providers of health care services other than
the contractor for the benefits covered in Article Four and
rendered during the term of this contract.
H. Time Period for Capitation Payment per Enrollee. The monthly
capitation payment per enrollee is due to the contractor from
the effective date of an enrollee's enrollment until the
effective date of termination of enrollment or termination of
this contract, whichever occurs first.
I. Payment If Enrollment Begins after First Day of Month. When
DMAHS' capitation payment obligation is computed, if an
enrollee's coverage begins after
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the first day of a month, DMAHS will pay the contractor a
fractional capitation payment that is proportionate to the
part of the month during which the contractor provides
coverage. Payments are calculated and made to the last day of
a calendar month except as noted in this Article.
J. Risk Assumption. The capitation rates shall not include any
amount for recoupment of any losses suffered by the contractor
for risks assumed under this contract or any prior contract
with the Department.
K. Hospitalizations. For any eligible person who applies for
participation in the contractor's plan, but who is
hospitalized prior to the time coverage under the plan becomes
effective, such coverage shall not commence until the date
after such person is discharged from the hospital and DMAHS
shall be liable for payment for the hospitalization, including
any charges for readmission within forty-eight (48) hours of
discharge for the same diagnosis. If an enrollee's
disenrollment or termination becomes effective during a
hospitalization, the contractor shall be liable for
hospitalization until the date such person is discharged from
the hospital, including any charges for readmission within
forty-eight (48) hours of discharge for the same diagnosis.
The contractor must notify DMAHS of these occurrences to
facilitate payment to appropriate providers.
L. Continuation of Benefits. The contractor shall continue
benefits for all enrollees for the duration of the contract
period for which capitation payments have been made, including
enrollees in an inpatient facility until discharge. The
contractor shall notify DMAHS of these occurrences.
8.9 CONTRACTOR ADVANCED PAYMENTS AND PIPS TO PROVIDERS
A. The contractor shall make advance payments to its providers,
capitation, FFS, or other financial reimbursement arrangement,
based on a provider's historical billing or utilization of
services if the contractor's claims processing systems become
inoperational or experience any difficulty in making timely
payments. Under no circumstances shall the contractor default
on the claims payment timeliness provisions of this contract.
Advance payments shall also be made when compliance with
claims payment timeliness is less than ninety (90) percent for
two (2) quarters. Such advance payments will continue until
the contractor is in full compliance with timely payment
provisions for two (2) successive quarters.
B. Periodic Interim Payments (PIPs) to Hospitals. The contractor
shall provide periodic interim payments to participating,
PIP-qualifying hospitals.
1. Designation of PIP-Qualifying Hospitals. Each
quarter, DMAHS shall determine which hospitals
qualify for monthly PIPs.
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2. When Contractor is Required to Make PIPs. The
contractor shall make PIPs to a participating
(network provider), qualifying hospital when the
average monthly payment from the contractor to the
hospital is at least $100,000 for the most recent
six-month period excluding outliers. An outlier is
defined as a single admission for which the payment
to the hospital exceeds $100,000. It should be noted
that outlier claims paid are included in the
establishment of the monthly PIPs and the
reconciliation of the PIPs.
3. Methodologies to Establish Amount of PIPs.
a. The contractor may work out a mutually
agreeable arrangement with the participating
PIP-qualifying hospitals for developing a
methodology for determining the amount of
the PIPs and reconciling the PIP advances to
paid claims. If a mutually agreeable
arrangement cannot be reached, the
contractor shall make PIPs in accordance
with the methodology described in 3.b.
below.
b. Beginning August 1, 2000, the contractor
shall provide a participating,
PIP-qualifying hospital with an initial
60-day PIP (representing two 30-day cash
advances) which shall be reconciled using a
claims offset process, with the first 30-day
PIP reconciled to claims adjudicated during
the first month following the initial PIP
(August), and the second 30-day PIP
reconciled to claims adjudicated during the
second month following the initial PIP
(September). In September 2000 and all
subsequent months, the hospital shall
receive a 30-day PIP which shall be offset
against claims adjudicated at the end of the
following month. At reconciliation, any
excess claims adjudicated above the PIP
amount shall result in an additional payment
to the hospital equal to the value of any
excess claims above the PIP. If the value of
claims adjudicated is less than the PIP, the
shortage shall be offset against the next
PIP made to the hospital. An example of how
this methodology shall work is as follows:
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EXAMPLE:
PIP Claims Reconciliation Net
Payment Adjudicated Adjustment Payment Balance
------- ----------- ---------- ------- -------
Aug 1 300,000(A)
Aug 1 300,000(B) 600,000
Aug 1-31 180,000 420,000
Sept 1 300,000(C) (120,000)(A) 180,000 600,000
Sept 1-30 270,000 330,000
Oct 1 300,000(D) (30,000)(B) 270,000 600,000
Oct 1-31 320,000 280,000
Nov 1 300,000(E) 20,000(C) 320,000 600,000
8.10 FEDERALLY QUALIFIED HEALTH CENTERS
A. Standards for Contractor FQHC Rates. The contractor shall not
reimburse FQHCs less than the level and amount of payment
which the contractor would make for a similar set of services
if the services were furnished by a non-FQHC. The contractor
may pay the FQHCs on a fee-for-service or capitated basis. The
contractor shall make payments for primary care equal to, or
greater than, the average amounts paid to other primary care
providers. Non-primary care services may be included if
mutually agreeable between the contractor and FQHC. For
non-primary care services, payments shall be equal to, or
greater than, the average amounts paid to other non-primary
care providers for equivalent services.
B. DMAHS Reimbursement to FQHCs. Under Title XIX, an FQHC shall
be paid reasonable cost reimbursement by DMAHS. At the end of
each fiscal year the contractor and the FQHC will complete
certain reporting requirements specified that will enable
DMAHS to determine reasonable costs and compare that to what
was actually paid by the contractor to the FQHC. DMAHS will
reimburse the FQHC for the difference (i.e., difference
between the determined reasonable cost per encounter and the
payments to the FQHC made by the contractor and DMAHS) if the
payments by the contractor to the FQHC are less than
reasonable costs. DMAHS will recoup payments from the FQHC in
excess of reasonable costs. FQHC providers must meet the
contractor's credentialing and program requirements.
C. Contractor Participation in Reconciliation Process. The
contractor shall participate in the reconciliation processes
if there is a dispute between what the contractor reported
(See Section A.7.20 of the Appendices (Table 18)) and what the
FQHC reported as valid encounters or payments. This
participation may include appearances in the Office of
Administrative Law, as well as meeting with DMAHS staff.
VIII-23
298
IN WITNESS WHEREOF, the parties hereto have caused this contract and Appendices
to be executed this _____ day of _____, 2000. This contract and Appendices are
hereby accepted and considered binding in accordance with the terms outlined in
the preceding statements.
CONTRACTOR STATE OF NEW JERSEY
ADDRESS DEPARTMENT OF HUMAN SERVICES
DIRECTOR, DIVISION MEDICAL ASSISTANCE
AND HEALTH SERVICES
BY:______________________ BY:________________________
TITLE:___________________ TITLE: Director, DMAHS
DATE:____________________ DATE:______________________
Approved As to Form
_______________________
Deputy Attorney General
Date:_________________
