N.J. Admin. Code § 10:58A-1.6

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:58A-1.6 - 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 in N.J.A.C. 10:49-9.

(b) Personal contribution to care for NJ FamilyCare-Plan C services is $ 5.00 a visit for office visits, except as noted in (c) below.

1. An office visit is defined as a face-to-face contact with a medical professional, which meets the documentation requirements at N.J.A.C. 10:58A-1.4.

2. Office visits include APN services provided in the office, beneficiary's home, or any other site, except a hospital, where the child may have been examined by the APN. Generally, these procedure codes are in the 90000 HCPCS series of reimbursable codes at N.J.A.C. 10:58A-4.

3. APN services which do not meet the requirements of an office visit as defined in this chapter, such as surgical services, immunizations, laboratory or x-ray services, do not require a personal contribution to care.

(c) APNs shall not charge a personal contribution to care for services provided to newborns, who are covered under fee-for-service for Plan C; for family planning services, for substance abuse treatment services, for prenatal care or for preventive services, including appropriate immunizations.

(d) The copayment for APN services under NJ FamilyCare-Plan D shall be $ 5.00 per office visit;

1. A $ 10.00 copayment shall apply for services rendered during non-office hours and for home visits.

2. The $ 5.00 copayment shall apply only to the first prenatal visit.

(e) APNs are required to collect the copayment specified in (d) above except as provided in (f) below. Copayments shall not be waived.

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

N.J. Admin. Code § 10:58A-1.6

New Rule, R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 with changes, effective 9/21/1998.
Amended by R.1999 d.211, effective 7/6/1999 (operative August 1, 1999).
See: 31 N.J.R. 998(a), 31 N.J.R. 1806(a), 31 N.J.R. 2879(b).
In (a), added reference to copayments for NJ KidCare-Plan D; added (d) through (f).
Amended by R.2000 d.265, effective 7/3/2000.
See: 32 N.J.R. 1127(a), 32 N.J.R. 2483(a).
In (b)2, substituted a reference to beneficiaries for a reference to patients throughout.
Amended by R.2004 d.334, effective 9/7/2004.
See: 36 N.J.R. 312(a), 36 N.J.R. 4136(a).
Amended by R.2004 d.409, effective 11/1/2004.
See: 35 N.J.R. 4977(a), 36 N.J.R. 4968(a).
Amended by R.2005 d.406, effective 11/21/2005.
See: 37 N.J.R. 2329(a), 37 N.J.R. 4445(a).
In (a), deleted "or" following "to care for."