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STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
AND
AMERIGROUP NEW JERSEY, INC.
AGREEMENT TO PROVIDE HMO SERVICES
In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract
between AMERIGROUP New Jersey, Inc. and the State of New Jersey, Department of
Human Services, Division of Medical Assistance and Health Services (DMAHS),
effective date October 1, 2000, all parties agree that the contract shall be
amended, effective August 1, 2003, as follows:
{PAGE}
Dental/Chiropractic Extension - August 1, 2003
1. ARTICLE 4, "PROVISION OF HEALTH CARE SERVICES," Sections 4.1;
4.1.1(G)3; 4.1.2(A)14; 4.1.2(A)23; 4.1.4(B); 4.1.9(S); 4.1.9(T);
4.2.1(B)3; 4.5.4(D); 4.6.2(P); 4.6.5(D); 4.8.8(I) and 4.8.8(M)2 shall
be amended as reflected in Article 4, Sections 4.1; 4.1.1(G)3;
4.1.2(A)14; 4.1.2(A)23; 4.1.4(B); 4.1.9(S); 4.1.9(T); 4.2.1(B)3;
4.5.4(D); 4.6.2(P); 4.6.5(D); 4.8.8(I) and 4.8.8(M)2 attached hereto
and incorporated herein.
2. ARTICLE 5, "ENROLLEE SERVICES," Sections 5.10.2(A)2(a)vi, vii (new);
5.15.2(B)6; 5.15.2(B)7 and 5.16.1(K) shall be amended as reflected in
Article 5, Sections 5.10.2(A)2(a)vi, vii; 5.15.2(B)6; 5.15.2(B)7 and
5.16.1(K) attached hereto and incorporated herein.
3. ARTICLE 6, "PROVIDER INFORMATION," Section 6.5(B)1 shall be amended as
reflected in Article 6, Section 6.5(B)1 attached hereto and
incorporated herein.
4. ARTICLE 7, "TERMS AND CONDITIONS," Sections 7.16.8.1 (E) and 7.38 shall
be amended as reflected in Article 7, Sections 7.16.8.1(E) and 7.38
attached hereto and incorporated herein.
5. ARTICLE 8, "FINANCIAL PROVISIONS," Sections 8.5.1; 8.5.2.1; 8.5.2.2;
8.5.2.4; 8.5.2.6; 8.5.2.8; 8.5.2.9; 8.5.2.10(deleted); 8.5.4; 8.5.5 and
8.5.6 shall be amended as reflected in Sections 8.5.1; 8.5.2.1;
8.5.2.2; 8.5.2.4; 8.5.2.6; 8.5.2.8; 8.5.2.9; 8.5.2.10; 8.5.4; 8.5.5 and
8.5.6 attached hereto and incorporated herein.
6. APPENDIX, SECTION A, "REPORTS"
A.4.1 - Provider Network File Electronic Media Provider Files,
Attachment A, Attachment B & Attachment D, shall be amended as
reflected in Appendix, Section A, A.4.1, Attachments A, B and D
attached hereto and incorporated herein.
7. APPENDIX, SECTION C, "CAPITATION RATES," shall be revised as reflected
in SFY 2004 Capitation Rates attached hereto and incorporated herein
{PAGE}
Dental/Chiropractic Extension - August 1, 2003
All other terms and conditions of the October 1, 2000 contract and subsequent
amendments remain unchanged except as noted above.
The contracting parties indicate their agreement by their signatures.
AMERIGROUP STATE OF NEW JERSEY
NEW JERSEY, INC. DEPARTMENT OF HUMAN SERVICES
BY: /S/ [ILLEGIBLE] BY: /S/ DAVID C. HEINS
------------------------ ----------------------
DAVID C. HEINS
TITLE: PRESIDENT AND CEO TITLE: ACTING DIRECTOR, DMAHS
DATE: JULY 17,2003 DATE: 7/28/03
APPROVED AS TO FORM ONLY
ATTORNEY GENERAL
STATE OF NEW JERSEY
BY: /S/ [ILLEGIBLE]
--------------------------
DEPUTY ATTORNEY GENERAL
DATE: 7/25/03
{PAGE}
ARTICLE FOUR: PROVISION OF HEALTH CARE SERVICES
4.1 COVERED SERVICES
For enrollees who are eligible through Title V, 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/NJ FamilyCare beneficiaries are entitled to receive under
Medicaid/NJ FamilyCare, 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/NJ FamilyCare 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; Part 438 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 Articles
4.1.6 and 4.1.7.
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.
Except for full-time students, the contractor shall not be
responsible for out-of-state coverage for care if the enrollee
resides out-of-state for more than 30 days. In this instance,
the individual will be disenrolled. This does not apply to
situations when the
IV-1
{PAGE}
enrollee is out of State for care provided/authorized by the
contractor, for example, prolonged hospital care for
transplants. For full time students 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 Medical
Assistance Customer Center (MACC), 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.
1. 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.
2. The contractor may pay an out-of-network hospital
provider, located outside the State of New Jersey,
the New Jersey Medicaid fee-for-service rate for the
applicable services rendered.
3. Whenever the contractor authorizes services by
out-of-network providers, the contractor shall
require those out-of-network providers to coordinate
with the contractor with respect to payment. Further,
the contractor shall ensure that [Reserved] the cost
[Reserved] to the enrollee is no greater than it
would be if the services were furnished within the
network.
IV-2
{PAGE}
retrovirals, blood clotting factors VIII and IX, and
coverage of protease inhibitors and 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 [Reserved]
15. Optometrist Services
16. Optical Appliances
17. Hearing Aid Services
18. Home Health Agency Services - Not a
contractor-covered benefit for the non-dually
eligible ABD population. All other services provided
to any enrollee in the home, including but not
limited to pharmacy and DME services, are the
contractor's fiscal and medical management
responsibility.
19. Hospice Services--are covered in the community as
well as in institutional settings. Room and board
services are included only when services are
delivered in an institutional (non-private residence)
setting.
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 [Reserved]
24. Organ Transplants - includes donor and recipient
costs. Exception: The contractor will not be
responsible for transplant-related donor and
recipient inpatient hospital costs for an individual
placed on a transplant list while in the Medicaid FFS
program prior to enrollment into the contractor's
plan.
IV-5
{PAGE}
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:
[Reserved]
- Atypical antipsychotic drugs within the Specific
Therapeutic Drug Classes H7T and H7X
- 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
- Genetically-equivalent drug products of the drugs
listed in this section.
C. Up to twelve (12) inpatient hospital days required for social
necessity in accordance with Medicaid regulations.
IV-9
{PAGE}
M. 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.
N. 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.
O. Any services or items furnished for which the
provider does not normally charge.
P. Services furnished by an immediate relative or member
of the Medicaid beneficiary's household.
Q. 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.
R. 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.
[Reserved]
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:
1. Placing the health of the person or others in serious
jeopardy;
2. Serious impairment to such person's bodily functions;
IV-20
{PAGE}
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 foster
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. Section 422. [Reserved] 113(c).
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 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.
IV-21
{PAGE}
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 who hold current RN licenses with at
least three (3) years experience serving enrollees
with special needs or a graduate degree in social
work with at least two (2) years experience serving
enrollees with special needs.
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, consultation with any specialists caring for
the enrollee, 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 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,
IV-55
{PAGE}
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.
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, 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:
{TABLE}
{CAPTION}
HEDIS Report Period
Reporting Set Measures by Contract Year
---------------------- ----------------
{S} {C}
Childhood Immunization Status annually
Adolescent Immunization Status annually
Well-Child Visits in first 15 months of life annually
Well-Child Visits in the 3rd, 4th, 5th and 6th year of life annually
Adolescent Well-Care Visits annually
Prenatal and Postpartum Care annually
Frequency of Ongoing Prenatal Care annually
Breast Cancer Screening annually
{/TABLE}
Childhood & Adolescent Immunization HEDIS data for NJ
FamilyCare enrollees up to the age of 19 years must be
reported separately.
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
IV-64
{PAGE}
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
forty-five (45) 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.
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, consultation
with any specialists caring for the enrollee, 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
IV-85
{PAGE}
I. Provider Network Access Standards and Ratios
{TABLE}
{CAPTION}
Specialty A - Miles per 2 B - Miles per 1 Min. No. Per County Capacity Limit
Urban Non-Urban Urban Non-urban Except Where Noted Per Provider
------------------------------------------------------------------------------------------------------------------------
{S} {C} {C} {C} {C} {C} {C}
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: 1,000
------------------------------------------------------------------------------------------------------------------------
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 1 1: 20,000
------------------------------------------------------------------------------------------------------------------------
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 (where available) 1: 30,000
------------------------------------------------------------------------------------------------------------------------
Gastroenterology 15 25 10 15 2 1: 100,000
------------------------------------------------------------------------------------------------------------------------
General Surgery 15 25 10 15 2 1: 30,000
------------------------------------------------------------------------------------------------------------------------
Geriatric Medicine 15 25 10 15 1 1: 10,000
------------------------------------------------------------------------------------------------------------------------
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 (where available) 1: 30,000
------------------------------------------------------------------------------------------------------------------------
Physical Medicine 15 25 10 15 [Reserved] (where applicable) 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 [Reserved] 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
------------------------------------------------------------------------------------------------------------------------
[Reserved] 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
(where applicable)
------------------------------------------------------------------------------------------------------------------------
Pharmacies 10 15 5 12 1: 1,000
------------------------------------------------------------------------------------------------------------------------
Laboratory N/A N/A 7 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
------------------------------------------------------------------------------------------------------------------------
{/TABLE}
IV-107
{PAGE}
12. The Department will make the final decision on the
appropriateness of increasing the ratio limits and
what the limit will be.
M. Regional/Statewide Networks
1. The contractor shall pay for organ transplants in
accordance with Article 4.1.2 and shall contract with or
refer to organ transplant providers/centers. The
contractor shall provide the name and address of a
transplant center for each type of organ transplant
required under this contract.
2. The providers/specialists listed below may be included in
the contractor's provider network on a regional or
statewide basis. The contractor shall indicate for each
group whether the services by each provider are provided
statewide or by region, specifying the counties in the
region. The contractor shall provide documentation
(license/certification) and certify that the providers
[Reserved] are willing, capable, and authorized (through
licensure or certification) to serve multiple counties or
statewide.
a. Medical Toxicology
b. Developmental & Behavioral Pediatrics
c. Medical Genetics
d. Specialty Centers (Centers of Excellence)
e. Other Specialty Centers/Providers
f. DME providers
g. Medical suppliers
h. Prosthetists, orthotists, pedorthists
i. Hearing aid suppliers
j. Transportation providers
3. Specialists. The contractor shall submit specific
provider information with the monthly network file with a
certification of the unavailability of the American Board
of Medical Specialists (ABMS) diplomates in the county,
the provider who shall provide the service and
documentation that the provider is able, willing, and
authorized to provide the service. The contractor shall
notify the DMAHS if the alternate provider terminates.
The contractor shall assure that the specialist or
alternate provider has privileges in a network hospital
or shall authorize and pay for services provided by the
specialist or alternate provider at an out of network
hospital provider. Where there is neither, a certified
specialist or acceptable alternative provider for a
particular specialty service, the contractor may refer an
enrollee out of county. For the physician specialist
types listed below, where there is documentation of
limited access or unavailability in a county of a
specific type of specialist, the contractor may indicate
the name of a contracted provider as an alternative for
the following:
a) Colon & Rectal surgeon - A general surgeon with
privileges to perform this surgery may be
substituted for a certified subspecialist in this
field
IV-112
{PAGE}
ii. Enrollee has filed a
grievance/appeal with the
contractor pursuant to the
applicable grievance/appeal
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/appeal, 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.
vi. Poor quality of care.
vii. Other for cause reasons pursuant to
42 CFR 438.56
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 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.
V-25
{PAGE}
1. Information to enrollees on how to file
complaints/grievances/appeals
2. Identification of who is responsible for processing
and reviewing grievances/appeals
3. Local or toll-free telephone number for filing of
complaints/grievances/appeals
4. Information on obtaining grievance/appeal forms and
copies of grievance/appeal procedures for each
primary medical/dental care site
5. Expected timeframes for acknowledgment of receipt of
grievances/appeals
6. Expected timeframes for disposition of
grievances/appeals in accordance with N.J.A.C. 8:38
et seq. and 42 CFR 438.408
7. Extensions of the grievance/appeal process if needed
and time frames in accordance with N.J.A.C. 8:38 et
seq. and [Reserved] 2 CFR- [Reserved] 438.408
8. 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/appeal
9. DHSS process for use of Independent Utilization
Review Organization (IURO)
C. A description of the process under which an enrollee may file
an appeal 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
4. The right to request a Medicaid Fair Hearing/DHSS
IURO processes where applicable to specific enrollee
eligibility categories
5.15.3 GRIEVANCE/APPEAL PROCEDURES
A. Availability. The contractor's grievance/appeal 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. The procedure shall
assure that grievances/appeals may be filed verbally directly
with the contractor.
V - 37
{PAGE}
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
438.56. 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'
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 and
ABD 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. The contractor shall explain that all health care benefits as
specified in Article 4.1 must be obtained through a PCP.
Q. The contractor shall periodically review and assess the
knowledge and performance of its marketing representatives.
V - 43
{PAGE}
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/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. Complaints, Grievances/Appeals. The contractor shall establish
and maintain provider complaint, grievance/appeal 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, to request
medical necessity reviews for administrative denials,
and get problems resolved without going through the
formal, written grievance/appeal process.
2. The contractor shall have in place a formal
grievance/appeal process which network providers and
non-participating providers can use to complain in
writing. The contractor shall issue a written
response to a grievance within 30 days. With respect
to appeals, the contractor shall also issue a written
response within 30 days.
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.
VI-4
{PAGE}
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.
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 [Reserved] 438.
6(h), 422.208, and 422.210.
F. Violates the prohibition of restricting provider-enrollee
communications.
G. Distributes directly or indirectly through any agent or
independent contracted entity, marketing materials that have
not been approved by DHS or that contain false or materially
misleading information.
H. Violates any of the requirements of sections 1903(m) or 1932
of the Social Security Act, and any implementing regulations.
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,
VII-31
{PAGE}
7.38 FRAUD AND ABUSE
The contractor shall have arrangements and procedures that
comply with all state and federal statutes and regulations,
including 42 CFR 438.608, governing fraud and abuse
requirements.
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. A means to verify services were actually provided.
4. Reporting investigation results within twenty (20)
business days to DMAHS.
5. Specifications of, and reports generated by, the
contractor's prepayment and postpayment surveillance
and utilization review systems, including prepayment
and postpayment edits.
VII-47
{PAGE}
Rates for DYFS, NJ FamilyCare Plans B, C, [Reserved] D, and H and the non
risk-adjusted rates for AIDS and clients of DDD are statewide. Rates for
[Reserved] all other premium groups are regional in each of the following
regions:
- Region 1: Bergen, Hudson, Hunterdon, Morris, Passaic, Somerset,
Sussex, and Warren counties
- Region 2: Essex, Union, Middlesex, and Mercer counties
- Region 3: Atlantic, Burlington, Camden, Cape May, Cumberland,
Gloucester, Monmouth, Ocean, and Salem counties
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 MAJOR PREMIUM GROUPS
The following is a list of the major premium groups. The individual
rate groups (e.g. children under 2 years, etc.) with their respective
rates are presented in the rate tables in the appendix.
8.5.2.1 AFDC/TANF, NJC PREGNANT WOMEN, AND NJ FAMILYCARE PLAN A CHILDREN
This grouping includes capitation rates for Aid to Families with
Dependent Children (AFDC)/Temporary Assistance for Needy Families
(TANF), New Jersey Care Pregnant Women and Children, and NJ FamilyCare
Plan A children ( [Reserved] includes individuals under 21 in PSC
380), but excludes individuals who have AIDS or are clients of DDD.
8.5.2.2 NJ FAMILYCARE PLANS B & C
This grouping includes capitation rates for NJ FamilyCare Plans B and C
enrollees, excluding individuals with AIDS and/or DDD clients.
8.5.2.3 NJ FAMILYCARE PLAN D CHILDREN
This grouping includes capitation rates for NJ FamilyCare Plan D
children, excluding individuals with AIDS.
8.5.2.4 NJ FAMILYCARE PLAN D PARENTS/CARETAKERS
This grouping includes capitation rates for NJ FamilyCare Plan D
parents/caretakers, excluding individuals with AIDS, and include only
enrollees 19 years of age or older.
VIII-6
{PAGE}
8.5.2.5 DYFS AND AGING OUT FOSTER CHILDREN
This grouping includes capitation rates for Division of Youth and
Family Services, excluding individuals with AIDS and clients of DDD.
8.5.2.6 ABD WITHOUT MEDICARE
Compensation to the contractor for the ABD individuals without Medicare
will be risk-adjusted using the Health Based Payments System (HBPS),
which is described in Article 8.6. [Reserved] 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.
8.5.2.7 ABD WITH MEDICARE
This grouping includes capitation rates for the ABD with Medicare
population, excluding individuals with AIDS and clients of DDD.
8.5.2.8 CLIENTS OF DDD
This grouping includes all enrollees except ABD individuals without
Medicare. The contractor shall be paid separate, statewide rates for
subgroups of the DDD population, excluding individuals with AIDS. These
rates include MH/SA services.
8.5.2.9 ENROLLEES WITH AIDS
This grouping includes all enrollees except ABD individuals without
Medicare.
A. The contractor shall be paid special statewide capitation
rates for enrollees with AIDS.
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.
8.5.2.10 RESERVED
[Reserved]
VIII-7
{PAGE}
8.5.3 NEWBORN INFANTS
The contractor shall be reimbursed for newborns from the date of birth
through the first 60 days after the birth through the period ending at
the end of the month in which the 60th day falls by a supplemental
payment as part of the supplemental maternity payment. Thereafter,
capitation payments will be made prospectively, i.e., only when the
baby's name and ID number are accreted to the Medicaid eligibility file
and formally enrolled in the contractor's plan.
8.5.4 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 for the first 60 days after the
birth plus through the end of the month in which the 60th day falls are
included (See Section 8.5.3). Regional [Reserved] payment shall be
made by the State to the contractor based on submission of appropriate
encounter data [Reserved] as specified by DMAHS.
8.5.5 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) notification
from the contractor to DMAHS within 12 months of the date of service of
identification of individuals with factor VII or IX hemophilia. Payment
for these products will be the lesser of: 1) Average Wholesale Price
(AWP) minus [Reserved] 12.5% and 2) rates paid by the contractor.
8.5.6 PAYMENT FOR HIV/AIDS DRUGS
The contractor shall be paid separately for protease inhibitors and
other anti-retroviral agents (First Data Bank Specific Therapeutic
Class Codes W5C, W5B, W5I, WSJ, W5K, W5L, W5M, W5N) for all eligibility
groups. Payment for protease inhibitors shall be made by DMAHS to the
contractor based on: 1) submission of appropriate encounter data; and
2) notification from the contractor to DMAHS within 12 months of the
date of service of identification of individuals with HIV/AIDS. Payment
for these products will be the lesser of: 1) Average Wholesale Price
(AWP) minus [Reserved] 12.5% and 2) rates paid by the contractor.
VIII-8
{PAGE}
ATTACHMENT A
New Jersey Department of Human Services, Division of
Medical Assistance, Office of Managed Health Care
HMO Non-Institutional Provider Network File Specifications
{TABLE}
{CAPTION}
--------------------------------------------------------------------------------------------------------------------------
When
Field Field Name Size Required Definition Example
--------------------------------------------------------------------------------------------------------------------------
{S} {C} {C} {C} {C} {C}
1 Last Name 22 A Individual Provider's Surname; may include Jr. or III Jones, Jr.
--------------------------------------------------------------------------------------------------------------------------
2 First Name 15 A Provider's First Name; should include middle initial Tom T.
--------------------------------------------------------------------------------------------------------------------------
3 SSN 9 A Provider's Social Security Number 150999999
--------------------------------------------------------------------------------------------------------------------------
4 Tax ID 9 B Provider's Tax ID Number 229999999
--------------------------------------------------------------------------------------------------------------------------
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