N.J. Admin. Code § 10:78-7.1

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

Section 10:78-7.1 - Scope of services

(a) The NJ FamilyCare "Plan A" service package shall contain those services described at N.J.A.C. 10:49-5.2.

(b) The NJ FamilyCare "Plan D" benefit package shall contain those services described at N.J.A.C. 10:49-5.7. Those FamilyCare Plan D beneficiaries whose income is above 150 percent of the Federal poverty level shall be responsible for copayments for services received, in accordance with the provisions of this chapter.

1. No cost sharing shall be imposed on children who are American Indians or Alaska Natives as defined at 42 CFR 457.10. Proof of Federally recognized AI/AN tribal status shall be provided in the form of a tribal card or letter.

(c) Individuals who would be eligible for AFDC-related Medicaid or NJ FamilyCare and who are subject to the Federal immigration residency restriction shall receive services and shall be subject to any applicable premium contribution based on income eligibility, under the provisions of N.J.A.C. 10:69 or 10:79.

(d) Except as noted in N.J.A.C. 10:49-5.7, 5.8 and 5.10, NJ FamilyCare beneficiaries shall receive services through managed care organizations operating under a contract with the Department of Human Services. Single adults and couples without dependent children whose gross income is not more than 100 percent of the Federal poverty level will be enrolled in a managed care service administrator program. Effective July 1, 2002, adults without dependent children who are not eligible for WFNJ/GA and whose income is below 100 percent of the Federal poverty level shall receive the NJ FamilyCare Plan H service package described at N.J.A.C. 10:49-5.8.

(e) Copayments required of NJ FamilyCare beneficiaries shall be as described at N.J.A.C.10:49-9.1. Premium payments required of NJ FamilyCare beneficiaries shall be as described at N.J.A.C. 10:49-9.2. Enrollment for these beneficiaries shall commence after their first premium payment has been received by the Statewide eligibility determination agency. No other NJ FamilyCare beneficiary will be responsible for a premium payment or a copayment.

(f) Drugs used exclusively to treat AIDS and HIV shall not be included in the FamilyCare services packages, but shall be made available to FamilyCare beneficiaries through the ADDP program in accordance with N.J.A.C. 8:61-3.

(g) Effective July 1, 2002, for WFNJ/GA-eligible individuals, no managed care services will be provided. WFNJ/GA-eligible individuals will receive medical services in accordance with N.J.A.C. 10:49-24.3. Effective July 1, 2003, all substance abuse services for WFNJ/GA-eligible individuals will be administered through the Substance Abuse Initiative (SAI).

1. Effective June 15, 2002, hospital services for WFNJ/GA-eligible individuals shall be submitted for reimbursement through charity care.

(h) Childless adults with incomes below 100 percent of the Federal poverty level who are not eligible for WFNJ/GA and who are enrolled in NJ FamilyCare on June 30, 2002 shall receive the Plan H service package described at N.J.A.C. 10:49-5.8.

1. Effective June 15, 2002, hospital-based behavioral health services for childless adults with incomes below 100 percent of the Federal poverty level who are not eligible for WFNJ/GA shall be submitted for reimbursement through charity care.

(i) Contingent upon continuing approval by the Centers for Medicare & Medicaid Services of New Jersey's Health Insurance Flexibility and Accountability Act (HIFA) waiver, certain parents/caretakers of children enrolled in NJ FamilyCare who have earned incomes below 134 percent of the Federal poverty level shall receive the Plan D benefit package described at N.J.A.C. 10:49-5.7. Those parents/caretakers who are awaiting enrollment in a managed care organization or who meet the standards for exemption from the requirement for enrollment in managed care will receive the Plan D benefit package on a fee-for-service basis, which shall be called Plan I. Services available under Plan I are described at N.J.A.C. 10:49-5.10.

1. Parents who are eligible for NJ FamilyCare Plan A in accordance with N.J.A.C. 10:69, AFDC-Related Medicaid, shall continue to receive the Plan A benefit package.

N.J. Admin. Code § 10:78-7.1

Special amendment, R.2001 d.304, effective 7/31/2001 (operative September 1, 2001).
See: 33 N.J.R. 2912(a).
In (d), substituted "shall not" for "may" preceding "be eligible"; added (g) and (h).
Special amendment, R.2002 d.214, effective 6/10/2002.
See: 34 N.J.R. 2338(a).
Rewrote (a), (d), (g) and (h).
Amended by R.2002 d.371, effective 11/18/2002.
See: 34 N.J.R. 2244(a), 34 N.J.R. 2549(b), 34 N.J.R. 3978(c).
Added b(1); added e(1).
Special amendment, R.2003 d.98, effective 1/31/2003 (to expire March 3, 2006).
See: 35 N.J.R. 1303(a).
In (b), rewrote the first sentence in the introductory paragraph; in (e), rewrote the introductory paragraph; added (i).
Special amendment, R.2003 d.417, effective 9/26/2003 (operative November 1, 2003).
See: 35 N.J.R. 4913(a).
Rewrote (d); in (g), substituted "2003" for "2002"; added (j).
Amended by R.2006 d.347, effective 10/2/2006.
See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a).
Rewrote the section.
Special amendment, R.2010 d.133, effective 6/1/2010.
See: 42 N.J.R. 1404(a).
Deleted (j).