New Jersey Administrative Code

(a) Each CMO shall catalog all available services and community resources available to support the ISP design, and shall provide a list of these services and resources to the CSA for inclusion in the Statewide database that shall be maintained for children's services. (b) Each CM…

(a) Under the CSOC children's system of care, the care provided and the payment for care is individualized and child centered rather than program and service centered. The CMO has responsibilities, as a systems partner, to assist in the implementation of this principle as outline…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context indicates otherwise: "Adult" means a beneficiary age 21 years or older. "Care management organization (CMO)" means an independent, community-based organization that …

(a) Each CMO shall establish and maintain an integrated electronic child and family file. (b) Each CMO shall use the software provided by the CSA to obtain, organize, analyze, and distribute the following information: 1. Records management, including creating and maintaining indi…

(a) Each CMO shall develop an annual Quality Assessment and Performance Improvement (QAPI) Plan. (b) In addition to the CMO's annual QAPI Plan, each CMO shall be evaluated by DCF, or its designated agent, based on various performance measures, including the following: 1. Timeline…

(a) CMO staffing shall include: 1. An administrative staff, to include an executive director; 2. Adequate support staff to effectively perform clerical, financial, quality management, and MIS functions; 3. Direct care staff for clinical operations; and 4. Support for the communit…

(a) The Executive Director shall have a Master's degree in a relevant discipline, such as social work, counseling, psychology, psychiatric nursing, criminal justice or special education, with a minimum of five years' post Master's related supervisory experience in child welfare, …

(a) Each CMO provider shall maintain all records in accordance with N.J.A.C. 10:3 and in compliance with all applicable State laws and rules including, but not limited to, N.J.A.C. 10:49-9.8. (b) Each CMO provider shall keep such individual legible records as are necessary to ful…

(a) Claims for CMO services shall be submitted on a monthly fee-for-service basis for the care management component of the CMO's services. 1. The CMO shall bill for the first month that a beneficiary begins receiving services from the CMO, regardless of the specific initial date …

(a) Prior to enrollment as a Medicaid/NJ FamilyCare provider, any agency applying to render Medicaid/NJ FamilyCare CMO services shall first be under contract with the New Jersey Department of Human Services as an approved CMO provider. Such contract shall be in full effect and sh…

(a) Under contract to the Department of Children and Families and working as a systems partner with CSOC, each CMO provider shall: 1. Provide initial and continuing case management services to children and families referred to them by the Department of Children and Families or ot…

(a) A child, youth, or young adult may be eligible for CMO services if: 1. He or she meets the requirements of this subchapter and is:i. Enrolled in Medicaid/NJ FamilyCare as described at N.J.A.C. 10:49-2, and not enrolled in: : (1) The Medically Needy Program, except that pregna…

(a) A child, youth, or young adult shall be discharged from CMO services if: 1. The child, youth, or young adult's CSOC assessment, ISP, and other relevant information indicate that the child, youth, or young adult no longer needs CMO services; or 2. The child, youth or young adu…

(a) All CMO providers shall: 1. Complete a presumptive eligibility (PE) application for each child, youth and young adult who is not otherwise covered under Medicaid/NJ FamilyCare at the time of the referral to the CMO, if the PE process has not already been initiated by another …

(a) The CMO shall initiate enrollment of the child, youth or young adult upon receipt of the referral from the Department of Children and Families or its designated agent and shall complete the electronic case record within seven calendar days of receipt of the referral. (b) The …

(a) To complete the comprehensive ISP, the CMO shall develop a Child/Family Team, in conjunction with the family member or caregiver, which shall consist of, at a minimum, the following members: 1. A CMO care manager; 2. The child, youth or young adult and the parent or other car…

(a) This subchapter sets forth the requirements that all providers shall follow to receive reimbursement for the provision of youth case management (YCM) services to eligible Medicaid/NJ FamilyCare beneficiaries and children, youth, and young adults receiving services from the Ch…

(a) Reimbursement for YCM services shall be fee-for-service. (b) All reimbursement shall be restricted to approved Medicaid/NJ FamilyCare YCM providers and shall be subject to all applicable Medicaid/NJ FamilyCare rules, including N.J.A.C. 10:49 and these rules. (c) A unit of ser…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Collateral contact or activities" means non face-to-face contact or activities that the youth case manager engages in on behalf of the …

(a) Prior to enrollment as a Medicaid/NJ FamilyCare provider, any agency applying to render youth case management services shall first be under contract with the Children's System of Care, and licensed by DHS as an approved youth case management provider. Such contract and licens…

(a) A child, youth, or young adult may be eligible for YCM services if: 1. He or she meets the requirements of this subchapter and is:i. Enrolled in Medicaid/NJ FamilyCare, as described at N.J.A.C. 10:49-2, and not enrolled in: (1) The Medically Needy Program, except that pregnan…

(a) Youth Case Management (YCM) services are case management services provided to Medicaid/NJ FamilyCare beneficiaries of CSOC services who are under the age of 18 or those young adults between the ages of 18 and 21 who are transitioning from the child service system to the adult…

(a) The CSA shall conduct a basic preliminary screening of each child, youth, or young adult referred to the CSA by the Children's System of Care to determine the level of case management appropriate to meet the case management needs of the child, youth, or young adult. Upon dete…

(a) The individual YCM service plan shall be based on the results of the YCM agency's evaluation of the mental health/behavioral health needs as well as the case management needs of the child, youth or young adult. The YCM service plan shall be completed and registered with the C…

Notes N.J. Admin. Code § 10:73-4.8 Repealed by R.2006 d.421, effective 5/21/2007. See: 38 N.J.R. 2585(a), 39 N.J.R. 2096(a). Section was "Authorization of services".

(a) YCM providers shall keep such individual records as are necessary to fully disclose the kind and extent of services provided. (b) Each YCM provider shall maintain the following data in support of all claims: 1. The name and address of the child, youth or young adult; 2. The r…

(a) The New Jersey Medicaid/NJ FamilyCare program adopted the Centers for Medicare & Medicaid Services Healthcare Common Procedure Coding System (HCPCS) codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act of…

HCPCS Maximum Fee IND Code Mod Description Allowance P T1017 TJ Youth Case Management Services (unit of $ 20.30/unit service=15 consecutive minutes) P Z5008 Care Management Organization (CMO) Services $ 960.00 for Children, Youth, and Young Adults receiving DCBHS Services; per mo…

The rules in this chapter set forth the manner in which the New Jersey Medicaid/NJ FamilyCare programs shall provide covered health services to eligible persons through the Managed Care program, by means of managed care organizations (MCOs). Notes N.J. Admin. Code § 10:74-1.1 Ame…

(a) The State Medicaid program provides managed medical services under the authority of the New Jersey 1115 demonstration project entitled "New Jersey FamilyCare Comprehensive Demonstration" and under Section 1932(a) of the Social Security Act (42 U.S.C. § 1396u-2(a)). (b) Manage…

(a) The provisions within this chapter affect Medicaid/NJ FamilyCare beneficiaries. (b) The rules in this chapter also affect Medicaid/NJ FamilyCare providers, including managed care entities and those providers who will continue to provide certain services on a fee-for-service b…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise: "ABD" means those individuals who are determined to be categorically eligible for Medicaid because they are aged, blind or disabled. Eligib…

(a) The managed care contractor may implement a lock-in program that restricts its enrollees to a single pharmacy and/or other provider type for a reasonable period of time. The program shall include policies, procedures, and criteria for establishing the need for the lock-in, wh…

(a) Each contractor shall maintain medical information on each member who has received medical services while enrolled in the contractor's plan, and shall retain such records in accordance with 45 CFR Part 74 and applicable Federal and State law and rule. (b) Each enrollee's medi…

(a) The Division and the U.S. Department of Health and Human Services shall have the right to inspect or otherwise evaluate the quality, appropriateness and timeliness of services performed by the contractor in accordance with State and Federal requirements. (b) The contractor sh…

Notes N.J. Admin. Code § 10:74-10.3 Recodified to N.J.A.C. 10:74-10.2 by R.2012 d.041, effective 2/21/2012. See: 43 N.J.R. 257(b), 44 N.J.R. 494(a). Section was "Quality Assurance".

(a) The contractor shall establish a grievance procedure for the receipt and adjudication of any and all complaints from enrollees or managed care providers on behalf of enrollees, with the enrollees' consent, relating to quality, scope, nature and delivery of services. (b) The g…

(a) The contractor shall ensure that all Medicaid and NJ FamilyCare-Plan A and Plan D adult enrollees with incomes under 134 percent of the FPL, shall be informed, in a simple, brief statement, of their rights to a fair hearing in accordance with N.J.A.C. 10:49-10, and of the con…

(a) Compensation to the contractor for MCO enrollees shall consist of monthly capitation payments for each enrollee. These payments shall be for a defined scope of services to be furnished to a defined number of enrollees, for providing the services contained in the Benefits Pack…

(a) Capitation rates shall be derived from MCO expenditure and encounter data. (b) Adjustments to capitation rates shall be made to address certain features such as trends, program changes and risk factors associated with certain enrollee populations. Notes N.J. Admin. Code § 10:…

(a) Capitation rates are prospective in nature and will not be adjusted retroactively. (b) Capitation rates shall not be subject to renegotiation during the contract period, except when any changes in Federal and/or State laws, rules, regulations or covered services so require. (…

(a) The monthly capitation payments are due to the contractor from the enrollees' effective dates of enrollment until the effective dates of disenrollment or termination of the MCO's contract, whichever occurs first. (b) When DMAHS's capitation payment obligation is computed, cap…

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 such person is discharged from the hospital, and DMAHS shall be lia…

Notes N.J. Admin. Code § 10:74-12.6 Amended by R.1998 d.116, effective 1/30/1998 (operative February 1, 1998; to expire July 31, 1998). See: 30 New Jersey Register 713(a). Inserted references to NJ KidCare-Plan A throughout. Adopted concurrent proposal, R.1998 d.426, effective 7/…

(a) The contractor shall not be responsible and shall not be paid when DMAHS has previously notified the contractor by mail specifying enrollee-months for which DMAHS is not responsible. (b) If an enrollee is deceased and appears on the beneficiary file as active, the contractor …

Notes N.J. Admin. Code § 10:74-12.8 Recodified to N.J.A.C. 10:74-12.7 by R.2000 d.370, effective 9/18/2000 (operative October 1, 2000). See: 32 New Jersey Register 1352(a), 32 New Jersey Register 3426(a).

(a) Each contractor shall furnish such timely information and reports as the Division may find necessary, and on such forms or in such format as the Division may prescribe, as specified in the contract. Such reports shall include information sufficient for Division management, mo…

(a) Provisions under federal law relating to imposition of penalties upon providers of health care services can be found at Section 1903(m)(5)(A) of the Social Security Act. (b) Monetary damages shall be imposed by DHS for failure of the contractor to comply with the timeliness a…

(a) The contractor shall: 1. Comply with the requirements of the New Jersey Certificate of Authority statutes and rules ( P.L. 1973, c. 337, N.J.S.A. 26:2J-1 et seq., and N.J.A.C. 11:24); 2. Provide to the Division of Medical Assistance and Health Services, Department of Human Se…

(a) The definition of "comprehensive risk contract" found at 42 CFR Part 438, as amended and supplemented, is incorporated herein by reference. (b) Under the risk contract, all MCO/managed health care contractors shall provide standard service packages as detailed in the managed …