N.J. Admin. Code § 10:52-4.8

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:52-4.8 - Personal contribution to care requirements for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D

(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D fee-for-service are set forth at N.J.A.C. 10:49-9.

(b) Personal contribution to care for NJ FamilyCare-Plan C services are $ 5.00 a visit for outpatient clinic visits and $ 10.00 for an emergency room visit that does not result in an inpatient hospital stay.

(c) Hospitals are required to collect the personal contribution to care for the above mentioned NJ FamilyCare-Plan C services if the NJ FamilyCare Identification Card indicates that a personal contribution to care is required and the beneficiary does not have a NJ FamilyCare form which indicates that the beneficiary has reached their cost share limit and no further personal contributions to care are required, until further notice. Personal contribution to care charges cannot be waived.

(d) Under NJ FamilyCare-Plan D, copayments in the amounts indicated below shall be collected by the hospital for the services as follows:

1. A $ 5.00 copayment per visit shall be required for the following services:

i. Outpatient rehabilitation services, including physical therapy, occupational therapy and speech therapy;

ii. Hospital outpatient department visits and diagnostic testing;

(1) For prenatal care, the $ 5.00 copayment shall apply only to the first visit;

2. A $ 25.00 copayment per visit shall be required for outpatient mental health visits; and

3. A $ 35.00 copayment per visit shall be required for outpatient emergency services including services provided in an outpatient hospital department or an urgent care facility.

i. No copayment shall be required if the beneficiary was referred to the emergency room by his or her primary care provider for services that should have been rendered in the primary care physician's office or if the beneficiary is admitted into the hospital.

4. No copayment shall be charged for the following services:

i. Outpatient surgery;

ii. Inpatient hospital services;

iii. Inpatient mental health services;

iv. Inpatient substance use disorder detoxification services; or

v. Skilled nursing facility services.

(e) Hospitals shall collect the copayment specified in (d) above except for those situations outlined in (f) below. Copayments shall not be waived.

(f) Hospitals shall not charge a copayment under Plan D for services provided to newborns, who are covered under fee-for-service for Plan D; or for preventive services, including well child visits and age-appropriate immunizations; for lead screenings and treatment, or for preventive dental services provided to children under the age of 12.

N.J. Admin. Code § 10:52-4.8

Amended by 50 N.J.R. 1261(a), effective 5/21/2018