N.J. Admin. Code § 10:74-5.1

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

Section 10:74-5.1 - Information to be provided to the enrollees by the contractor

(a) At such time as a Medicaid/NJ FamilyCare beneficiary signs an enrollment application of an MCO, the contractor shall inform the beneficiary that:

1. There is normally a minimum 30 to 45-day processing period between the date of application and the effective date of enrollment;

2. During this interim period, the Medicaid/NJ FamilyCare-Plan A only enrollee may continue to receive health services under his or her current arrangement as long as he or she retains Medicaid/NJ FamilyCare-Plan A eligibility; and

3. Subject to the termination of Medicaid/NJ FamilyCare eligibility, the disenrollment rules in N. J.A.C. 10:74-7 and the termination provisions in the contract between the contractor and the Department, the initial enrollment period shall extend for one year.

(b) At such time as a NJ FamilyCare-Plans B, C or D beneficiary signs an enrollment application of an MCO, the contractor shall inform the beneficiary that:

1. There is normally a minimum 30- to 45-day processing period between the date of application and the effective date of enrollment; and

2. Subject to the termination of NJ FamilyCare-Plans B, C or D eligibility, the disenrollment rules in N.J.A.C. 10:74-7, and the termination provisions in the contract between the contractor and the Department, the initial enrollment period shall extend for 12 months.

(c) Prior to, but not later than, the effective date of coverage, or as specified in the contract, the MCO shall provide the following in writing to a new enrollee:

1. Notification of his or her effective date of enrollment;

2. An identification card clearly indicating that the bearer is an enrollee in the managed care organization;

3. Specific written details on benefits, limitations, exclusions, and availability and location of services and facilities. Thereafter, such notification shall be provided whenever there are significant changes in the services provided and the locations where they can be obtained, or other changes in program nature, but not less than annually;

4. An explanation of the procedure for obtaining benefits, including treatment for emergency care, the addresses and telephone numbers of the enrollee's primary care provider for each member;

5. Information regarding continued enrollment in the contractor's plan including patient's rights and patient's responsibilities, the reasons a person may lose eligibility for the plan, and what should be done if this occurs;

6. Procedures for resolving complaints;

7. Reasons and procedures for disenrollment;

8. Any other information essential to the proper use of the plan as may be required by the Division;

9. An explanation of where and how 24 hour a day emergency medical care and out-of-area coverage is available; and

10. An explanation of how to obtain noncovered MCO services that are Medicaid/NJ FamilyCare benefits.

(d) Such information shall be provided to each enrolled family household at least 10 days prior to such change.

N.J. Admin. Code § 10:74-5.1

Amended by 51 N.J.R. 1359(a), effective 8/19/2019