Exhibit 10.25.3

         

Jon S. Corzine
Governor
  (STATE OF NEW JERSEY LOGO) [w37497w3749701.gif]
State of New Jersey
Department of Human Services
Division of Medical Assistance and Health Services
P.O. Box 712
Trenton, NJ 08625-0712
Telephone 1-800-356-1561
June 8, 2007  

Jennifer Velez
Acting Commissioner

John R. Guhl
Director

Peter D. Haytaian
President and Chief Executive Officer
AMERIGROUP New Jersey, Inc.
399 Thornall Street, 9th Floor
Edison, NJ 08837
Dear Mr. Haytaian:
Enclosed is your copy of a recently processed contract amendment. This amendment
will extend the managed care contract through June 30, 2008. The amendment has
been approved by the Centers for Medicare and Medicaid Services.
Thank your for your continued interest in Medicaid managed care.
Sincerely,
(-s- RITA HEMINGWAY) [w37497w3749702.gif])
Rita Hemingway
Director, Contract Relations
Office of Managed Health Care
RH;dg
Enclosure

c:   Jill Simone, MD
John Koehn
Jennifer Langer

New Jersey Is An Equal Opportunity Employer

 

--------------------------------------------------------------------------------

 

STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
AND
AMERIGROUP NEW JERSEY, INC.
AGREEMENT TO PROVIDE HMO SERVICES
In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract
between AMERIGROUP New Jersey, Inc. and the State of New Jersey, Department of
Human Services, Division of Medical Assistance and Health Services (DMAHS),
effective date October 1, 2000, all parties agree that the contract shall be
amended, effective July 1, 2007, as follows:

 

--------------------------------------------------------------------------------

 

1.   Article 1, “Definitions” section — for the following definitions:

  •   NJ FamilyCare Plan D (revised)     •   NJ FamilyCare Plan H (revised)    
•   State Fiscal Year (new)

    shall be amended as reflected in the relevant pages of Article 1 attached
hereto and incorporated herein.   2.   Article 3, “Managed Care Management
Information Systems” Sections 3.3.1 (A); 3.4.4 and 3.9.1(C) (new) shall be
amended as reflected in Article 3, Sections 3.3.1 (A), 3.4.4 and 3.9.1
(C) attached hereto and incorporated herein.   3.   Article 4, “Provision of
Health Care Services” Sections 4.1.1(E); 4.1.2(A)9; 4.1.2(A)27; 4.1.4(A);
4.1.4(A)3(a); 4.2.4(B)5(g)i, ii (new); 4.2.6(A)4; 4.5.2(A)1; 4.5.3(A)4;
4.5.4(F); 4.5.4(F)2 (new);. 4.6.5(A)4; 4.6.5(A)4(a), (b) (new); 4.8.3; 4.8.3(A);
4.8.3(A)1; 4.8.3(A)2; 4.8.3(B); 4.8.3(C); 4.8.3(D); 4.8.8(M)3(b) and
4.8.8(M)3(q) shall be amended as reflected in Article 4, Sections 4.1.1(E),
4.1.2(A)9, 4.1.2(A)27, 4.1.4(A), 4.1.4(A)3(a), 4.2.4(B)5(g)i, ii, 4.2.6(A)4,
4.5.2(A)1, 4.5.3(A)4, 4.5.4(F), 4.5.4(F)2, 4.6.5(A)4, 4.6.5(A)4(a), (b), 4.8.3,
4.8.3(A), 4.8.3(A)1, 4.8.3(A)2, 4.8.3(B), 4.8.3(C), 4.8.3(D), 4.8.8(M)3(b) and
4.8.8(M)3(q) attached hereto and incorporated herein.   4.   Article 5,
“Enrollee Services” Sections 5.8.2(E); 5.8.3(B) (new); 5.16.1(l) and 5.16.2(C)2
shall be amended as reflected in Article 5, Sections 5.8.2(E), 5.8.3(B),
5.16.1(l) and 5.16.2(C)2 attached hereto and incorporated herein.   5.  
Article 7, “Terms and Conditions” Sections 7.16.3(B)2 (new); 7.16.4(B)3 (new);
7.16.5; 7.26(G) and 7.27.1(B) shall be amended as reflected in Article 7,
Sections 7.16.3(B)2, 7.16.4(B)3, 7.16.5, 7.26(G) and 7.27.1(B) attached hereto
and incorporated herein.

 

--------------------------------------------------------------------------------

 

6.   Article 8, “Financial Provisions,” Sections 8.4.1(A)2; 8.4.1(A)3; 8.4.3;
8.5.2.1 and 8.5.2.5 (reserved) shall be amended as reflected in Article 8,
Sections 8.4.1(A)2, 8.4.1(A)3, 8.4.3, 8.5.2.1 and 8.5.2.5 attached hereto and
incorporated herein.   7.   Appendix, Section A, “Reports”

  •   Narrative     •   A.7.21 — Table 19 — Contractor Financial Reporting
Manual for Medicaid/NJ FamilyCare Rate Cell Grouping Costs (revised)

    shall be amended as reflected in Appendix, Section A and A.7.21 attached
hereto and incorporated herein.   8.   Appendix, Section B, “Reference
Materials”

  •   B.4.11 — Special Child Health Services Network (correct citation)

    shall be amended as reflected in Appendix, Section B, B.4.11 attached hereto
and incorporated herein.   9.   Appendix, Section C, “Capitation Rates” shall be
revised as reflected in SFY 2007 Capitation Rates attached hereto and
incorporated herein.

 

--------------------------------------------------------------------------------

 

All other terms and conditions of the October 1, 2000 contract and subsequent
amendments remain unchanged except as noted above.
The contracting parties indicate their agreement by their signatures.

                      AMERIGROUP
  State of New Jersey
New Jersey, Inc.
  Department of Human Services

 
                   
BY:
  /s/ Peter D. Haytaian
 
Peter D. Haytaian       BY:   /s/ John R. Guhl
 
John R. Guhl    
 
                    TITLE: President & CEO   TITLE: Director, DMAHS
 
                    DATE: 4/13/07   date: 4/20/07
 
                    APPROVED AS TO FORM ONLY            
 
                    Attorney General            
 
                    State of New Jersey            
 
                   
BY:
  [ILLEGIBLE]
 
Deputy Attorney General                
 
                    DATE: 4/17/07            

 

--------------------------------------------------------------------------------

 

    may access certain other services which are paid fee-for-service and not
covered under this contract.       NJ FamilyCare Plan C—means the State-operated
program which provides comprehensive managed care coverage, including all
benefits provided through the New Jersey Care...Special Medicaid Programs, to
uninsured children below the age of 19 with family incomes above 150 percent and
up to and including 200 percent of the federal poverty level. Eligibles are
required to participate in cost-sharing in the form of monthly premiums and a
personal contribution to care for most services. Exception — Both Eskimos and
Native American Indians under the age of 19 years old, identified by Race Code
3, shall not participate in cost sharing, and shall not be required to pay a
personal contribution to care. In addition to covered managed care services,
eligibles under this program may access certain other services which are paid
fee-for-service and not covered under this contract.       NJ FamilyCare Plan
D—means the State-operated program which provides managed care coverage to
uninsured:

  •   Parents/caretakers with children below the age of 19 who do not qualify
for AFDC Medicaid with family incomes up to and including 200 percent of the
federal poverty level; and     •   Parents/caretakers with children below the
age of 23 years and children from the age of 19 through 22 years who are full
time students who do not qualify for AFDC Medicaid with family incomes up to and
including 250 percent of the federal poverty level; and     •   Children below
the age of 19 with family incomes between 201 percent and up to and including
350 percent of the federal poverty level.     •   Adults and couples without
dependent children under the age of 19 with family incomes up to and including
100 percent of the federal poverty level;     •   Adults and couples without
dependent children under the age of 23 years, who do not qualify for AFDC
Medicaid, with family incomes up to and including 250 percent of the federal
poverty level.     •   Restricted alien parents over 21 years of age not
including pregnant women.

    Eligibles with incomes above 150 percent of the federal poverty level are
required to participate in cost sharing in the form of monthly premiums and
copayments for most services with the exception of both Eskimos and Native
American Indians under the age of 19 years. These groups are identified by
Program Status Codes (PSCs) or Race Code on the eligibility system as indicated
below. For clarity, the Program Status Codes or Race Code, in the case of
Eskimos and Native American Indians under the age of 19 years, related to Plan D
non-cost sharing groups are also listed. Some of the Program Status Codes listed
below can include restricted alien parents. Therefore, it is necessary to rely
on the capitation code to identify these clients.

      7/2007 Changes 01/2007 Accepted   I-19

 

--------------------------------------------------------------------------------

 

          PSC   PSC   Race Code Cost Sharing   No Cost Sharing   No Cost Sharing
301   300   3 493   380     494   497     495   700     498   763     498
(w/corresponding
cap code)
701   380, 310, 320, 330,
410, 420, 430, 470,
497 (with
corresponding cap
codes)    

    In addition to covered managed care services, eligibles under these programs
may access certain services which are paid fee-for-service and not covered under
this contract.       NJ FamilyCare Plan H—means the State-operated program which
provides managed care administrative services coverage to uninsured. On or about
July 1, 2007, the DMAHS will begin to transition Plan H enrollees to Plan D.
When the transition is completed, Plan H will end.

  •   Adults and couples without dependent children under the age of 19 with
family incomes up to and including 100 percent of the federal poverty level;    
•   Adults and couples without dependent children under the age of 23 years, who
do not qualify for AFDC Medicaid, with family incomes up to and including
250 percent of the federal poverty level.     •   Restricted alien parents over
21 years of age not including pregnant women.

    Plan H eligibles will be identified by a capitation code. Capitation codes
drive the service package. The Program Status Code drives the cost-sharing
requirements.       Any of the Program Status Codes listed below can include
restricted alien parents. Therefore, it is necessary to rely on the capitation
code to identify Plan H eligibles. Eligibles with incomes above 150 percent of
the federal poverty level are required to participate in cost sharing in the
form of monthly premiums and copayments for most services. These groups are
identified by the program status code (PSC) indicated below. For clarity, the
program status codes related to Plan H non-cost sharing groups are also listed.

      PSC   PSC Cost Sharing   No Cost Sharing 498 (w/corresponding
cap code)
701   380, 310, 320, 330, 410, 420,
430, 470, 497 (with
corresponding cap codes)     700     763

      7/2007 Changes 01/2007 Accepted   I-20

 

--------------------------------------------------------------------------------

 

    Standard Service Package—see “Covered Services” and “Benefits Package”      
State—the State of New Jersey.       State Fiscal Year—the period between July 1
through the following June 30 of every year.       State Plan—see “New Jersey
State Plan”       Stop-Loss—the dollar amount threshold above which the
contractor insures the financial coverage for the cost of care for an enrollee
through the use of an insurance underwritten policy.       Subcontract—any
written contract between the contractor and a third party to perform a specified
part of the contractor’s obligations under this contract.      
Subcontractor—any third party who has a written contract with the contractor to
perform a specified part of the contractor’s obligations under this contract.  
    Subcontractor Payments—any amounts the contractor pays a provider or
subcontractor for services they furnish directly, plus amounts paid for
administration and amounts paid (in whole or in part) based on use and costs of
referral services (such as withhold amounts, bonuses based on referral levels,
and any other compensation to the physician or physician group to influence the
use of referral services). Bonuses and other compensation that are not based on
referral levels (such as bonuses based solely on quality of care furnished,
patient satisfaction, and participation on committees) are not considered
payments for purposes of physician incentive plans.       Substantial
Contractual Relationship—any contractual relationship that provides for one or
more of the following services: 1) the administration, management, or provision
of medical services; and 2) the establishment of policies, or the provision of
operational support, for the administration, management, or provision of medical
services.       TANF—Temporary Assistance for Needy Families, which replaced the
federal AFDC program.       Target Population—the population of individuals
eligible for Medicaid/NJ FamilyCare residing within the stated enrollment area
and belonging to one of the categories of eligibility found in Article Five from
which the contractor may enroll, not to exceed any limit specified in the
contract.       TDD—Telecommunication Device for the Deaf.       TT—Tech
Telephone.       Terminal Illness—a condition in which it is recognized that
there will be no recovery, the patient is nearing the “terminus” of life and
restorative treatment is no longer effective.

      7/2007 Changes 01/2007 Accepted   I-27

 

--------------------------------------------------------------------------------

 

3.3   PROVIDER SERVICES       The contractor’s system shall collect, process,
and maintain current and historical data on program providers. This information
shall be accessible to all parts of the MCMIS for editing and reporting.   3.3.1
  PROVIDER INFORMATION AND PROCESSING REQUIREMENTS

  A.   Provider Data. The contractor shall maintain individual and group
provider network information with basic demographics, EIN or tax identification
number, professional credentials, license and/or certification numbers and
dates, sites, risk arrangements (i.e., individual and group risk pools),
services provided, payment methodology and/or reimbursement schedules,
group/individual provider relationships, facility linkages, number of grievances
and/or complaints.         For PCPs, the contractor shall maintain
identification as traditional or safety net provider, specialties, enrollees
with beginning and ending effective dates, capacity, emergency arrangements or
contact, other limitations or restrictions, languages spoken, address, office
hours, disability access. See Articles 4.8 and 5.         The contractor shall
maintain provider history files and provide for easy data retrieval. The system
should maintain audit trails of key updates.         Providers should be
identified with a unique number. The contractor shall be able to cross-reference
its provider number with the provider’s EIN or tax number, the provider’s
license number, UPIN, National Provider Identifier, Medicaid provider number,
and Medicare provider number where applicable. The contractor shall comply with
HIPAA requirements for provider identification.     B.   Updates. The contractor
shall apply updates to the provider file daily.     C.   Complaint Tracking
System. The system shall provide for the capabilities to track and report
provider complaints as specified in Article 6.5. The contractor shall provide
detail reports identifying open complaints and summary statistics by provider on
the types of complaints, resolution, and average time for resolution.

3.3.2   PROVIDER CREDENTIALING

  A.   Credentialing. The contractor shall credential and re-credential each
network provider as specified in Article 4.6.1. The system should provide a
tracking and reporting system to support this process.     B.   Review. The
contractor shall be able to flag providers for review based on problems
identified during credentialing, information received from the State,
information received from CMS, complaints, and in-house utilization review
results. Flagging providers should cause all claims to deny as appropriate.

      7/2007 Changes 1/2007 Accepted   III-7

 

--------------------------------------------------------------------------------

 

  B.   The contractor shall produce reports according to the timeframes and
specification outlined in Section A of the Appendices.

3.4.4   REMITTANCE ADVICE AND CAPITATION LISTS       The contractor shall
provide federally qualified health centers with electronic remittance advices
and electronic capitation lists of enrollees. In addition, the contractor shall
provide electronic copies of or aan electronic report of the data elements of
the electronic remittance advices and capitation lists in Excel format to the
DMAHS by the 45th day after the close of the calendar quarter in which the files
and reports are provided to the FQHCs.   3.5   PRIOR AUTHORIZATION, REFERRAL AND
UTILIZATION MANAGEMENT       The prior authorization/referral and utilization
management functions shall be an integrated component of the MCMIS. It shall
allow for effective management of delivery of care. It shall provide a
sophisticated environment for managing the monitoring of both inpatient and
outpatient care on a proactive basis.   3.5.1   FUNCTIONS AND CAPABILITIES

  A.   Prior Authorizations. The contractor shall provide an automated system
that includes the following:

  1.   Enrollee eligibility, utilization, and case management information.    
2.   Edits to ensure enrollee is eligible, provider is eligible, and service is
covered.     3.   Predefined treatment criteria to aid in adjudicating the
requests.     4.   Notification to provider of approval or denial.     5.  
Notification to enrollees of any denials or cutbacks of service.     6.  
Interface with claims processing system for editing.

  B.   Referrals. The contractor shall provide an automated system that includes
the following:

  1.   Ability for providers to enter referral information directly, fax
information to the contractor, or call in on dedicated phone lines.     2.  
Interface with claims processing system for editing.

  C.   Utilization Management. The contractor should provide an automated system
that includes the following:

  1.   Provides case tracking, notifies the case worker of outstanding actions.
    2.   Provide case history of all activity.     3.   Provide online access to
cases by enrollee and provider numbers.     4.   Includes an automated
correspondence generator for letters to clients and network providers.     5.  
Reports for case analysis, concurrent review, and case follow up including
hospital admissions, discharges, and census reports.

      7/2007 Changes 1/2007 Accepted   III-11

 

--------------------------------------------------------------------------------

 

  B.   The contractor shall ensure that data received from providers is accurate
and complete by:

  1.   Verifying the accuracy and timeliness of reported data;     2.  
Screening the data for completeness, logic, and consistency; and     3.  
Collecting service information in standardized formats to the extent feasible
and appropriate.

  C.   Regardless of whether the contractor is considered a covered entity under
HIPAA, the contractor shall use the HIPAA Transaction and Code Sets as the
exclusive format for the electronic communication of health care claims and
encounter data for data submitted on or after January 1, 2005, regardless of
date of service. The contractor shall adhere to all HIPAA transaction set
requirements as specified in the national HIPAA Implementation Guide and the New
Jersey Medicaid HIPAA Companion Guide when submitting encounters.

3.9.1   REQUIRED ENCOUNTER DATA ELEMENTS

  A.   The contractor must report encounter data at least quarterly. The data
shall be enrollee specific, listing all encounter data elements of the services
provided. Encounter report files will be used to create a database that can be
used in a manner similar to fee-for-service history files to analyze plan
utilization, reimburse the contractor for supplemental payments, and calculate
capitation premiums. DMAHS will edit the data to assure consistency and
readability. Ifdata are not of an acceptable quality or submitted timely, the
contractor will not be considered in compliance with this contract requirement
until an acceptable file is submitted.     B.   Data Elements. The required data
elements shall be in compliance with HIPAA transaction set requirements (see
3.9.C) Inpatient hospital claims and encounters shall be combined into a single
stay when the enrollee’s dates of services are consecutive.     C.   National
Provider Identifier (NPI). The contractor shall report no later than the
compliance date established by CMS the NPIs for all of its providers, who are
covered entities or health care providers and eligible to receive an NPI, on all
claims and encounter data submitted to the State.

3.9.2   SUBMISSION OF TEST ENCOUNTER DATA

  A.   Submitter ID. The contractor shall make application in order to obtain a
Submitter Identification Number, according to the instructions listed in the
HIPAA Implementation and Companion Guides.     B.   Test Requirement The
contractor shall be required to pass a testing phase for each of the eight
encounter claim types before production encounter data will be accepted. The
contractor shall pass the testing phase for all encounter claim type

      7/2007 Changes 1/2007 Accepted   III-17

 

--------------------------------------------------------------------------------

 

      the individual will be disenrolled. This does not apply to situations when
the enrollee is out of State for care provided/authorized by the contractor, for
example, prolonged hospital care for transplants. For full time students
attending school and residing out of the country, the contractor shall not be
responsible for health care benefits while the individual is in school.     E.  
Existing Plans of Care. The contractor shall honor and pay for plans of care for
new enrollees, including prescriptions, durable medical equipment, medical
supplies, prosthetic and orthotic appliances, and any other on-going services
initiated prior to enrollment with the contractor. Services shall be continued
until the enrollee is evaluated by his/her primary care physician and a new plan
of care is established with the contractor.         The contractor shall use its
best efforts to contact the new enrollee or, where applicable, authorized person
and/or contractor care manager. However, if after documented, appropriate and
reasonable outreach (i.e., at least three (3) attempts to reach the enrollees
through mailers, certified mail, use of MEDM system provided by the State,
contact with the Medical Assistance Customer Center (MACC), DDD, or DYFS to
confirm addresses and/or to request assistance in locating the enrollee) the
enrollee fails to respond within 20 working days of certified mail, the
contractor may cease paying for the pre-existing service until the enrollee or,
where applicable, authorized person, contacts the contractor for re-evaluation.
        For MCSA enrollees, the contractor shall case manage these services.
(Not applicable to non-MCSA contractor).     F.   Routine Physicals. The
contractor shall provide for routine physical examinations required for
employment, school, camp or other entities/programs that require such
examinations as a condition of employment or participation.     G.  
Non-Participating Providers.

  1.   The contractor shall pay for services furnished by non-participating
providers to whom an enrollee was referred, even if erroneously referred, by
his/her PCP or network specialist. Under no circumstances shall the enrollee
bear the cost of such services when referral errors by the contractor or its
providers occur. It is the sole responsibility of the contractor to provide
regular updates on complete network information to all its providers as well as
appropriate policies and procedures for provider referrals.     2.   The
contractor may pay an out-of-network hospital provider, located outside the
State of New Jersey, the New Jersey Medicaid fee-for-service rate for the
applicable services rendered.     3.   Whenever the contractor authorizes
services by out-of-network providers, the contractor shall require those
out-of-network providers to coordinate with the contractor with respect to
payment. Further, the contractor shall

      7/2007 Changes 1/2007 Accepted   IV-2

 

--------------------------------------------------------------------------------

 

  R.   The contractor is not required to pay for non-HMO covered benefits.
However, if the contractor does pay for non-HMO covered benefits in error, the
Division shall have the right to not reimburse the contractor for those costs.

4.1.2   BENEFIT PACKAGE

  A.   The following categories of services shall be provided by the contractor
for all Medicaid and NJ FamilyCare Plans A, B, and C enrollees, except where
indicated. See Section B.4.1 of the Appendices for complete definitions of the
covered services.     1.   Primary and Specialty Care by physicians and, within
the scope of practice and in accordance with State certification/licensure
requirements, standards and practices, by Certified Nurse Midwives, Certified
Nurse Practitioners, Clinical Nurse Specialists, and Physician Assistants     2.
  Preventive Health Care and Counseling and Health Promotion     3.   Early and
Periodic Screening, Diagnosis, and Treatment (EPSDT) Program Services        
For NJ FamilyCare Plans B and C participants, coverage includes early and
periodic screening and diagnosis medical examinations, dental, vision, hearing,
and lead screening services. It includes only those treatment services
identified through the examination that are available under the contractor’s
benefit package or specified services under the FFS program.     4.   Emergency
Medical Care     5.   Inpatient Hospital Services including acute care
hospitals, rehabilitation hospitals, and special hospitals.     6.   Outpatient
Hospital Services     7.   Laboratory Services [Except routine testing related
to administration of Clozapine and the other psychotropic drugs listed in
Article 4.1.4B for non-DDD clients.]     8.   Radiology Services — diagnostic
and therapeutic     9.   Prescription Drugs (legend and non-legend covered by
the Medicaid program) — For payment method for Protease Inhibitors, certain
other anti-retrovirals, blood clotting factors VIII and IX, and coverage of
protease inhibitors and certain other anti-retrovirals under NJ FamilyCare, see
Article 8. Exception: not a contractor-covered benefit for the ABD population
and other dual eligible individuals identified by cap codes pertaining to
enrollees with Medicare. However, the contractor shall continue to cover
physician administered drugs for all enrollees in accordance with the list of
applicable codes provided by DMAHS.

      7/2007 Changes 1/2007 Accepted   IV-5

 

--------------------------------------------------------------------------------

 

  27.   Mental Health/Substance Abuse Services for enrollees who are clients of
the Division of Developmental Disabilities. Exception — partial care and partial
hospitalization services are not covered by the contractor. Partial
hospitalization is a contractor covered service for DDD clients.

  B.   Conditions Altering Mental Status. Those diagnoses which are categorized
as altering the mental status of an individual but are of organic origin shall
be part of the contractor’s medical, financial and care management
responsibilities for all categories of enrollees. These include the diagnoses in
the following ICD-9-CM Series:

             
1.
    290.0     Senile dementia, simple type
2.
    290.1     Presenile dementia
3.
    290.10     Presenile dementia, uncomplicated
4.
    290.11     Presenile dementia with delerium
5.
    290.12     Presenile dementia with delusional features
6.
    290.13     Presenile dementia with depressive features
7.
    290.2     Senile dementia with delusional or depressive features
8.
    290.20     Senile dementia with delusional features
9.
    290.21     Senile dementia with depressive features
10.
    290.3     Senile dementia with delerium
11.
    290.4     Arteriosclerotic dementia
12.
    290.40     Arteriosclerotic dementia, uncomplicated
13.
    290.41     Arteriosclerotic dementia with delirium
14.
    290.42     Arteriosclerotic dementia with delusional features
15.
    290.43     Arteriosclerotic dementia with depressive features
16.
    290.8     Other specific senile psychotic conditions
17.
    290.9     Unspecified senile psychotic condition
18.
    291.1     Alcohol amnestic syndrome
19.
    291.2     Other alcoholic dementia
20.
    292.82     Drug induced dementia
21.
    292.83     Drug-induced amnestic syndrome
22.
    292.9     Unspecified drug induced mental disorders
23.
    293.0     Acute delirium
24.
    293.1     Subacute delirium
25.
    293.8     Other specific transient organic mental disorders
26.
    293.81     Organic delusional syndrome
27.
    293.82     Organic hallucinosis syndrome
28.
    293.83     Organic affective syndrome
29.
    293.84     Organic anxiety syndrome
30.
    294.0     Amnestic syndrome
31.
    294.1     Dementia in conditions classified elsewhere
32.
    294.8     Other specified organic brain syndromes (chronic)
33.
    294.9     Unspecified organic brain syndrome (chronic)
34.
    305.1     Non-dependent abuse of drugs — tobacco
35.
    310.0     Frontal lobe syndrome
36.
    310.2     Postconcussion syndrome
37.
    310.8     Other specified nonpsychotic mental disorder following
organic brain damage

      7/2007 Changes 1/2007 Accepted   IV-7

 

--------------------------------------------------------------------------------

 

      07110         07130         07210

4.1.4   MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR

  A.   Mental Health/Substance Abuse. The following mental health/substance
abuse services (except for the conditions listed in 4.1.2.B) will be managed by
the State or its agent for non-DDD enrollees, including all NJ FamilyCare
enrollees. (The contractor will retain responsibility for furnishing mental
health/substance abuse services, excluding partial care and partial
hospitalization services and the cost of the drugs listed below, to Medicaid
enrollees who are clients of the Division of Developmental Disabilities).

  1.   Substance Abuse Services—diagnosis, treatment, and detoxification     2.
  Costs for Methadone maintenance and its administration     3.   Mental Health
Services

  a.   Partial care and partial hospitalization services are covered by the
Medicaid program.

  B.   Drugs. The following drugs will be paid fee-for-service by the Medicaid
program for all DMAHS enrollees:

  •   Atypical antipsychotic drugs within the Specific Therapeutic Drug Classes
H7T and H7X     •   Methadone maintenance — cost and its administration. Except
as provided in Article 4.4, the contractor will remain responsible for the
medical care of enrollees requiring substance abuse treatment     •  
Generically-equivalent drug products of the drugs listed in this section.

  C.   Up to twelve (12) inpatient hospital days required for social necessity
in accordance with Medicaid regulations.     D.   DDD/CCW waiver services:
individual supports (which includes personal care and training), habilitation,
case management, respite, and Personal Emergency Response Systems (PERS).

4.1.5   INSTITUTIONAL FEE-FOR-SERVICE BENEFITS — NO COORDINATION BY THE
CONTRACTOR       The following institutional services shall remain in the
fee-for-service program without requiring coordination by the contractor. In
addition, Medicaid beneficiaries participating in a waiver (except the Division
of Developmental Disabilities Community Care Waiver) or demonstration program or
admitted for long term care treatment in one of the following shall be
disenrolled from the contractor’s plan on the date of admission to
institutionalized care.

      7/2007 Changes 1/2007 Accepted   IV-10

 

--------------------------------------------------------------------------------

 

      therapeutic substitution of a prescribed drug without a prescriber’s
authorization.     e.   The contractor shall not penalize the prescriber or
enrollee, financially or otherwise, for such requests and approvals.     f.  
Determinations shall be made within twenty-four (24) hours of receipt of all
necessary information. The contractor shall provide for a 72-hour supply of
medication while awaiting a prior authorization determination.     g.   Denials
of off-formulary requests or offering of an alternative medication shall be
provided to the prescriber and/or enrollee in writing.

  i.   An enrollee receiving a prescription drug that was on the contractor’s
formulary and subsequently removed or changed shall be permitted to continue to
receive that prescription drug if requested by the enrollee and prescriber for
as long as the enrollee is a member of the contractor’s plan.     ii.   All
denials shall be reported to the DMAHS quarterly-and include the following data:

–name of non-formulary drug
–total number of requests
–total number of denials

  6.   Submission and Publication of the Formulary.

  a.   The contractor shall publish and distribute hard copy or on-line, at
least annually, its current formulary (if the contractor uses a formulary) to
all prescribing providers and pharmacists. Updates to the formulary shall be
distributed in all formats within sixty (60) days of the changes.     b.   The
contractor shall submit its formulary to DMAHS quarterly.     c.   It is
strongly encouraged that the contractor publish the formulary on its internet
website.

  7.   If the formulary includes generic equivalents, the contractor shall
provide for a brand name exception process for prescribers to use when medically
necessary. For MCSA enrollees, the contractor should implement a mandatory
generic drug substitution program consistent with Medicaid program requirements.
(Not applicable to non-MCSA contractor).     8.   The contractor shall establish
and maintain a procedure, approved by DMAHS, for internal review and resolution
of complaints, such as timely access and coverage issues, drug utilization
review, and claim management based on standards of drug utilization review.

      7/2007 Changes 1/2007 Accepted   IV-27

 

--------------------------------------------------------------------------------

 

  E.   The contractor shall permit its pharmacy providers to dispense a 72-hour
supply of any drug, on or off the formulary, that is subject to a prior
authorization process. (e.g., Article 4.2.4.B.5.f)

4.2.5   LABORATORY SERVICES

  A.   Urgent/Emergent Results. The contractor shall develop policies and
procedures to require providers to notify enrollees of laboratory and radiology
results within twenty-four (24) hours of receipt of results in urgent or
emergent cases. The contractor may allow its providers to arrange an appointment
to discuss laboratory/radiology results within 24 hours of receipt of results
when it is deemed face-to-face discussion with the enrollee/authorized person
may be necessary. Urgent/emergency appointment standards must be followed (see
Article 5.12). Rapid strep test results must be available to the enrollee within
24 hours of the test.     B.   Routine Results. The contractor shall assure that
its providers establish a mechanism to notify enrollees of non-urgent or
non-emergent laboratory and radiology results within ten business days of
receipt of the results.     C.   The contractor shall reimburse, on a fee-for
service basis, PCPs and other providers for blood drawing in the office for lead
screening.

4.2.6   EPSDT SCREENING SERVICES

  A.   The contractor shall comply with EPSDT program requirements and
performance standards found below.

  1.   The contractor shall provide EPSDT services.     2.   NJ FamilyCare Plans
B and C. For children eligible solely through NJ FamilyCare Plans B and C,
coverage includes all preventive screening and diagnostic services, medical
examinations, immunizations, dental, vision, lead screening and hearing
services. Includes only those treatment services identified through the
examination that are included under the contractor’s benefit package or
specified services through the FFS program. Other services identified through an
EPSDT examination that are not included in the covered benefits package are not
covered.     3.   Enrollee Notification. The contractor shall provide written
notification to its enrollees under twenty-one (21) years of age when
appropriate periodic assessments or needed services are due and must coordinate
appointments for care.     4.   Missed Appointments. The contractor shall
implement policies and procedures and shall monitor its providers to provide
follow up on missed appointments and referrals for problems identified through
the EPSDT exams. Appropriate and rReasonable outreach shall be documented and
must consist of: a minimum of three (3) attempts to reach the enrollee through
mailers, certified mail as necessary; telephone calls; use of MEDM system
provided by the State; and contact with the Medical

      7/2007 Changes 1/2007 Accepted   IV-29

 

--------------------------------------------------------------------------------

 

4.5   ENROLLEES WITH SPECIAL NEEDS   4.5.1   INTRODUCTION       For purposes of
this contract, adults with special needs includes complex/chronic medical
conditions requiring specialized health care services, including persons with
physical, mental, substance abuse, and/or developmental disabilities, including
such persons who are homeless. Children with special health care needs are those
who have or are at increased risk for a chronic physical, developmental,
behavioral, or emotional condition and who also require health and related
services of a type or amount beyond that required by children generally.      
In addition to the standards set forth in this Article, contractor shall make
all reasonable efforts and accommodations to ensure that services provided to
enrollees with special needs are equal in quality and accessibility to those
provided to all other enrollees.   4.5.2   GENERAL REQUIREMENTS

  A.   Identification and Service Delivery. The contractor shall have in place
all of the following to identify and serve enrollees with special needs:

  1.   Methods for identifying persons at risk of, or having special needs who
should be referred for a comprehensive needs assessment. (See Articles 4.5.4B
and 4.6.5D for information on Complex Needs Assessments). Such methods should
include the application of screening procedures/instruments for new enrollees as
well as the conditions and indicators listed in Article 4.6.5B.D.1-and-2. These
include review of hospital and pharmacy utilization and policies and procedures
for providers or, where applicable, authorized persons, to make referrals of
assessment candidates and for enrollees to self-refer for a Complex Needs
Assessment.     2.   Methods and guidelines for determining the specific needs
of referred individuals who have been identified through a Complex Needs
Assessment as having complex needs and developing care plans that address their
service requirements with respect to specialist physician care, durable medical
equipment, medical supplies, home health services, social services,
transportation, etc. Article 4.5.4D contains additional information on
Individual Health Care Plans.     3.   Care management systems to ensure all
required services, as identified through a Complex Needs Assessment, are
furnished on a timely basis, and that communication occurs between participating
and non- participating providers (to the extent the latter are used). Articles
4.5.4 and 4.6.5 contain additional information on care management.     4.  
Policies and procedures to allow for the continuation of existing relationships
with non-participating providers, when appropriate providers are not available
within network or it is otherwise considered by the contractor to be in the best
medical interest of the enrollee with special

      7/2007 Changes 1/2007 Accepted   IV-46

 

--------------------------------------------------------------------------------

 

  5.   Holding community events as part of its provider and consumer education
responsibilities in places of public accommodation, i.e., facilities readily
accessible to and useable by qualified individuals with disabilities.     6.  
How the contractor will ensure it will link qualified individuals with
disabilities with the providers/specialists with the knowledge and expertise in
treating the illness, condition, and special needs of the enrollees.

4.5.3   PROVIDER NETWORK REQUIREMENTS

  A.   General. The contractor’s provider network shall include primary care and
specialist providers who are trained and experienced in treating individuals
with special needs. The contractor shall ensure that such providers will be
equally accessible to all enrollees covered under this contract.

  1.   The contractor shall operate a program to provide services for enrollees
with special needs that emphasizes: (a) that providers are educated regarding
the needs of enrollees with special needs; (b) that providers will reasonably
accommodate enrollees with special needs; (c) that providers will assist
enrollees in maximizing involvement in the care they receive and in making
decisions about such care; and (d) that providers maximize for enrollees with
special needs independence and functioning through health promotions and
preventive care, decreased hospitalization and emergency room care, and the
ability to be cared for at home.     2.   The contractor shall describe how its
provider network will respond to the cultural and linguistic needs of enrollees
with special needs.     3.   The network shall include primary care providers
and dentists whose clinical practice has specialized to some degree in treating
one or more groups of children and adults with complex/chronic or disabling
conditions. To the extent possible, children and adults with complex physical
conditions should be in the care of board certified pediatricians and family
practitioners or internists, respectively, or subspecialists, as appropriate.  
  4.   The network shall include adult and pediatric subspecialists as indicated
in Article 4.8.8.C for cardiology, hematology/oncology, gastroenterology,
emergency medicine, endocrinology, infectious disease, orthopedics, neurology,
neurosurgery, ophthalmology, physiatry, pulmonology, surgery, and urology, as
well as providers who have knowledge and experience in behavioral-developmental
pediatrics, adolescent health, geriatrics, and chronic illness management.    
5.   The network shall include an appropriate and accessible number of
institutional facilities, professional allied personnel, home care and community
based services to perform the contractor-covered services included in this
contract.

      7/2007 Changes 1/2007 Accepted   IV-51

 

--------------------------------------------------------------------------------

 

      promotion of communication among providers and the consumer and of
continuity of care, will be greater. The contractor shall provide these
enrollees greater assistance with scheduling appointments/visits. The intensity
and frequency of interaction with the enrollee and other members of the
treatment team will also be greater. The care manager shall contact the enrollee
bi-weekly or as needed.

  1.   At a minimum, the care manager for this level of care management shall
include, but is not limited to, individuals who hold current RN licenses with at
least three (3) years experience serving enrollees with special needs or a
graduate degree in social work with at least two (2) years experience serving
enrollees with special needs.     2.   The contractor shall ensure that the care
manager’s caseload is adjusted, as needed, to accommodate the work and level of
effort needed to meet the needs of the entire case mix of assigned enrollees
including those determined to be high risk.     3.   The contractor should
include care managers with experience working with pediatric as well as adult
enrollees with special needs.

  D.   IHCPs. The contractor through its care manager shall ensure that an
Individual Health Care Plan (IHCP) is developed and implemented as soon as
possible, according to the circumstances of the enrollee. The contractor shall
ensure the full participation and consent of the enrollee or, where applicable,
authorized person and participation of the enrollee’s PCP, consultation with any
specialists caring for the enrollee, and other case managers identified through
the Complex Needs Assessment (e.g. DDD case manager) in the development of the
plan.     E.   The contractor shall provide written notification to the
enrollee, or authorized person, of the name of the care manager as soon as the
IHCP is completed. The contractor shall have a mechanism to allow for changing
levels of care management as needs change.     F.   Offering-Level of Service.

  1.   The contractor shall offer and document the enrollee’s response for this
higher level care management to enrollees (or, where applicable, authorized
persons) who, upon completion of a Complex Needs Assessment, are determined to
have complex needs which merit development of an IHCP and comprehensive service
coordination by a care manager. Enrollees shall have the right to decline
coordination of care services; however, such refusal does not preclude the
contractor from case managing the enrollee’s care.     2.   At the time of
enrollment, the contractor shall place all children, who are under DYFS, into
its care management program at a level of 2 or 3 initially. The contractor may
manage the enrollee at a lower level of care, after assessment and coordination
of needed services and stability are determined by the contractor with input
from the PCP,

      7/2007 Changes 1/2007 Accepted   IV-53

 

--------------------------------------------------------------------------------

 

      contractor’s care managers and medical director, DYFS case worker or
authorized representative.

4.5.5   CHILDREN WITH SPECIAL HEALTH CARE NEEDS

  A.   The contractor shall provide services to children with special health
care needs, who may have or are suspected of having serious or chronic physical,
developmental, behavioral, or emotional conditions (short-term, intermittent,
persistent, or terminal), who manifest some degree of delay or disability in one
or more of the following areas: communication, cognition, mobility,
self-direction, and self-care; and with specified clinically significant
disturbance of thought, behavior, emotions, or relationships that can be
described as a syndrome or pattern, generally resulting from neurochemical
dysfunction, negative environmental influences, or some combination of both.
Services needed by these children may include but are not limited to psychiatric
care and substance abuse counseling for DDD clients (appropriate referrals for
all other pediatric enrollees); medications; crisis intervention; inpatient
hospital services; and intensive care management to assure adherence to
treatment requirements.     B.   The contractor shall be responsible for
establishing:

  1.   Methods for well child care, health promotion, and disease prevention,
specialty care for those who require such care, diagnostic and intervention
strategies, home therapies, and ongoing ancillary services, as well as the
long-term management of ongoing medical complications.     2.   Care management
systems for assuring that children with serious, chronic, and rare disorders
receive appropriate diagnostic work-ups on a timely basis.     3.   Access to
specialty centers in and out of New Jersey for diagnosis and treatment of rare
disorders. A listing of specialty centers is included in Section B.4.10 of the
Appendices.     4.   Policies and procedures to allow for continuation of
existing relationships with out-of-network providers, when considered to be in
the best medical interest of the enrollee.

  C.   Linkages. The contractor shall have methods for coordinating care and
creating linkages with external organizations, including but not limited to
school districts, child protective service agencies, early intervention
agencies, behavioral health, and developmental disabilities service
organizations. At a minimum, linkages shall address:

  1.   Contractor’s process for generating or receiving referrals, and sharing
information;     2.   Contractor’s process for obtaining consent from enrollees
or, where applicable, authorized persons to share individual beneficiary medical
information; and

      7/2007 Changes 1/2007 Accepted   IV-54

 

--------------------------------------------------------------------------------

 

4.6.5   CARE MANAGEMENT

  A.   Care Management Standards. The contractor shall develop and implement
care management as defined in Article 1 with adequate capacity to provide
services to all enrollees who would benefit from care management services. In
addition, the contractor shall develop a higher level of care management for
enrollees with special needs, as described in Article 4.5.4. Specific care
management activities shall include at least the following:

  1.   An effective mechanism to initiate and discontinue care management
services in both inpatient and outpatient settings, in addition to catastrophic
incidents.     2.   An effective mechanism to coordinate services required by
enrollees, including community support services. When appropriate, such
activities shall be coordinated with those of the Division of Family Development
(DFD), Division of Youth and Family Services (DYFS), Division of Mental Health
Services (DMHS), Division of Developmental Disabilities, Special Child Health
Services County Case Management Units, Division of Addiction Services, and
community agencies.     3.   Care plans specifically developed for each care
managed enrollee which ensure continuity and coordination of care among the
various clinical and non-clinical disciplines and services.     4.   A process
to evaluate and improve individual care management services as well as the
effectiveness of care management as a whole. The contractor shall have written
policies and procedures that include:

  a.   A consistent internal communication system between the contractor’s units
and departments to ensure that enrollees with special health care needs are
readily identified and the implementation of care management services is
expedited.     b.   Description of how the care of enrollees with special needs
participating in a disease management program is coordinated so that all
identified needs are addressed and coordination of all needed services is
performed.

  5.   Protocols for the following care management activities:

  a.   Pregnancy services;     b.   All EPSDT services and coordination for
children with elevated blood lead levels;     c.   Mental health/substance abuse
services coordination;     d.   HIV/AIDS services coordination; and     e.  
Dental services for enrollees with developmental disabilities.

  B.   Early Identification. The contractor shall develop policies and
procedures for early identification of enrollees who require care management.
The contractor

      7/2007 Changes 1/2007 Accepted   IV-80

 

--------------------------------------------------------------------------------

 

      traditional PCP. Such physicians having the clinical skills, capacity,
accessibility, and availability shall be specially credentialed and
contractually obligated to assume the responsibility for overall health care
coordination and assuring that the special needs person receives all necessary
specialty care related to their special need, as well as providing for or
arranging all routine preventive care and health maintenance services, which may
not customarily be provided by or the responsibility of such specialist
physicians.     4.   Where a specialist acting as a PCP is not available for
chronically ill persons or enrollees with complex health care needs, those
enrollees shall have the option to select a traditional PCP upon enrollment,
with the understanding that the contractor may permit a more liberal, direct
specialty access (See section 4.5.2) to a specific specialist for the explicit
purpose of meeting those specific specialty service needs. The PCP shall in this
case retain all responsibility for provision of primary care services and for
overall coordination of care, including specialty care.     5.   If the
enrollee’s existing PCP is a participating provider in the contractor’s network,
and if the enrollee wishes to retain the PCP, contractor shall ensure that the
PCP is assigned, even if the PCP’s panel is otherwise closed at the time of the
enrollee’s enrollment.

  C.   In addition to offering, at a minimum, a choice of two or more primary
care physicians, the contractor shall also offer an enrollee or, where
applicable, an authorized person the option of choosing a certified nurse
midwife, certified nurse practitioner or clinical nurse specialist whose
services must be provided within the scope of his/her license. The contractor
shall submit to DMAHS for review a detailed description of the CNP/CNS’s
responsibilities and health care delivery system within the contractor’s plan.

4.8.3   PROVIDER NETWORK FILE REQUIREMENTS       The contractor shall provide a
certified [see Appendix A.4.4 for form] provider network file monthlyquarterly,
to be reported electronically in a format and software application system
determined by DMAHS that will include the names and addresses of every provider
in the contractor’s network. The file shall be submitted electronically by the
close of business on the fourth Monday of every monththe last month in the
calendar quarter. This includes all contracted providers and required
established relationships. It excludes all non-participating providers. The
format for computer electronic submission is found in Section A.4.1 of the
Appendices.

  A.   The contractor shall provide the DMAHS a full network, monthlyquarterly,
electronically in accordance with the specifications provided in Section A.4.1
of the Appendices. The contractor shall phase-in use of HIPAA Taxonomy Specialty
Codes with full implementation by January 2007. The network file shall include
an indicator for new additions and deletions and shall include:

      7/2007 Changes 1/2007 Accepted   IV-94

 

--------------------------------------------------------------------------------

 

  1.   Any and all changes in participating primary care providers, including,
for example, additions, deletions, or closed panels., must be reported monthly
to DMAHS.     2.   Any and all changes in participating physician specialists,
health care providers, CNPs/CNSs, ancillary providers, and other subcontractors.
must be reported to DMAHS on a monthly basis.     3.   The contractor shall not
allow enrollment freezes for any provider unless the same limitations apply to
all non-Medicaid/NJ FamilyCare members as well, or contract capacity limits have
been reached

  B.   DMAHS review of provider network deficiencies will be conducted on a
quarterly semi annual basis or more frequently as may be required.     C.   The
contractor shall provide the HBC with a full network on a monthly quarterly
basis in accordance with the specifications found in Section A.4.1 of the
Appendices. The electronic files shall be sent to DMAHS, and a copy to the
DMAHS’ designee for distribution.     D.   The monthly quarterly provider file
shall include an identifier for every provider including the SSN, tax ID# or
professional license number.

4.8.4   PROVIDER DIRECTORY REQUIREMENTS       The contractor shall prepare a
provider directory which shall be presented in the following manner. Fifty
(50) copies of the contractor’s up-to-date provider directory shall be provided
to the HBC and ten (10) copies shall be provided to DMAHS at least every six
months or within 30 days of an update, whichever is earlier. Up-to-date,
web-based provider directories shall also be maintained with updates made no
later than every 30 days.

  A.   Primary care providers who will serve enrollees listed by

  •   County, by city, by specialty     •   Provider name and degree; specialty
board eligibility/certification status; office address(es) (actual street
address); telephone number; fax number if available; office hours at each
location; indicate if a provider serves enrollees with disabilities and how to
receive additional information such as type of disability; hospital
affiliations; transportation availability; special appointment instructions if
any; languages spoken; disability access; and any other pertinent information
that would assist the enrollee in choosing a PCP.

  B.   Contracted specialists and ancillary services providers who will serve
enrollees

  •   Listed by county, by city, by physician specialty, by non-physician
specialty, and by adult specialist and by pediatric specialist for those
specialties indicated in Section 4.8.8.C.

      7/2007 Changes 1/2007 Accepted   IV-95

 

--------------------------------------------------------------------------------

 

      providers are willing, capable, and authorized (through licensure or
certification) to serve multiple counties or statewide.

  a.   Medical Toxicology   b.   Developmental & Behavioral Pediatrics   c.  
Medical Genetics   d.   Specialty Centers (Centers of Excellence)   e.   Other
Specialty Centers/Providers   f.   DME providers   g.   Medical suppliers   h.  
Prosthetists, orthotists, pedorthists   i.   Hearing aid suppliers   j.  
Transportation providers

  3.   Specialists. The contractor shall submit specific provider information
with the monthly network file with a certification of the unavailability of the
American Board of Medical Specialists (ABMS) diplomates in the county, the
provider who shall provide the service and documentation that the provider is
able, willing, and authorized to provide the service. The contractor shall
notify the DMAHS if the alternate provider terminates. The contractor shall
assure that the specialist or alternate provider has privileges in a network
hospital or shall authorize and pay for services provided by the specialist or
alternate provider at an out of network hospital provider. Where there is
neither a certified specialist or acceptable alternative provider for a
particular specialty service, the contractor may refer an enrollee out of
county. For the physician specialist types listed below, where there is
documentation of limited access or unavailability in a county of a specific type
of specialist, the contractor may indicate the name of a contracted provider as
an alternative for the following:

  a.   Cardiology, pediatric — In-county alternative: adult cardiovascular
disease; out of county pediatric referral applies to: Cumberland, Gloucester,
Hunterdon, Salem, Somerset, Sussex, Warren.     b.   Colon & Rectal surgeon — A
general surgeon with privileges to perform this surgery may be substituted for a
certified subspecialist in this field of medicine in the following counties:
Cape May, Cumberland, Gloucester, Hunterdon, Mercer, Morris, Salem, Sussex,
Union.     c.   Endocrinology, adult — In-county alternative: none, refer out of
county for Cape May, Gloucester, Salem, Sussex, Warren.     d.   Endocrinology,
pediatric — In-county alternative: adult endocrinologist; out of county referral
for pediatric endocrinology applies to: Atlantic, Cape May, Cumberland,
Gloucester, Hunterdon, Mercer, Ocean, Salem, Somerset, Sussex, Warren.     e.  
Gastroenterology, pediatric — In-county alternative: adult gastroenterologists;
out of county referral for pediatric gastroenterology applies to: Atlantic,
Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Mercer, Ocean, Salem,
Sussex, Warren.

      7/2007 Changes 1/2007 Accepted   IV-109

 

--------------------------------------------------------------------------------

 

  f.   General Surgery, pediatric — In-county alternative: adult general
surgery; out of county referral for pediatrics applies to: Burlington, Cape May,
Cumberland, Gloucester, Hunterdon, Mercer, Morris, Salem, Somerset, Sussex,
Union, Warren.     g.   Geriatrics — In-county alternative: Family Practitioner
or Internist; applies to: Cape May, Cumberland, Gloucester, Mercer, Morris,
Salem, Somerset, Sussex, Warren.     h.   Hematology/Oncology, pediatric —
In-county alternative: none; out of county pediatrics referral applies to:
Burlington, Cape May, Cumberland, Gloucester, Hudson, Hunteredon, Mercer, Ocean,
Salem, Somerset, Sussex, Warren.     i.   Infectious Disease — In-county
alternatives: none; out of county referral applies to: Warren.     j.  
Infectious Disease, pediatric — In-county alternative: Adult infectious disease;
out of county pediatric referral applies to: Atlantic, Burlington, Cape May,
Cumberland, Gloucester, Hunterdon, Ocean, Salem, Somerset, Sussex, Warren.    
k.   Nephrology, adult — In-county alternative: none; refer out of county for
Cape May, Sussex, Warren.     l.   Nephrology, pediatric — In-county
alternative: adult nephrologist; out of county pediatric referral applies to:
Atlantic; Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Mercer,
Monmouth, Ocean, Passaic, Salem, Somerset, Sussex, Union, Warren.     m.  
Neonatal/Perinatal medicine — Alternative: none, refer out of county.     n.  
Neurological Surgery — In-county alternative: none; out of county referral
applies to: Bergen, Burlington, Cape May, Cumberland, Gloucester, Hudson,
Hunterdon, Morris, Ocean, Passaic, Salem, Somerset, Sussex, Warren.     o.  
Pain Management — In-county alternative: none; out of county referral applies
to: Sussex, Warren.     p.   Plastic Surgery — In-county alternative: none; out
of county referral applies to: Cape May, Hunterdon, Ocean, Salem, Somerset,
Sussex, Warren.     q.   Pulmonary Disease, pediatric — In-county alternative:
Adult pulmonary disease; out of county pediatric referral applies to:
Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Ocean, Salem, Sussex,
Warren.

      7/2007 Changes 1/2007 Accepted   IV-110

 

--------------------------------------------------------------------------------

 

  D.   An explanation of the use of the contractor’s toll free telephone number
(staffed for twenty-four (24) hours per day/seven (7) days per week
communication);     E.   Information about how to obtain aA listing of primary
care practitioners (in the format described in Article 4.8.4);     F.   An
identification card clearly indicating that the bearer is an enrollee of the
contractor’s plan; and the name of the primary care practitioner and telephone
number on the card; a description of the enrollee identification card to be
issued by the contractor; and an explanation as to its use in assisting
beneficiaries to obtain services;     G.   An explanation that beneficiaries
shall obtain all covered non-emergency health care services through the
contractor’s providers;     H.   An explanation of the process for accessing
emergency services and services which require or do not require referrals;    
I.   A definition of the terms “emergency medical condition” and “post
stabilization care services” and an explanation of the procedure for obtaining
emergency services, including the need to contact the PCP for urgent care
situations and prior to accessing such services in the emergency room;     J.  
An explanation of the importance of contacting the PCP immediately for an
appointment and appointment procedures;     K.   An explanation of where and how
twenty-four (24) hour per day, seven (7) day per week, emergency services are
available, including out-of-area coverage, and procedures for emergency and
urgent health care service, including the fact that the enrollee has a right to
use any hospital or other setting for emergency care;     L.   A list of the
Medicaid and/or NJ FamilyCare services not covered by the contractor and an
explanation of how to receive services not covered by this contract including
the fact that such services may be obtained through the provider of their choice
according to regular Medicaid program regulations. The contractor may also
assist an enrollee or, where applicable, an authorized person, in locating a
referral provider;     M.   A notification of the enrollee’s right to obtain
family planning services from the contractor or from any appropriate Medicaid
participating family planning provider (42 C.F.R. § 431.51(b)); as well as an
explanation that enrollees covered under NJ FamilyCare Plan D (except PSC 380)
and Plan H may only obtain family planning services through the contractor’s
provider network, and that family planning services outside the contractor’s
provider network are not covered services.

      7/2007 Changes 1/2007 Accepted   V-14

 

--------------------------------------------------------------------------------

 

  3.   The need for the family to keep track of the cost-sharing amounts paid;
and     4.   Instructions on what to do if the cost-sharing requirements are
exceeded.

  XX.   An explanation on how to access WIC services;     YY.   Any other
information essential to the proper use of the contractor’s plan as may be
required by the Division;     ZZ.   Inform enrollees of the availability of care
management services;     AAA.   Enrollee right to adequate and timely
information related to physician incentives;     BBB.   An explanation that
Medicaid benefits received after age 55 may be reimbursable to the State of New
Jersey from the enrollee’s estate. The recovery may include premium payments
made on behalf of the beneficiary to the managed care organization in which the
beneficiary enrolls; and     CCC.   Information on how to obtain continued
services during a transition, i.e., from the Medicaid FFS program to the
contractor’s plan, from one MCO to another MCO, from the contractor’s plan to
Medicaid FFS, when applicable.

5.8.3   ANNUAL INFORMATION TO ENROLLEES

  A.   The contractor shall distribute an updated handbook which will include
the information specified in Article 5.8.2 to each enrollee or enrollee’s family
unit and to all providers at least once every twelve (12) months.     B.   The
contractor shall, at a minimum, issue an annual written notice to all of its
enrollees of their right to request and obtain information of all of the
contractor’s providers as specified in Article 4.8.4. The information shall be
made available and sent in hard copy format upon request and may be made
available in other formats as well.

5.8.4   NOTIFICATION OF CHANGES IN SERVICES       The contractor shall revise
and distribute the information specified in Article 5.8 at least thirty
(30) calendar days prior to any changes that the contractor makes in services
provided or in the locations at which services may be obtained, or other changes
of a program nature or in administration, to each enrollee and all providers
affected by that change.   5.8.5   ID CARD

      7/2007 Changes 1/2007 Accepted   V-19

 

--------------------------------------------------------------------------------

 

      place. The schedules can be submitted in any format, but must include the
full name of the marketing representative, the name and full address of the
location where marketing is being conducted, the date(s) and beginning and
ending times of the activity. All schedules will be reviewed and must be
approved in writing by the DMAHS. Plans may not commence any marketing activity
without prior DMAHS approval.

H.   With the exception allowed under Article 5.16.1I, neither the contractor
nor its marketing representatives may put into effect a plan under which
compensation, reward, gift, or opportunity are offered to eligible enrollees as
an inducement to enroll in the contractor’s plan other than to offer the health
care benefits from the contractor pursuant to this contract. The contractor is
prohibited from influencing an individual’s enrollment with the contractor in
conjunction with the sale of any other insurance.   I.   The contractor may
offer promotional give-aways that shall not exceed a combined total of $10 15 to
any one individual or family for marketing purposes. Giveaways and premiums that
have DMAHS approval may be distributed at approved events. These items shall be
limited to items that promote good health behavior (e.g., toothbrushes,
immunization schedules). For NJ FamilyCare, other promotional items shall be
considered with prior approval by DMAHS.   J.   The contractor shall ensure that
marketing representatives are appropriately trained and capable of performing
marketing activities in accordance with terms of this contract, N.J.A.C. 11:17,
11:2-11, 11:4-17, 8:38-13.2, N.J.S.A. 17:22 A-l, 26:2J-16, and the marketing
standards described in Article 5.16.   K.   The contractor shall ensure that
marketing representatives are versed in and adhere to Medicaid policy regarding
beneficiary enrollment and disenrollment as stated in 42 C.F.R. §438.56. This
policy includes, but is not limited to, requirements that enrollees do not
experience unreasonable barriers to disenroll, and that the contractor shall not
act to discriminate on the basis of adverse health status or greater use or need
for health care services.   L.   Door-to-door canvassing, telephone,
telemarketing, or “cold call” marketing of enrollment activities, by the
contractor itself or an agent or independent contractor thereof, shall not be
permitted. For NJ FamilyCare (Plans B, C, D), telemarketing shall be permitted
after review and prior approval by DMAHS of the contractor’s marketing plan,
scripts and methods to use this approach.   M.   Contractor employees or agents
shall not present themselves unannounced at an enrollee’s home for marketing or
“educational” purposes. This shall not limit such visits for medical
emergencies, urgent medical care, clinical outreach, and health promotion for
known enrollees.

      7/2007 Changes 1/2007 Accepted   V-43

 

--------------------------------------------------------------------------------

 

  a.   The contractor shall also review disenrollment information/surveys and
all complaints/grievances specifically referencing marketing staff.

  2.   Marketing commissions (including cash, prizes, contests, trips, dinners,
and other incentives) shall not exceed thirty (30) percent of the
representative’s monthly salary.

  C.   Enrollment Inducements

  1.   The contractor’s marketing representatives and other contractor’s staff
are prohibited from offering or giving cash or any other form of compensation to
a Medicaid beneficiary as an inducement or reward for enrolling in the
contractor’s plan.     2.   Promotional items, gifts, “give-aways” for marketing
purposes shall be permitted, but will be limited to items that promote good
health behavior (e.g., toothbrushes, immunization schedules). However, the
combined total of such gifts or gift package shall not exceed an amount of $10
15 to any one individual or family. Such items:

  a.   Shall be offered to the general public for marketing purposes whether or
not an individual chooses to enroll in the contractor’s plan.     b.   Shall
only be given at the time of marketing presentations and may not be a
continuous, periodic activity for the same individual, e.g., monthly or
quarterly give-aways, as an inducement to remain enrolled.     c.   Shall not be
in the form of cash.

      For NJ FamilyCare, other promotional items shall be considered with prior
approval by DMAHS.     3.   Raffles shall not be allowed.

  D.   Sanctions         Violations of any of the above may result in any one or
combination of the following:

  1.   Cessation or reduction of enrollment including auto assignment.     2.  
Reduction or elimination of marketing and/or community event participation.

      7/2007 Changes 1/2007 Accepted   V-47

 

--------------------------------------------------------------------------------

 

Liquidated Damages:
If the contractor does not provide or perform the requirement within fifteen
(15) business days of the written notice, or longer if allowed by the
Department, or through an approved corrective action plan, the Department may
impose liquidated damages of $250 per requirement per day for each day the
requirement continues not to be provided or performed. If after fifteen
(15) additional days from the date the Department imposes liquidated damages,
the requirement still has not been provided or performed, the Department, after
written notice to the contractor, may increase the liquidated damages to $500
per requirement per day for each day the requirement continues to be unprovided
or unperformed.
Note: If the failure to provide required services or the contractor’s operations
are interrupted or compromised due to a natural disaster and/or Act of God and
after diligent efforts, the contractor cannot make other provisions for the
delivery of services or conduct of operations, the Department may determine, at
its sole discretion, not to impose liquidated damages. The contractor shall
present a plan of correction to the Department for approval within two
(2) business days of the event or where possible, prior to the event when known,
such as advance warnings of an oncoming hurricane.
7.16.3 TIMELY REPORTING REQUIREMENTS

  A.   The contractor shall produce and deliver timely reports within the
specified timeframes and descriptions in the contract including information
required by the ERO. Reports shall be produced and delivered on both a scheduled
and mutually agreed upon on-request basis according to the schedule established
by DMAHS.     B.   Liquidated Damages:

  1.   For each late report, the Department shall have the right to impose
liquidated damages of $250 per day per report until the report is provided. For
any late report that is not delivered after thirty (30) days or such longer
period as the Department shall allow, the Department, after written notice,
shall have the right to increase the liquidated damages assessment to $500 per
day per report until the report is provided.     2.   Damages for Annual Rate
Development Financial Reporting. In the case of submission of the financial
reports referenced in the “Contractors Financial Reporting Manual,” any such
report that is more than one business day past the due date, the Department
shall have the right to impose an immediate sanction of $1,000 in damages and an
additional $500 per day for each subsequent day the report(s) are late.

      7/2007 Changes 1/2007 Accepted   VII-26

 

--------------------------------------------------------------------------------

 

7.16.4 ACCURATE REPORTING REQUIREMENTS

  A.   Every report due the State shall contain sufficient and accurate
information and in the approved media format to fulfill the State’s purpose for
which the report was generated.         If the Department imposes liquidated
damages, it shall give the contractor written notice of a report that is either
insufficient or inaccurate and that liquidated damages will be assessed
accordingly. After such notice, the contractor shall have fifteen (15) business
days, or such longer period as the Department may allow, to correct the report.
        Encounter data shall be accurate and complete, i.e., have no missing
encounters or required data elements, and shall have no more than 5% edit
errors.     B.   Liquidated Damages:

  1.   If the contractor fails to correct the report within the fifteen
(15) business days, or such longer period as the Department may allow, the
Department shall have the right to impose liquidated damages of $250 per day per
report until the corrected report is delivered. If the report remains
uncorrected for more than thirty (30) days from the date liquidated damages are
imposed, the Department, after written notice, shall have the right to increase
the liquidated damages assessment to $500 per day per report until the report is
corrected.     2.   The State will use encounter data completeness benchmarks to
identify areas where encounter data appear to have been underreported. These
benchmarks will be periodically revised to ensure that they are reasonable, and
accurately reflect minimum reporting expectations. If the contractor falls
outside of encounter data completeness benchmarks for any Managed Care Category
of Service, the contractor will be notified that reporting deficiencies may have
occurred for specified service date ranges. In this event, the State may require
documentation regarding the potential deficiency and/or a plan of corrective
action from the contractor. If the contractor is unable to demonstrate that
encounter data reports are complete, the State will conduct reviews of medical
records, or utilize. other means to determine reporting compliance. The State
reserves the right to consider utilization rates reported via encounter data in
the process of calculating capitation rates. Additionally the State reserves the
right to reconsider the use of the benchmarks to measure reporting completeness.
        In addition to conducting routine monitoring, the DMAHS will conduct, on
a calendar year basis, annual reviews of encounter data to determine compliance
performance. Encounter data will be reviewed for missing or omitted encounter
data and for pending encounters or edit errors. An

      7/2007 Changes 1/2007 Accepted   VII-27

 

--------------------------------------------------------------------------------

 

      amount of $1 may be assessed for each missing or omitted encounter. In
addition, $1 per encounter or encounter data element may be assessed for any
pending encounter or error that is not corrected and returned to DMAHS within
thirty (30) days after notification by DMAHS that the data are incomplete or
incorrect. The Department shall have the right to calculate the total number of
missing or omitted encounters and encounter data by extrapolating from a sample
of missing or omitted encounters and encounter data.     3.   Damages for Annual
Rate Development Financial Reporting. In the case of submission of the financial
reports referenced in the “Contractor’s Financial Reporting Manual,” for any
such report that is inaccurate or incomplete, the Department shall have the
right to impose an immediate sanction of $1,000 and an additional $500 per day
for each subsequent day the reports remain inaccurate or incomplete as
determined by the DMAHS.

7.16.5 TIMELY PAYMENTS TO MEDICAL PROVIDERS
The contractor shall process claims in accordance with New Jersey laws and
regulations and shall be subject to damages pursuant to such laws and
regulations. In addition, pursuant to this contract the Department may assess
liquidated damages if the contractor does not process (pay or deny) claims
within the following timeframes: ninety (90) percent of all claims (the totality
of claims received whether contested or uncontested) submitted electronically by
medical providers within thirty (30) days of receipt; ninety (90) percent of all
claims filed manually within forty (40) days of receipt; ninety-nine
(99) percent of all claims, whether submitted electronically or manually, within
sixty (60) days of receipt; and one hundred (100)ninety-nine and one half (99.5)
percent of all claims within ninety (90) days of receipt. Claims processed for
providers under investigation for fraud or abuse and claims suppressed pursuant
to Article 8.9 (regarding PIPs) are not subject to these requirements. The
amount of time required to process a paid claim shall be computed in days by
comparing the initial date of receipt with the check mailing date. The amount of
time required to process a denied claim (whether all or part of the claim is
denied) shall be computed in days by comparing the date of initial receipt with
the denial notice mailing date. Claims processed during the quarter shall be
reported in required categories through the Claims Lag report (See
Section A.7.21 of the Appendices (Tables 4A and B)). Table 4A shall be used to
report claims submitted manually and Table 4B shall be used to report claims
submitted electronically.
Liquidated Damages:
Liquidated damages may be assessed if the contractor does not meet the above
requirements on a quarterly basis. Based on the contractor-reported information
on the claims lag reports, the Department shall determine for each time period
(thirty (30)/forty (40), sixty (60), and ninety (90) days) the actual percentage
of claims processed (electronic and manual claims shall be added together). This
number shall be subtracted

      7/2007 Changes 1/2007 Accepted   VII-28

 

--------------------------------------------------------------------------------

 

      data using statistically valid sampling techniques including, but not
limited to, the following:         Primary care practitioner audits; specialty
audits; inpatient mortality audits; quality of care and provider performance
assessments; quality assurance referrals; credentialing and recredentialing;
verification of encounter reporting rates; quality assurance committee and
subcommittee meeting agendas and minutes; enrollee complaints, grievances, and
follow-up actions; providers identified for trending and sanctioning, including
providers with low blood lead screening rates; special quality assurance studies
or projects; prospective, concurrent, and retrospective utilization reviews of
inpatient hospital stays; and denials of off-formulary drug requests.     F.  
The contractor shall prepare and submit to DMAHS quarterly reports to be
submitted electronically (e.g., email) in report-ready form in a format and
software application system determined by DMAHS, containing summary information
on the contractor’s operations for each quarter of the program (See Section A.7
of the Appendices, Tables 1 through 22. Exceptions — Tables 3A and 3B shall be
submitted monthly by the fifteenth (15th) of every month; Table 5 shall be
submitted annually, Table 9 shall be submitted semi-annually; Table 22 shall be
submitted weekly). These reports shall be received by DMAHS no later than
forty-five (45) calendar days after the end of the quarter. Any
contract-required report submission may be electronic in the format specified by
DMAHS staff accompanied by the appropriate certification (where applicable)
unless otherwise noted in the contract.         The contractor shall be
responsible for continued reporting beyond the term of the contract because of
lag time in submitting source documents by providers.     G.   The contractor
may submit encounter reports records daily but must submit encounter reports
records at least quarterlymonthly. However,- encounter- reports will be
processed by DMAHS’ fiscal agent no more frequently than monthly. All encounters
shall be reported to DMAHS within seventy-five-(75)sixty (60) days of the end of
the quarter in which they are receivedadjudication by the contractor and within
one year plus seventy-five (75) days twelve (12) months from the date of service
(for hospital admissions, 12 months from date of discharge). Each provider is
required to have a unique identifier and qualified providers must have a
National Provider Identifier on or after the compliance date established by CMS.
    H.   The contractor shall annually and at the time changes are made report
its staffing positions including the names of supervisory personnel (Director
level and above and the QM/UR personnel), organizational chart, and any position
vacancies in these major areas.

      7/2007 Changes 1/2007 Accepted   VII-40

 

--------------------------------------------------------------------------------

 

  I.   DMAHS shall have the right to create additional reporting requirements at
any time as required by applicable federal or State laws and regulations, as
they exist or may hereafter be amended and incorporated into this contract.    
J.   Reports that shall be submitted on an annual or semi-annual basis, as
specified in this contract, shall be due within sixty (60) days of the close of
the reporting period, unless specified otherwise.     K.   MCSA Paid Claims
Reconciliation. On a quarterly basis, the contractor shall provide paid claims
data, via an encounter data file or separate paid claims file, that meet the
HIPAA format requirements for audit and reconciliation purposes. The contractor
shall provide documentation that demonstrates a 100% reconciliation of the
amounts paid to the amounts billed to the DMAHS. The paid claims data shall
include at a minimum, claim type, provider type, category of service, diagnosis
code (5 digits), procedure/revenue code, Internal Control Number or Patient
Account Number under HIPAA, provider ID, dates of services, that will allow the
DMAHS to price claims in comparison to Medicaid fee schedules for evaluation
purposes. (This section not applicable to non-MCSA contractor).     L.  
Encounter Data Submissions. The contractor shall cooperate with the DMAHS in its
review of the status of encounter data submissions to determine needed
improvements for accuracy and completeness of encounter data submissions. With
the contract period beginning July 2005, the contractor will be subject to
additional sanctions if not in full compliance with encounter data submission
standards.

7.27 FINANCIAL STATEMENTS
7.27.1 AUDITED FINANCIAL STATEMENTS (SAP BASIS)

  A.   Annual Audit. The contractor shall submit its audited annual financial
statements prepared in accordance with Statutory Accounting Principles (SAP)
certified by an independent public accountant no later than June 1 of each year,
for the immediately preceding calendar year as well as for any company that is a
financial guarantor for the contractor in accordance with N.J.S.A. 8:38-11.6.  
  B.   Audit of Income Statements by Rate Cell Grouping         The contractor
shall submit, quarterly, reports found in Appendix, Section A in accordance with
the “HMO Financial Reporting Manual for Medicaid/NJ FamilyCare Rate Cell
Grouping Costs” (Appendix, Section A.7.21). These reports shall be reviewed by
an independent public accountant in accordance with the procedures and for the
cost categories that will be detailed by DMAHS on or before December 31 each
year, to be effective the following July (Appendix, Section A).

      7/2007 Changes 1/2007 Accepted   VII-41

 

--------------------------------------------------------------------------------

 

The contractor shall require its independent public accountant to prepare a
letter and report of findings which shall be submitted to DMAHS by June 1 of
each year. Only the fourth quarter report (period October 1 through December 31)
of each calendar year will be subject to this Audit of Income Statements by Rate
Cell Grouping.
The contractor shall require its independent public accountant to explain any
differences between the Statewide Income Statement by Rate Cell Grouping Cost
Reports (Report 2 — Parts SI through S3) and the annual audit statements in the
letter.
When findings indicate significantly reduced Medical/Hospital Expenses from
those originally reported, a corresponding rate reduction may take effect in
future periods.
The Department at its sole discretion shall have the right to conduct targeted
audits, request additional information or reporting, and/or investigate or
verify submitted reports for any period of the contract term at the contractor’s
expense.
7.27.2 UNAUDITED FINANCIAL STATEMENTS (SAP)
Contractor shall submit to DMAHS all quarterly and annual financial statements
and annual supplements in accordance with Statutory Accounting Principles
(SAP) required in N.J.A.C. 8:38-11.6. Submissions to DMAHS shall be on the same
time frame described in N.J.A.C. 8:38-14, i.e., quarterly reports are due the
fifteenth (15th) day of the second month following the quarter end and statutory
unaudited statement and the annual supplemental are due March 1 covering the
preceding calendar year. Such information shall be subject to the
confidentiality provisions in Article 7.40.
7.28 FEDERAL APPROVAL AND FUNDING
This managed care contract shall not be implemented until and unless all
necessary federal approval and funding have been obtained.
7.29 CONFLICT OF INTEREST

  A.   No contractor shall pay, offer to pay, or agree to pay, either directly
or indirectly, any fee, commission, compensation, gift, gratuity, or other thing
of value of any kind to any State officer or employee or special State officer
or employee, as defined by N.J.S.A. 52:13D-13b and e, in the Department or any
other agency with which such contractor transacts or offers or proposes to
transact business, or to any member of the immediate family, as defined by
N.J.S.A. 52:13D-13i, of any such officer or employee, or partnership, firm or
corporation with which they are employed or associated, or in which such officer
or employee has an interest within the meaning of N.J.S.A. 52:13D-13g.

      7/2007 Changes 1/2007 Accepted   VII-42

 

--------------------------------------------------------------------------------

 

8.4 MEDICAL COST RATIO
8.4.1 MEDICAL COST RATIO STANDARD
The contractor including its subcontractors shall in the aggregate maintain
direct medical expenditures for enrollees equal to or greater than eighty
(80) percent of premiums paid in all forms from the State. This medical cost
ratio (MCR) shall apply to annual periods from the contract effective date (if
the contract ends before the completion of an annual period, the MCR shall apply
to that shorter period). The MCR shall be based on reports completed by the
contractor and acceptable to the Department.

  A.   Direct Medical Expenditures. Direct medical expenditures are the incurred
costs of providing direct care to enrollees for covered health care services as
stated in Article 4.1 (Report on Table 19). Costs related to information and
materials for general education and outreach and/or administration are not
considered direct medical expenditures.         Personnel costs are generally
considered to be administrative in nature and must be reported as an
administrative expense on Table 19 (Income Statement by Rate Cell Grouping) on
line for Compensation. However, a portion of these costs may qualify as direct
medical expenditures, subject to prior review and approval by the State. Those
activities that the contractor including its subcontractors expects to generate
these costs must be specified and detailed in a Medical Cost Ratio — Direct
Medical Expenditures Plan which must be reviewed and approved by the State. At
the end of the reporting period, the contractor’s reporting shall be based only
on the approved Medical Cost Ratio — Direct Medical Expenditures Plan. In order
to consider these costs as Direct Medical Expenditures, the contractor must
complete Table 6, entitled “Allowable Direct Medical Expenditures,” which will
be used by the State to determine the allowable portion of costs. The allowable
components of these personnel costs include the following activities:

  1.   Care Management. Allowable direct medical expenditures for care
management include: 1) assessment(s) of an enrollee’s risk factors; and 2)
development of Individual Health Care Plans. The costs of performing these two
allowable components may be considered a direct medical expenditure for purposes
of calculating MCR and must be reported on Table 6.     2.   The cost associated
with the provision of a one-on-one face-to-face home visitencounter by the
contractor’s clinical personnel for the purpose of medical education or
anticipatory guidance can be considered a direct medical expenditure (Report on
Table 6).     3.   Costs for activities required to achieve compliance standards
for EPSDT participation, lead screening, and prenatal care as specified in
Article IV may be considered direct medical expenditures. The contractor’s
reporting shall be

      7/2007 Changes 1/2007 Accepted   VIII-4

 

--------------------------------------------------------------------------------

 

      based only on the approved Medical Cost Ratio — Direct Medical
Expenditures Plan (Report on Table 6).

Calculation of MCR. The calculation of MCR will be made using information
submitted by each the contractor on the quarterly reports — Income Statement by
Rate Cell Grouping (Section A.7.21 of the Appendices, Table 19, ). The costs
related to 8.4. 1.A 1-3 are to be reported on Table 6 and the allowable amount
will be added to the calculation of Medical and Hospital Expenses. The sum of
all applicable quarters in the SFY for which the MCR is calculated for Total
Medical and Hospital Expenses less Coordination of Benefits (COB) and less
reinsurance recoveries will be divided by the sum of all applicable quarters of
Medicaid/NJ FamilyCare premiums to arrive at the ratio. In addition, the DMAHS
will allow for any applicable premium adjustments in the MCR calculation. At its
sole discretion, the State reserves the right to recompute the MCR to determine
direct medical expenditures of eighty (80) percent for a period of up to three
(3) years prior to the close of the state fiscal year under review for MCR
determination and recover the underexpenditure as delineated in Article 8.4.3.
8.4.2 RESERVED
8.4.3 DAMAGESRECOVERY OF UNDEREXPENDITURE
The Department shall have the right to impose damages on a contractor that has
failed to maintain an appropriate MCR.recover the amount of payments from the
State not spent on medical costs as defined above. The damages shall be assessed
when MCR is below 80% and an underexpenditure occurs. The formula for- imposing
damages follows:
     ACTUAL MCR
     80% or above          NONE          NONE
          .15 times          .15 times
                    underexpenditure     underexpenditure
     75.00 77.99%     .50 times     .50 times
                    underexpenditure     underexpenditure
     74.99 or below     .90 times     1.00 times
                    underexpenditure     underexpenditure
If at 180 days after the SFY end the MCR is below 80.0%, the State shall recover
100% of the underexpenditure. If the contractor fails to meet the MCR
requirement and a penalty is appliedrecovery is made, a plan of corrective
action shall be required.
8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS

      7/2007 Changes 1/2007 Accepted   VIII-5

 

--------------------------------------------------------------------------------

 

8.5.1 REGIONS
Capitation rates for DYFS, NJ FamilyCare Plans B, C, and D and the non
risk-adjusted rates for AIDS and clients of DDD are statewide. Rates for all
other premium groups are regional in each of the following regions:

  •   Region 1: Bergen, Hudson, Hunterdon, Morris, Passaic, Somerset, Sussex,
and Warren counties     •   Region 2: Essex, Union, Middlesex, and Mercer
counties     •   Region 3: Atlantic, Burlington, Camden, Cape May, Cumberland,
Gloucester, Monmouth, Ocean, and Salem counties

Contractors may contract for one or more regions but, except as provided in
Article 2, may not contract for part of a region.
8.5.2 MAJOR PREMIUM GROUPS
The following is a list of the major premium groups. The individual rate groups
(e.g. children under 2 years, etc.) with their respective rates are presented in
the rate tables in the appendix.
8.5.2.1 AFDC/TANF, DYFS AND AGING OUT FOSTER CARE CHILDREN, NJC PREGNANT WOMEN,
AND NJ FAMILYCARE PLAN A CHILDREN
This grouping includes capitation rates for Aid to Families with Dependent
Children (AFDC)/Temporary Assistance for Needy Families (TANF), DYFS and Aging
Out Children in Foster Care, New Jersey Care Pregnant Women and Children, and NJ
FamilyCare Plan A children (includes individuals under 21 in PSC 380), but
excludes individuals who have AIDS or are clients of DDD, as well as AFDC/TANF
restricted alien individuals over the age of 20.99 years old.
8.5.2.2 NJ FAMILYCARE PLANS B & C
This grouping includes capitation rates for NJ FamilyCare Plans B and C
enrollees, excluding individuals with AIDS and/or DDD clients.
8.5.2.3 NJ FAMILYCARE PLAN D CHILDREN
This grouping includes capitation rates for NJ FamilyCare Plan D children,
excluding individuals with AIDS.
8.5.2.4 NJ FAMILYCARE PLAN D PARENTS/CARETAKERS

      7/2007 Changes 1 /2007 Accepted   VIII-6

 

--------------------------------------------------------------------------------

 

This grouping includes capitation rates for NJ FamilyCare Plan D
parents/caretakers, excluding individuals with AIDS, and restricted alien
individuals, and include only enrollees 19 years of age or older.
8.5.2.5 RESERVED DYFS AND AGING OUT FOSTER CHILDREN
This grouping includes capitation rates for Division of Youth and Family
Services, excluding individuals with AIDS and clients of DDD.
8.5.2.6 ABD WITHOUT MEDICARE
Compensation to the contractor for the ABD individuals without Medicare will be
risk-adjusted using the Health Based Payments System (HBPS), which is described
in Article 8.6. HBPS adjusts for the diagnosis of AIDS; therefore, separate AIDS
rates are not necessary for this population. Finally, the HBPS adjusts for age
and sex so separate rates for age and sex within this population are not
necessary.
8.5.2.7 ABD WITH MEDICARE AND OTHER DUAL ELIGIBLES
This grouping includes capitation rates for all enrollees with Medicare,
excluding dual eligibles (Medicaid and Medicare) individuals with AIDS and
clients of DDD.
8.5.2.8 CLIENTS OF DDD
This grouping includes all enrollees except ABD individuals without Medicare.
The contractor shall be paid separate, statewide rates for subgroups of the DDD
population, excluding individuals with AIDS. These rates include covered MH/SA
services.
8.5.2.9 ENROLLEES WITH AIDS
This grouping includes all enrollees except ABD individuals without Medicare.

  A.   The contractor shall be paid special statewide capitation rates for
enrollees with AIDS.     B.   The contractor will be reimbursed double the AIDS
rate, once in a member lifetime, in the first month of payment for a recorded
diagnosis of AIDS, prospective and newly diagnosed. This is a
one-time-only-per-member payment, regardless of MCE.

8.5.2.10 RESERVED
8.5.3 NEWBORN INFANTS
The contractor shall be reimbursed for newborns from the date of birth through
the first 60 days after the birth through the period ending at the end of the
month in which the 60th day falls by a supplemental payment as part of the
supplemental maternity payment.

      7/2007 Changes 1 /2007 Accepted   VIII-7

 

--------------------------------------------------------------------------------

 

SECTION A
REPORTS
The State has defined operational and financial reports the contractor must
submit. The reports in this section are those for which the State has a defined
format or template or multiple data elements. The reports are referenced
according to the contract Article to which they correspond, beginning with
Article 3. In cases where a specific report format or template does not exist,
the State instead has defined required report elements, all of which must be
addressed in full. The actual structure of such reports is being left to the
discretion of the contractor with prior DMAHS approval. Note that additional
reports are required and described in the contract.
1/20077/2007 Changes

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual for Medicaid/NJ FamilyCare Rate Cell
Grouping Costs
State of New Jersey

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

Contents

         
1. Introduction
    1  
 
       
2. General Instructions
    7667  
 
       
3. Reporting Specifications
    109910  
§ Table 20: Lag Reports (Parts A-ED)
    109910  
§ Table 19: Income Statement by Rate Cell Grouping (Parts A — R2, U, V)
    1314  
- Parts A-R2, U, V
       
- Part S2: Summary
       
- Part S3: Reconciliations
       
- Part T: Non-State Plan Services
       
§ Table 21: Maternity Outcome Counts
    24112223  
§ Table 4: Claims Processing Lag Report (Parts A & B)
    25112324  
§ Table 7: Stop Loss Summary (Parts A — C)
    29112728  
§ Table 10: Third Party Liability and Fraud/Abuse Collections
    30112829  
§ Table 11: Utilization and Unit Cost Information (Parts A—B)
    31112930  
§ Table 14: Supplemental Data (Parts A — C)
    32113031  
 
       
4. Appendix A— Incurred But Not Reported (IBNR) Methodology
    3634  
 
       
5. Appendix B — Key Utilization Definitions
    4038  
 
       
6. Appendix C — Managed Care Category of Service Codes
    4341  
 
       
7. Appendix D — Report Forms
    4442  
 
       
8. Appendix E — Certification Statement at Each Quarter End
    4644  

      Date Effective: July 1, 20076   i

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

11
Introduction
Purpose
The objective of this Financial Reporting Specifications is to ensure
uniformity, accuracy and completeness in reporting Medicaid/NJ FamilyCare rate
cell groupings. In addition, the provision of this Financial Reporting
Specifications to the Contractors will help to eliminate inconsistencies, as
reports can vary in the presentation of items such as allocation of expenses,
accrual of incurred-but-not-reported (IBNR) claims, handling of maternity
claims, and other items. All reports shall be submitted as outlined in the
general instructions. The financial reports submitted from this Financial
Reporting Specifications will be used in future rate setting and to better
assess the financial performance of Contractors.
The reports in this Financial Reporting Specifications are to supplement, not
replace, the reporting requirements currently required in the Division of
Medical Assistance and Health Services (DMAHS) Managed Care Contract (please
refer to Section A of the contract). Key differences between this Financial
Reporting Specifications and the reports currently submitted to DMAHS are as
follows:

§   Rate cell grouping detail;

§   Regional detail;

§   IBNR calculation detail; and

§   Timing of submissions.

      Date Effective: July 1, 20076   1

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

Rate Cell Groupings
—This Financial Reporting Specifications requires key cost reporting by rate
cell grouping. Rate cells have been combined into 15 rate cell groupings for
these reporting purposes (seventeen rate cell groupings for Medicaid/NJ
FamilyCare Managed Care
at riskreporting purposes populations and two rate cell groupings for Managed
Care Service Administrator (MCSA) populations). Please note where Acquired
Immunodeficiency Syndrome (AIDS) individuals are included or excluded in the
rate cell groupings. Also note that maternity and newborn costs are reported as
separate rate cell groupings and shall be excluded from other rate cell
groupings. The rate cell groupings are as follows:

              Rate Cell       Capitation     Reference   Rate Cell Grouping  
Code   Description AFDC/SSI/DDD

 
           
Table #19—
Parts A, B, C
  AFDC/NJCPW/NJ KidCare A

(Excluding AIDS)   125R1-125R3
143R1-143R3
171R1-171R3
172R1-172R3
183R1-183R3
  Individuals eligible for Aid to Families with Dependent Children (AFDC), New
Jersey Care Pregnant Women (NJCPW), or NJ KidCare A (children below the age of
19 with family incomes up to and including 133% of the federal poverty level
(FPL)), excluding individuals with AIDS.
 
           
Table #19
Part D
  DYFS Clients
(Excluding AIDS)   32599. 34399   Individuals eligible through the Division of
Youth and Family Services (DYFS), including Foster Care children and children
with Adoption Assistance, excluding individuals with AIDS.
 
           
Table #19—
Part E
  ABD with Medicare and Other Dual Eligibles — DDD

(Excluding AIDS)   48399    ABD (Aged, Blind, and/or Disabled) individuals who
receive Medicare and are eligible for services through the Division of
Developmental Disabilities (DDD), excluding individuals with AIDS.
 
           
Table #19—
Part F
  ABD with Medicare and Other Dual Eligibles — Non-DDD

(Excluding AIDS)   711R1-711R3
813R1-813R3
823R1-823R3
863R1-863R3   ABD individuals who receive Medicare and are not eligible for
services through the DDD, excluding individuals with AIDS.
 
           
Table #19—
Part G
  Non-ABD — ODD

(Excluding AIDS)   47399    Non-ABD individuals eligible for services through
the DDD, excluding individuals with AIDS.

      Date Effective: July 1, 20076   2

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

              Rate Cell       Capitation     Reference   Rate Cell Grouping  
Code   Description
Table #19—
Part H
  ABD without Medicare —DDD

(Including AIDS)   49399, 49499    ABD individuals not receiving Medicare and
eligible for services through the DDD, including individuals with AIDS.
 
           
Table #19—
Part l
  ABD without Medicare —Non-DDD

(Including AIDS)   71099, 81099,
81299    ABD individuals not receiving Medicare and not eligible for services
through the DDD, including individuals with AIDS.
 
            NJ FamilyCare/NJ KidCare

 
           
Table #19—
Part J
  NJ KidCare B&C

(Excluding AIDS)   62599, 63399    Eligible children under age 19 with family
income above 133% and up to and including 200% FPL, excluding individuals with
AIDS.
 
           
Table #19—
Part K
  NJ KidCare D

(Excluding AIDS)   92599, 93399    Eligible children under age 19 with family
income between 201% and up to and including 350% FPL, excluding individuals with
AIDS.
 
           
Table #19—
Part M
  NJ Family Care Parents /Adults NJ
FamilyCare
Parents 0 133% FPL

(Excluding AIDS)   56199, 56299,
57399 57199
57899,58499   Parents with dependent children with family income between-0% and
133% FPL, excluding individuals with AIDS. Parents/caretakers with children
below the age of 23, and children from the age of 19 through 22 years, who are
full-time students who do not qualify for AFDC Medicaid, excluding individuals
with AIDS.

Single adults and couples without dependent children. Includes Health Access
individuals without dependent children.

Parents over 21 years of age with classification based on restricted alien
status.

      Date Effective: July 1, 20076   3

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

              Rate Cell       Capitation     Reference   Rate Cell Grouping  
Code   Description
Table # 19-
Part O

  NJ FamilyCare
Parents 13/1-250% FPL

(Excluding AIDS)   95499,
97-199, 98199   Parents with dependent children with family income between 134%
and 200% FPL, Parents/caretakers with children below the age of 23, and children
from the age of 19 through 22 years, who are full time students who do not
qualify for AFDC Medicaid with family incomes up to and including 250% of FPL,
excluding individuals with AIDS.
 
            Special Populations/Data

 
           
Table #19—
Part P
  ABD with Medicare and Other Dual Eligibles — AIDS   28499, 48499   ABD
individuals with AIDS who receive Medicare, including those eligible for DDD,
excluding the risk-adjusted populations.
 
           
Table #19—
Part Q
  Non-ABD — AIDS   27499, 47499,
27699   Non-ABD individuals with AIDS including AFDC, NJCPW, NJ KidCare, and NJ
FamilyCare Parents, excluding the risk-adjusted populations.
 
           
Table #19—
Part R1
  Maternity   N/A   Please refer to criteria outlined in the instructions for
Table 19 Part R1 in the Report Specifications section.
 
           
Table #19—
Part R2
  Newborn   Includes
newborn claims
costs
associated
within: 103R1 -
103R3, 30399,
60399, 80399,
90399   Please refer to criteria outlined in the instructions for Table 19 Part
R2, in the Report Specifications section.
 
            MCSA

 
           
Table #19
Part U

  NJ FamilyCare
Adults 0 100% FPL

(Excluding AIDS)   65499,
67499, 68499   Single adults and couples without dependent children with family
income between 0% and 100% FPL, adults and couples without dependent children
under the ago of 23 with family incomes up to and including 250% FPL, excluding
individuals with AIDS. Includes Health -Access individuals without dependent
children

      Date Effective: July 1, 20076   4

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

              Rate Cell       Capitation     Reference   Rate Cell Grouping  
Code   Description
Table #19
Part V

  Adult Restricted Aliens   40199,
40299, 40399   Classification based on restricted alien status in PSCs 310 -330,
410 — 430, -470 and 380 over the age of 20, or NJ FamilyCare PSCs 763, and -497
& 498 with corresponding cap codes.

      Date Effective: July 1, 20076   5

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

Geographic Regions
Some of the reports in this Contractor Reporting Specifications request
information from the three geographic regions corresponding to those used in
rate setting. Listed below are the counties included in each geographic region:

          Northern (Region 1)   Central (Region 2)   Southern (Region 3)
Bergen
  Essex   Atlantic
Hudson
  Mercer   Burlington
Hunterdon
  Middlesex   Camden
Morris
  Union   Cape May
Passaic
      Cumberland
Somerset
      Gloucester
Sussex
      Monmouth
Warren
      Ocean
 
      Salem

      Date Effective: July 1, 20076   6

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

2 2
General Instructions
The following are general instructions for completing the various tables
required to be submitted by the Contractors to DMAHS. These instructions are
designed to promote uniformity in reporting.
Due Dates
All Medicaid/NJ FamilyCare revenues and expenses must be reported using the
accrual basis of accounting except for Table 19, Parts T V (Non-State Plan
Services by rate cell grouping and MCSA groupings). Table 19, Parts T V shall be
reported on a paid basis. Reports shall be submitted quarterly and are due
45 days following each quarter end:
12-Month Period End Reports Due Each Quarter

      Quarter Ending:   Due Date:
March 31
  May 15
June 30
  August 15
September 30
  November 15
December 31
  February 15

Annual Supplemental Reports Due

      Quarter Ending:   Due Date:
September 30
  November 105

If a due date falls on a weekend or state holiday, reports will be due the next
business day. Any additional information beyond this reporting manual critical
to the actuarially

      Date Effective: July 1, 20076   7

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

-sound development of capitation rates will be requested in writing and be due
within 15 days of the request. Please submit the completed reports to:
State of New Jersey
Director, HMO Financial Reporting
David.Moran@dhs.state.nj.us
and
Mercer Government Human Services Consulting
Actuarial Services
Mike.Nordstrom@mercer.com
In the event that Medicaid financial statements are submitted with errors that
require restatement, DMAHS, in its sole discretion, shall require the Contractor
to engage independent auditors to do a more thorough review or audit of the
financial statements. DMAHS shall not reimburse the Contractor for any
additional costs related to an additional review or audit.
Format
The Contractor will submit these reports electronically, using Excel
spreadsheets in the formats and on the forms specified in this manual without
alteration, to the e-mail addresses listed above or to an alternate DMAHS secure
website it may establish during the period of this contract. Copies of the
reports are included in Appendix D of this manual.
Web-Based Financial Reporting
The contractor will log into a secure web-based portal to submit the Excel
spreadsheets that comprise the Medicaid Financial Reports (MFR). Upon
submission, the MFR data will pass through a series of edits to measure
completeness and the basic accuracy of the mandatory reports. The contractor
will then be notified via the system if the reports were rejected along with a
description of the error

      Date Effective: July 1, 20076   8

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

Annual Audit Requirement
Please refer to Section 7.27 for the audit requirements in the managed care
contract.
Other Instructions
Line titles and columnar headings of the various reports are, in general,
self-explanatory. Specific instructions are provided for items that may have
some question as to content. Any entry for which no specific instructions are
included shall be made in accordance with sound accounting principles and in a
manner consistent with related items covered by specific instructions.
Incorporate adjustments to prior data in the current reporting period.
Adjustments for prior period IBNR estimates shall be included on Table 19,
Part S2, in Line 45, and a detailed reconciliation shall be included on Table
19, Part S3. Information about any adjustments that pertain to prior periods
shall be explained in a note to the reports. However, if there was material
error in preparation of the prior period report, a revised report shall be
submitted.
Unanswered questions or blank lines on any report or schedule will render the
report or schedule incomplete and may result in a resubmission request. Any
resubmission must be clearly identified as such. If no answers or entries are to
be made, write “None”, “Not Applicable (N/A)”, or “-0-” in the space provided.
Always use predefined categories or classifications before reporting an amount
as “Other”.
Dollar amounts shall be reported to the nearest dollar. Per member per month
(PMPM) amounts, however, shall be shown with two digits to the right of the
decimal point.
Additional sheets referencing the applicable reports must be attached for
further explanation. The Contractor shall use “Notes to Financial Reports” in
Appendix B for write-ins and explanations.

      Date Effective: July 1 , 20076   9

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

33
Report Specifications
Table 20: Lag Reports (Parts A-ED)
Submission Due at Each Quarter End
Analyzing the accuracy of historical medical claims liability estimates is
necessary in assessing the adequacy of current liabilities. In addition, valid
IBNR liability estimates are crucial when utilizing financial statements in the
managed care rate setting process. This schedule provides, the necessary
information to make this analysis.
Information is provided on Inpatient Hospital, Physician, Pharmacy, and Other
Medical Payments on Parts A through D, respectively, with all rate cell
groupings combined,excluding the Managed Care Service Administrator (MCSA) rate
cell groupings. Lag report information shall be provided for each Medical Cost
Grouping as defined below and map to the corresponding consolidated category of
service for the corresponding incurral period within Table 19, Part S2. A
detailed reconciliation of the lag report information and Income Statements by
Rate Cell Group shall be included on Table 19, Part S3. Information about any
adjustments that pertain shall be explained in a note to the reports.

                      Medical     Consolidated   Income Statement   Cost   Lag
Report Category of Service   Reference   Grouping   Reference
Inpatient Hospital
  Table #19 — Part S2, Line 9   Inpatient
Hospital   Table #20 — Part A
 
           
Primary Care
  Table #19 — Part S2,
Line 10   Physician   Table #20 — Part B
 
           
Physician Specialty
Services
  Table #19 — Part S2, Line 11   Physician   Table #20 — Part B

      Date Effective: July 1 , 20076   10

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

                      Medical     Consolidated   Income Statement   Cost   Lag
Report Category of Service   Reference   Grouping   Reference
Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products)
  Table #19 — Part S2, Line 18   Pharmacy   Table #20 — Part C
 
           
Reimbursable HIV/AIDS Drugs and Blood Products
  Table #19 — Part S2, Line 19   Pharmacy   Table #20 — Part C
 
           
Outpatient Hospital
(excludes ER)
  Table #19 — Part S2, Line 12   Other   Table #20 — Part D
 
           
Other Professional Services
  Table #19 — Part S2, Line 13   Other   Table #20 — Part D
 
           
Emergency Room
  Table #19 — Part S2, Line 14   Other   Table #20 — Part D
 
           
DME/Medical Supplies
  Table #19 — Part S2, Line 15   Other   Table #20 — Part D
 
           
Prosthetics and Orthotics
  Table #19 — Part S2, Line 16   Other   Table #20 — Part D
 
           
Dental
  Table #19 — Part S2, Line 17   Other   Table #20 — Part D
 
           
Home Health, Hospice,. &PDN
  Table #19 — Part S2, Line 20   Other   Table #20 — Part D
 
           
Transportation
  Table #19 — Part S2, Line 21   Other   Table #20 — Part D
 
           
Lab & X-ray
  Table #19 — Part S2, Line 22   Other   Table #20 — Part D
 
           
Vision Care including
Eyeglasses
  Table #19 — Part S2, Line 23   Other   Table #20 — Part D
 
           
Mental Health/ Substance Abuse
  Table #19 — Part S2, Line 24   Other   Table #20 — Part D
 
           
EPSDT Medical & PDN
  Table #19 — Part S2, Line 26   Other   Table #20 — Part D
 
           
EPSDT Dental
  Table #19 — Part S2, Line 27   Other   Table #20 — Part D
 
           
Family Planning
  Table #19 — Part S2, Line 28   Other   Table #20 — Part D
 
           
Other Medical
  Table #19 — Part S2, Line 29   Other   Table #20 — Part D

 

*   Please reference Appendix C for the new Managed Care Category of Srvice
codes.

      Date Effective: July 1 , 20076   11

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

The schedules are arranged with the month of service horizontally and the month
of payment vertically. Therefore, payments made during the current month for
services rendered during the current month would be reported in Line 1, Column
3, while payments made during the current month for services rendered in prior
months would be reported on Line 1, Columns 4 through 39. Please note that
columns 13 through 38 and rows 11 through 36 are hidden in the sample worksheet.
Lines 1 through 3 contain data for payments made in the current period. Earlier
data on Lines 4 through 37 shall match data on appropriate lines on the prior
period’s submission. If Lines 4 through 37 changes from the prior period’s
submission, include an explanation. The current month is the last month of the
period that is being reported. For example, in the report for the period ended
June 30, 2003, the current month would be June 2003, and the first prior month
would be May 2003. Do not include risk pool distributions as payments in this
schedule.
Table 20 must provide data for the period beginning with the first month the
Contractor is responsible for providing medical benefits to Medicaid/NJ
FamilyCare recipients, and ending with the current month.
Line 39 — Subcapitation payments shall be reported here, by month of payment.
They are not to be included above Line 39. For the current period, Line 39 shall
contain new data in Columns 3 through 5. Data in columns 6 through 38 shall
match data in appropriate columns on the prior period’s submission. If columns 6
through 38 change from the prior period’s submission, include an explanation.
Line 40 — Report pharmacy rebates anticipated for drugs dispensed this period.
Adjust as appropriate any adjustment applicable to a prior period. Only complete
for the Pharmacy Payment report, Part C.
Line 41 — The Contractor shall report payments on Lines 1 — 36. If the
Contractor makes a settlement or other payment that cannot be reported on Lines
1-36 due to lack of data, the amount shall be reported on Line 41. If the
service month(s) can be determined, the settlement dollars can be allocated to
the service month. Otherwise, the payment month can be used as a substitute for
the service month. If an amount is shown on Line 41 in columns 3 through 5,
include an explanation. If columns 6 and greater change from the prior
submission, also include an explanation.
Line 42 — This line is the total amount paid to date for services rendered. Line
42 shall equal the sum of Lines 38, 39, and 41. For the Pharmacy Payment report,
Part C, also include Line 40.
Line 43 — This line provides the current estimate of remaining liability for
unpaid claims for each month of service. The amount in each column on this line
must be updated each period. The amount in Column 40 is the sum of amounts in
Columns 3 through 39. The sum of the amounts in Column 40, in parts A through D,
is the unpaid claim liability (IBNR and reported-but-unpaid-claims (RBUC)).
Please refer to Attachment A for a methodology for calculating IBNR.

      Date Effective: July 1, 20076   12

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

Line 44 — The total incurred claims is the sum of Lines 42 (the amounts paid to
date) and Line 43 (estimate of unpaid claims liability). Amounts on Line 44 are
shown for each month.
DMAHS recognizes that claims liabilities may include the administrative portion
of claim settlement expenses. Any liability for future claim settlement expense
must be disclosed in the notes in the reports.
The NJ FamilyCare Adults 0 — 100 percent of FPL, Health Access individuals
without dependent children, and Adult Restricted Aliens (excluding pregnant
women) populations are classified into two groups under the MCSA program. As
DMAHS has assumed the responsibility for financial risk for medical costs of
these populations, the medical expenses for these populations shall be excluded
from Parts A — D of the Lag Report. All medical expenses for these populations
must be reported within Part E of the Lag Report.

      Date Effective: July 1, 20076   13

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

Table 19: Income Statement by Rate Cell Grouping (Parts A – R2, U, V)
Submission Due at Each Quarter End
This report is meant to provide detailed summary information on revenues and
expenses. A consolidated report is to be completed for each of the fifteen rate
cell groupings and for Maternity and Newborn, with Table 19 Part S2 being the
summation of Parts A-R2 respectively for the 12-months ending. For reporting
purposes, AIDS revenues and expenses are included or excluded from the rate cell
groupings as indicated on the report forms and in the chart defining the rate
cell groupings provided on page 2.
Additionally, State fiscal year-end information will be provided on the first
fiscal quarter ending reports (September 30). This information shall include all
data with incurred dates through the most recent completed state fiscal year,
with paid data through September 30 (incurred in 12 months, paid in 15 months).
Reports are to be completed for each of the 15 rate cell groupings and for
Maternity and Newborn categories. Besides quarter ending September 30, this
information is not required for any other quarter ending time periods.
The NJ FamilyCare Adults 0 – 100 percent of FPL, Health Access individuals
without dependent children, and Adult Restricted Aliens (excluding pregnant
women) populations are classified into two groups under the MCSA program. As
DMAHS has assumed the responsibility for financial risk for medical costs of
these populations, the medical and administrative expenses and premiums for
these populations shall be excluded from all rate cell groupings in Parts A – T
and reported separately in Parts U and V. Part V has been created to provide
information on services for the non-risk Adult Restricted Aliens (excluding
pregnant women). The Adult Restricted Aliens (excluding pregnant women) expenses
and revenues, which have been scattered across several categories of aid, shall
now only be included in Part V. Revenue and expenses for non-risk NJ FamilyCare
Adults 0 – 100 percent of FPL will be reported within Part U.
Do not include maternity or newborn revenues or expenses in Parts A – Q. Only
include Maternity and newborn revenues and maternity expenses on the Income
Statement for Maternity, Part R1, and for All Rate Cell Groupings, Part S2.
Include newborn expenses on the Income Statement for Newborn, Part R2, and for
All Rate Cell Groupings, Part S2. Include Maternity costs associated with the
following codes for still births or live births after the twelfth week of
gestation, excluding elective/induced abortions:
DRG Codes:
§ 370–375 or 650–652;or
DRG Codes only with specific ICD-9 Diagnosis Codes:
§ DRG codes 380 or 381 plus one of the following ICD-9 codes: 632, 634.0-634.99
and 637.0-637.99; or

      Date Effective: July 1, 2007 6   14

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

§   DRG codes 460 through 469 plus one of the following ICD-9 codes, V27-V27.9

Additionally, Table 19, Part R2 (Income Statement for Newborn) includes newborn
claims for the partial month of birth and the first two (2) months thereafter,
previously reported in the AFDC/NJCPW/KidCare A, NJ KidCare B, C, and D, DYFS.
and Blind/Disabled rate cell groupings. Age shall be determined by counting the
child’s age as of their last birthday, on the first of the month in which the
claim is incurred.
Except for non-State Plan services (Part T) and MCSA reports (Parts U – V), all
revenues and expenses must be reported on Table 19 (A-R2) using the accrual
basis of accounting for the requested period. Each report is based on statewide
reporting except for the rate cell grouping AFDC/NJCPW/NJ KidCare A, which is to
be reported for each of the Northern, Central and Southern regions (Table 19
Parts A-C). Each report must provide total dollar amounts and PMPM amounts.
Cells shaded are not to be filled out.
The non-State Plan services (see: Supplemental Benefits, Article 4.1.8 of the
contract) report (Part T) has been created to provide information on
benefits/services reported within Table 19, Parts A-S2 in excess of the State
Plan. All medical and administrative expenses must be reported using actual
incurred and paid data for the requested period. Unit cost expenses for the
non-State Plan services must also be provided. An example of non-State Plan
approved medical expenses would be enhanced eyeglass allowance and
over-the-counter drugs for adults.
All medical and administrative expenses within the MCSA reports (Parts U – V)
must be reported using paid - data for-the current period of the calendar year.
Member Months
A member month is equivalent to the one member for whom the Contractor has
recognized capitation-based revenue for the entire month. Where the revenue is
recognized for only part of a month for a given individual, a partial, pro-rated
member month shall be counted. A partial member month is pro-rated based on the
actual number of days in a particular month. The member months shall be reported
on a cumulative basis by the rate cell grouping as shown on the report. Enter
the number of member months for the current period in the second column of the
Member Months line and the member months for the year-to-date in the fourth
column.
The Maternity Income Statement, Part R1, shall list number of deliveries, rather
than member months.
Newborn member months will be reported within Part R2 and are not to be included
with Part S2. It is expected that there shall be approximately 2.5 member months
reported for each delivery as the newborn time period is on average 75 days. Any
variation from 2.5 member months may suggest a reporting inconsistency. For
counting newborn member months, it is appropriate to group by age (in months)
and then sum the first 2 months. As defined in the previous section, age should
be determined by counting the

      Date Effective: July 1, 2007 6   15

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

child’s age as of their last birthday, on the first of the month in which the
claim was incurred. The following example illustrates the formula for
determining a child’s age in months:
Example: Date of birth = January 15
Age on January 1st - 0 months (count of 17/31 is 0 month age)
Age on February 1st - 0 months (an additional count of 1 goes into 0 month age)
Age on March 1st - 1 month (count of 1 for 1 month age)
Age on April 1st - 2 months (count of 1 placed in 2 month age)
Sum = Newborn Member Months (through example expect to have average 2.5 newborn
member months per delivery)

      Date Effective: July 1, 20076   16

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

This is consistent with the logic that DMAHS uses when making a capitation
payment. If it is easier for the Contractor to count in whole numbers in the
0 month age cell (replace the pro-rated 17/31 with a count of 1). If this logic
is utilized, the Contractor must note the counting methodology.
Revenue
Line 1 — Capitated Premiums—Revenue recognized on a prepaid basis for enrollees
for provision of a specified range of health services over a defined period of
time, generally one month. If advance payments are made to the Contractor, for
more than one reporting period, the portion of the payment that has not been
earned must be treated as a liability (Unearned Premiums). Refer to Part S3 for
reconciliations.
Line 2 — Supplemental Premiums—Revenue paid to the Contractor in addition to
capitated premiums for certain services provided. See Lines 2a through 2f below.
Line 2a — Maternity1—Supplemental payment per pregnancy outcome. This line item
shall only be included in Part R1 (Maternity) and Part S2 (All Rate Cell
Groupings).
Line 2b — Reimbursable HIV/AIDS Drugs and Blood Products—Supplemental payment
for HIV/AIDS Drugs (protease inhibitors and, effective 7/1/01 other
anti-retrovirals) and clotting factor VIII and IX blood products.
Line 2c — Early and Periodic Screening, Diagnosis and Treatment
(EPSDT) Incentive Payment—Supplemental payment for EPSDT services.
Line 2d—Reimbursable Medical and Hospital—Supplemental-payment-for- medical and
hospital expenses for FamilyCare Adults 0—100 percent of FPL, Health Access
individuals without-dependent children, and Adult-Restricted Aliens (excluding
pregnant women) populations who are under a MCSA program. This revenue shall
only bo included in Part U (FamilyCare Adults 0—100 percent of FPL) and Part V
(Adult Restricted Aliens), and is not-be-included in Part S2 (All Rate Cell
Groupings).
Line-2e—Managed Care Service Administrator Premium—Supplemental-payment for
administrative expenses for FamilyCare Adults 0—100 percent of FPL, Health
Access individuals without dependent children, and Adult Restricted Aliens
(excluding pregnant women) populations who are under a-MCSA program. This
revenue shall only be
 

1   Because costs for pregnancy outcomes were not included in the capitation
rates, a separate maternity payment is paid for pregnancy outcomes (each live
birth, still birth, or miscarriage occurring at or after the thirteenth (13th)
week of gestation). This supplemental payment reimburses Contractors for its
inpatient hospital, antepartum, and postpartum costs incurred in connection with
delivery. Costs for care of the baby are included only for the first two months
of newborn claims in the AFDC/NJCPW/NJ KidCare A, NJ KidCare B, C, and D, DYFS,
and Blind/Disabled rate cell groupings.

      Date Effective: July 1, 20076   17

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

included in Part U (FamilyCare Adults 0—100 percent of FPL), and Part V (Adult
Restricted Aliens), and is not be included in Part S2 (All Rate Cell Groupings).
Line 2fd — Other—Any other revenue paid by DMAHS to the Contractor in addition
to capitation for covered services that is not included in Lines 2a, 2b, 2c, 2d,
or 2e above.
Line 3 — Total Premiums—All Medicaid/NJ FamilyCare premiums paid to the
Contractor reported on lines 1, 2a, 2b, 2c, 2d, 2e, and 2f. A detailed
reconciliation of total premiums received and reported on the Income Statement
in Part S2 shall be included on Table 19, Part S3. Information about any
differences shall be explained in a note to the reports.
Line 4 — Interest—Interest earned from all sources including escrow and reserve
accounts.
Line 5 — C.O.B.—Income from Coordination of Benefits (COB) and Subrogation.
Alternatively, COB for a particular claim may be recognized as a negative claim
expense.
Line 6 — Reinsurance Recoveries—Income from the settlement of claims resulting
from a policy with a private reinsurance carrier.
Line 7 — Other Revenue—Revenue from sources not covered in the previous revenue
accounts.
Line 8 — Total Revenue — Total revenue (the sum of lines 3 through 7).
Expenses
Medical and Hospital
Line 9 — Inpatient Hospital—Code 01—See the Managed Care Category of Service
Codes.
Line 10 — Primary Care—Code 10P— See the Managed Care Category of Service Codes
Line 11 — Physician Specialty Services—Code 10S— See the Managed Care Category
of Service Codes
Line 12 — Outpatient Hospital (excludes ER)—Code 04N— See the Managed Care
Category of Service Codes.
Line 13 — Other Professional Services—Codes 14, 15S, 17, PAS— See the Managed
Care Category of Service Codes.

      Date Effective: July 1, 20076   18

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Line 14 — Emergency Room—Code 04E— See the Managed Care Category of Service
Codes.
Line 15 — DME/Medical Supplies—Codes 30, 31, 32— See the Managed Care Category
of Service Codes.
Line 16 — Prosthetics and Orthotics—Code 18— See the Managed Care Category of
Service Codes.
Line 17 — Covered Dental—Code 11— See the Managed Care Category of Service
Codes.
Line 18 — Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood
Products)—Code 20N- See the Managed Care Category of Service Codes.
Line 19 — Reimbursable HIV/AIDS Drugs and Blood Products—Code 20H— See the
Managed Care Category of Service Codes.
Line 20 — Home Health, Hospice, PDN—Codes 40, 50, PDN— See the Managed Care
Category of Service Codes.
Line 21 — Transportation—Code 70— See the Managed Care Category of Service
Codes.
Line 22 — Lab & X-ray—Codes 60, 65— See the Managed Care Category of Service
Codes.
Line 23 -Vision Care including Eyeglasses—Codes 09,13— See the Managed Care
Category of Service Codes.
Line 24 — Mental Health/Substance Abuse—Codes MH, SA— See the Managed Care
Category of Service Codes.
Line 25 — Reinsurance Expenses—Expenses for reinsurance or “stop-loss” insurance
made to a contracted reinsurer.
Line 26 — EPSDT Medical & PDN —Codes 08D, EPM— See the Managed Care Category of
Service Codes.
Line 27 — EPSDT Dental —Code EPD— See the Managed Care Category of Service
Codes.
Line 28 — Family Planning—Code FP— See the Managed Care Category of Service
Codes.

      Date Effective: July 1, 20076   19

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Line 29 — Other Medical—Code XM— See the Managed Care Category of Service Codes.
Line 30 — Total Medical and Hospital—The total of all medical and hospital
expenses.
(sum of lines 9 through 29)
Administration
Administrative expenses are only required to be reported on designated forms for
the MCSA populations (Parts U and V) and the forms for all rate cell groupings
Table 19 (Part S2). Except for the MCSA rate cell groupings, tThis eliminates
the need to allocate these costs across the remaining rate cell groupings,
although the Contractor has the option of reporting this allocation. As DMAHS
has the responsibility for financial risk for medical costs of tho NJ FamilyCare
Adults 0—100 percent of FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations,
the administrative expenses for these populations shall be excluded from
Part S2. The administration expenses for these populations shall be
reported-separately in Parts U—V.Administration must also be reported on Part T
if the Contractor provides any non-State Plan services. Costs associated with
the overall management and operation of the Contractor including the following
components:
Line 31 — Compensation—All expenses for administrative services including
compensation and fringe benefits for personnel time devoted to or in direct
support of administration. Include expenses for management contracts. Do not
include marketing expenses here.
Line 32 — Occupancy, Depreciation, and Amortization.
Line 33 — Interest expense—Interest paid during the period on loans.
Line 34 — Education/Outreach and Marketing—Expenses incurred for education and
outreach activities for enrollees. Expenses directly related to marketing
activities including advertising, printing, marketing salaries and fringe
benefits, commissions, broker fees, travel, occupancy, and other expenses
allocated to the marketing activity.
Line 35 — Sanctions—Expenses related to events where DMAHS finds the contractor
to be out of compliance with the program standards, performance standards, or
the terms and conditions of the Medicaid managed care contract.
Line 36 — Corporate Overhead Allocations—All expenses for management fees, and
other allocations of corporate expenses. Methodologies for allocated expenses
may include PMPM, percent of revenue, percent of head counts and/or full-time
equivalents (FTE), etc. Include an explanation of the expenses included and the
basis of methodology in the notes to the financial reports.

      Date Effective: July 1, 20076   20

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Line 37 — Subcontracted/Delegated Administrative Services—Administrative portion
of delegated administrative expenses such as Pharmacy Benefits Manager (PBM) or
Third Party Administrators (TPA) payments that cover costs such as claims
processing and medical management of the PBM/TPA. An example of TPA expenses
includes dental subcontractors and delegated case management administrative
expenses.
Line 38 — Other Costs which are not appropriately assigned to the health plan
administration categories defined in lines 31 to 37 above.
Line 39 — Total Administration—The total of costs of administration (the sum of
lines 31 through 38).
Line 40 — Total Expenses—The sum of Total Medical and Hospital Expenses (line
30) and Total Administration (line 39).
Line 41 — Operation Income (Loss)—Excess or deficiency of Total Revenue (line 8)
minus Total Expenses (line 40).
Line 42 — Extraordinary Item—A non-recurring gain or loss.
Line 43 — Provision for State, Federal, and Other Governmental Income Taxes—All
income taxes for the period.
Line 44 — Other than Income Taxes—Expenses other than state or federal income
taxes (i.e. State assessments irrespective of profit position).
Line 45 — Adjustment for prior period IBNR estimates—Shall include a
reconciliationreconciliation within Part S3, an explanation of prior period IBNR
estimates, and a detailed calculation within Table 20, Parts A through D. A
contra-expense would be reported if IBNR estimates exceeded actual expenses.

      Date Effective: July 1, 20076   21

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

In the explanation below, the term “IBNR” (Incurred But Not Reported) is used to
represent all claims incurred but unpaid. In statutory accounting for HMOs the
incurred claims for a period are calculated as follows:

                  Example for 12 Month Ending   Example using     06/30/20xx
Reporting Period   Dollars
Claims paid in the period
  Claims paid in 12 Month ending
06/30/20xx   $ 48,000,000    
+ IBNR at the end of the period
  + IBNR as of 06/30/20xx   + $ 11,000,000    
- IBNR at the end of the prior period
  -IBNR as of 03/31/20xx   - $ 9,000,000    
+ Subcapitation Payments, Pharmacy Rebates, Settlements at the end of the period
  + Subcapitation Payments, Pharmacy Rebates, Settlements as of 06/30/20xx   + $
500,000  
- Subcapitation Payments, Pharmacy Rebates, Settlements at the end of the prior
period
  - Subcapitation Payments, Pharmacy Rebates, Settlements as of 03/31/20xx   - $
450,000    
Claims incurred in the period
  Claims incurred in 12 Month
ending 06/30/20xx   $ 50,050,000  

      Date Effective: July 1, 20076   22

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

The above calculation can be split into two components — the first for services
rendered in the period and the second for services rendered prior to the period,
as follows:

                              Incurred in 12             Month Ending   Incurred
in         06/30/20xx   03/31/20XX & Prior   Total
Claims Paid in Qtr Ending 06/30/20xx
  $ 39,500,000     $ 8,500,000     $ 48,000,000    
+ IBNR as of 06/30/20xx
  $ 10,900,000     $ 100,000     $ 11,000,000    
-IBNR as of 03/31/20xx
  None   $ 9,000,000     $ 9,000,000    
+ Subcapitation Payments, Pharmacy Rebates, Settlements as of 06/30/20xx
  $ 50,000     $ 450,000     $ 500,000    
- Subcapitation Payments, Pharmacy Rebates, Settlements as of 03/31/20xx
  None   $ 450,000     $ 450,000    
Recognized in Qtr Ending 06/30/20xx
  $ 50,450,000     -$ 400,000     $ 50,050,000  

In the example, claims incurred in the 12 month ending 06/30/20xx are
$50.45 million. This is the amount that would be shown on Report #2S19S2 line
30; the Statewide Total Hospital and Medical Expense for the 3-12 months ended
06/30/20xx. The negative $0.4 million would be reported on line 45 Adjustment
for prior period IBNR estimates. This is the effect of the estimation error for
the prior year-end IBNR. Such estimation errors are to be expected, since the
actual amount of unpaid claims will never exactly match the estimate made
earlier.
The sum of the amounts on lines 30 and 45 shall be consistent with the statutory
accounting amount of claims recognized as incurred in the period, $50 million in
the example above. Any non-claim adjustments for prior periods which are not to
be grouped into Line 45, but in line 46, and shall be explained in a note to the
reports. A detailed reconciliation of prior period IBNR shall be included on
Table 19, Part S3.
Line 46 — Non-claim adjustments for prior periods.
Line 47 — Net Income (Loss)—Operation Income (Loss) (line 41) minus Lines 42,
43, 44, 45, and 46.

      Date Effective: July 1, 20076   23

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Table 21: Maternity Outcome Counts
Submission Due at Each Quarter End
This report provides counts of second and third trimester maternity outcomes2
for the current period and year-to-date. Please refer to the report
specifications of Table 19: Income Statement by Rate Cell Grouping in the member
month section regarding newborn member months relative to this report.
The Contractor will provide counts for the following:

§   Live births

  –   Cesarean Section deliveries     –   Vaginal deliveries

§   Non-live births

These counts will be reported for the following rate cell groupings and
geographic areas:

      Rate Cell Grouping   Geographic Area AFDC/NJCPW/NJ KidCare A   Northern
AFDC/NJCPW/NJ KidCare A   Central AFDC/NJCPW/NJ KidCare A   Southern
All Other
  Statewide

Multiple births should be counted as one maternity outcome.
 

2   Still or live births at or after the thirteenth week of gestation, excluding
elective abortions.

      Date Effective: July 1, 20076   24

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Table 4: Claims Processing Lag Report (Parts A & B)
Submission Due at Each Quarter End
This report is meant to provide a detailed summary of manual and electronic
submitted claims that were processed during the quarter.
Table 4A
Use Table 4A, to report manually submitted claims that were processed during the
quarterly period. Claims submitted and processed electronically must be reported
separately on Table 4B. Manual claims submission shall be processed within
40 days of receipt. Report amounts for each consolidated category of service and
total listed in Column 1 in the following columns:
Column 2 — Non-Processed Claims from Prior Quarters — Enter the number of
manually submitted claims on-hand that were unprocessed as of the closing date
of the last quarterly period. The number shall be the same as was reported in
Column 16 of the prior quarterly report.
Column 3 — Claims Received During Quarter—Enter the amount of all manually
submitted claims that were received during the quarterly period being reported.
Column 4 — Total Claims — Enter the sum of Columns 2 and 3.

Column 5 — Claims Processed This Quarter — Enter the amount of all manually
submitted claims processed (both paid and denied) during the quarterly period
being reported. Do not count pended claims.

Column 6 — 01-40 Days — Enter the number of manually submitted claims that were
processed (either paid or denied) within 40 days of their receipt. Note: The
number of days required to process a claim is calculated by comparing the date
the claim was received by the contractor to the date the claim was paid or
denied by the contractor (See Article 7.16.5 of the contract for further
detail).
Column 7 — Percent of Total — Enter the percentage of manually submitted claims
processed within 40 days (Compared to total claims processed. Divide Column 6 by
Column 5 to arrive at percent.)
Column 8 — 41-60 Days — Enter the number of manually submitted claims that were
processed (either paid or denied) between 41-60 days of their receipt.
Column 9 — Percent of Total — Enter the percentage of manually submitted claims
processed between 41-60 days (Compared to total claims processed. Divide Column
8 by Column 5 to arrive at percent.)

      Date Effective: July 1, 20076   25

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Column 10 — 61-90 Days — Enter the number of manually submitted claims that were
processed (either paid or denied) between 61-90 days of their receipt.
Column 11 — Percent of Total — Enter the percentage of manually submitted claims
processed between 61-90 days (Compared to total claims processed. Divide Column
10 by Column 5 to arrive at percent.).
Column 12—91—120 Days — Enter the number of manually submitted claims that were
processed (either paid or denied) between 91-120 days of their receipt.
Column 13 — Percent of Total — Enter the percentage of manually submitted claims
processed between 91-120 days of their receipt (Compared to total claims
processed. Divide Column 12 by Column 5 to arrive at percent.)
Column 14 — >120 Days — Enter the number of manually submitted claims that were
processed (either paid or denied) after 120 days of their receipt.
Column 15 — Percent of Total — Enter the percentage of manually submitted claims
processed after 120 days (Compared to total claims processed. Divide Column 14
by Column 5 to arrive at percent.)
Column 16 — Non-processed Claims on Hand at End of Quarter — Enter the number of
manually submitted claims on hand that were not processed as of closing date of
the last report period. (Should be the difference of Column 4 minus Column 5).
Same number should match number of claims entered in Column 2 of next quarter
report.
Column 17 — Percent of Claims Not Processed at End of Quarter — Divide Column 16
by Column 4 to arrive at percent.
Table 4B
Use Table 4B to report electronically submitted claims that were processed
during the quarterly period. Claims submitted and processed manually must be
reported separately on Table 4A. Electronic claims submission shall be processed
within 30 days of receipt. Report amounts for each consolidated category of
service and total listed in Column 1 in the following columns:
Column 2 — Non-Processed Claims from Prior Quarters — Enter the number of
electronically submitted claims on-hand that were unprocessed as of the closing
date of the last quarterly period. The number should be the same as was reported
in Column 16 of the prior quarterly report.
Column 3 — Claims Received During Quarter— Enter the amount of all
electronically submitted claims that were received during the quarterly period
being reported.

      Date Effective: July 1, 20076   26

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Column 4 — Total Claims — Enter the sum of Columns 2 and 3.
Column 5 — Claims Processed This Quarter — Enter the amount of all
electronically submitted claims processed (both paid and denied) during the
quarterly period being reported. Do not count pended claims.
Column 6 — 01-30 Days — Enter the number of electronically submitted claims that
were processed (either paid or denied) within 40 days of their receipt. Note:
The number of days required to process a claim is calculated by comparing the
date the claim was received by the contractor to the date the claim was paid or
denied by the contractor (See Article 7.16.5 of the contract for further
detail).
Column 7 — Percent of Total — Enter the percentage of electronically submitted
claims processed within 40 days (Compared to total claims processed. Divide
Column 6 by Column 5 to arrive at percent.)
Column 8 — 31-60 Days — Enter the number of electronically submitted claims that
were processed (either paid or denied) between 41-60 days of their receipt.
Column 9 — Percent of Total — Enter the percentage of electronically submitted
claims processed between 41-60 days (Compared to total claims processed. Divide
Column 8 by Column 5 to arrive at percent.)
Column 10 — 61-90 Days — Enter the number of electronically submitted claims
that were processed (either paid or denied) between 61-90 days of their receipt.
Column 11 — Percent of Total — Enter the percentage of electronically submitted
claims processed between 61-90 days (Compared to total claims processed. Divide
Column 10 by Column 5 to arrive at percent.)
Column 12—91-120 Days — Enter the number of electronically submitted claims that
were processed (either paid or denied) between 91-120 days of their receipt.
Column 13 — Percent of Total — Enter the percentage of electronically submitted
claims processed between 91-120 days of their receipt (Compared to total claims
processed. Divide Column 12 by Column 5 to arrive at percent.)
Column 14 — >120 Days — Enter the number of electronically submitted claims that
were processed (either paid or denied) after 120 days of their receipt.
Column 15 — Percent of Total — Enter the percentage of electronically submitted
claims processed after 120 days (Compared to total claims processed. Divide
Column 14 by Column 5 to arrive at percent.)

      Date Effective: July 1, 20076   27

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Column 16 — Non-processed Claims on Hand at End of Quarter — Enter the number of
electronically submitted claims on hand that were not processed as of closing
date of the last report period. (Should be the difference of Column 4 minus
Column 5). Same number should match number of claims entered in Column 2 of next
quarter report.
Column 17 — Percent of Claims Not Processed at End of Quarter— Divide Column 16
by Column 4 to arrive at percent.

      Date Effective: July 1, 20076   28

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Table 7: Stop Loss Summary (Parts A — C)
Submission Due at Each Quarter End
The contractor shall identify reinsurance coverage in effect during the calendar
year for the reporting period ending December 31 of each year. For each of the
designated eligibility categories, the contractor shall report the total number
of enrollees that exceeded the stop-loss threshold and the total net
expenditures exceeding the stop-loss threshold during the period.

      Date Effective: July 1, 20076   29

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Table 10: Third Party Liability and Fraud/Abuse Collections
Submission Due at Each Quarter End
The Contractor shall report quarterly the categories of all third party
liability collections and shall include the amounts and nature of all third
party payments recovered for Medicaid/ NJ FamilyCare enrollees, including but
not limited to, payments for services and conditions which are:

§   covered through coordination of benefits;   §   employment related injuries
or illnesses;   §   related to motor vehicle accidents, whether injured as
pedestrians, drivers, passengers, or bicyclists; and   §   contained in
diagnosis Codes 800 through 999 (ICD9CM) with the exception of Code 994.6.

The Contractor shall report quarterly all fraud and abuse collections recovered
through the Contractor’s Fraud and Abuse (FA) unit for Medicaid/NJ FamilyCare
enrollees. The contractor shall report the elimination of provider contracts
that resulted from the FA unit investigations.
The Contractor shall note if third party liability collections and fraud and
abuse collections are reflected as income or negative claims within Tables 19
and 20.

      Date Effective: July 1, 20076   30

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Table 11: Utilization and Unit Cost Information (Parts A — B)
Annual Submission Due at September 30 Quarter End
The Contractor shall submit on an annual basis a detailed summary of utilization
and unit cost information during the year.
Cost & Utilization by AFDC Rate Cell Grouping
The Contractor shall complete the Excel template labeled “11 A” providing a
year-over-year comparison of the current and preceding state fiscal year
incurred claims experience. This information will be provided on the first
fiscal quarter endingthe annual supplemental reports (September 30). The
information shall include all data with incurred dates through the previous and
most recent state fiscal year, with paid data through September 30 (incurred in
12 months, paid in 27 months for previous state fiscal year, and 15 months for
recent state fiscal year.) Besides quarter ending September 30, this information
is not required for any other quarter ending time periods. Data must reconcile
to the consolidated financial submissions.
Cost & Utilization by FamilyCare Rate Cell Grouping
The Contractor shall complete the Excel template labeled “11B” providing a
year-over-year comparison of the current and preceding state fiscal year
incurred claims experience. This information will be provided on the first
fiscal quarter endingannual supplemental reports (September 30). The information
shall include all data with incurred dates through the previous and most recent
state fiscal year, with paid data through September 30 (incurred in 12 months,
paid in 27 months for previous state fiscal year, and 15 months for recent state
fiscal year.) . Besides quarter ending September 30, this information is not
required for any other quarter ending time periods. Data must reconcile to the
consolidated financial submissions.
Definitions of key utilization measures are provided in Appendix B.

      Date Effective: July 1, 20076   31

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Table 14: Supplemental Data (Parts A—C)
Annual Submission Due at September 30 Quarter End
The Contractor shall submit on the fiscal quarter year ending reports
(September 30) a detailed summary of administrative and claims expense
information during the year. Besides quarter ending September 30, this
information is not required for any other quarter ending time periods.
Documentation
The Contractor shall provide with Table 14 a chart of general ledger expense
accounts and a crosswalk mapping of these accounts to the reporting manual’s
rate cell grouping costs. Detail shall include the following:

§   account name,

§   account description,

§   SFY-end, total year-ending balance,

§   SFY-end, total year-ending balance allocated to Medicaid/NJ FamilyCare
program, and

§   designation between medical and administrative expense account.

The Contractor shall provide all corporate cost allocation schedules and
methodologies for allocated Contractor expenditures and corporate administrative
allocations to each line of business. In addition, the Contractor shall provide
all allocation schedules and the methodology used to allocate administrative
expenditures to general ledger accounts that are not directly chargeable to a
specific account. Note: If there are no changes since last year’s submission,
the Contractor shall indicate as such and provide no additional information.
Administrative Contracts and Related Party Charges
The Contractor shall provide a copy of all administrative services contracts and
management agreements (including price page) delegating administrative functions
to a third party, including related or affiliated parties. In addition, the
Contractor shall provide all contracts with related or affiliated parties
applicable during any part of SFY-end. Note: If there are no changes since last
year’s submission, the Contractor shall indicate as such and shall not provide
the contracts. If the Contractor does not wish to send contracts, the Contractor
shall provide a detailed list of such contracts, the total cost, and the amount
charged to Medicaid/NJ FamilyCare program for SFY-end. For each contract the
Contractor shall also provide the total cost of the contract and the amount
charged to Medicaid/NJ FamilyCare program for SFY-end. This shall include, but
not be limited to, the following:

§   management service agreements,

§   PBM services agreement,

§   delegated CM/DM agreements,

      Date Effective: July 1, 20076   32

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

§   delegated member/provider services agreements,

§   claims processing agreements,

§   integrated delivery system agreements,

§   agreements for the administration of dental, vision, and pharmacy claims
and/or benefits, and

§   any other contract with a related or affiliated party for non-medical
services or charges.

Member Month and Income Statement Information
The Contractor shall complete and submit the Excel template labeled “Table
14A-Member Months & Income Statement”.
Administrative Cost Detail
Table 14B is broken out by the various administrative expense components from
Table 19. DMAHS recognizes that certain administrative expenses may be under a
combination of departmental functions and, consequently, requests that each
expense component is broken out to its specific administrative cost category
(department) to replicate that which was reported for the SFY-end, Table 19. The
Contractor shall reconcile the amount reported per the SFY-end, Table 19, with
the information being submitted in Table 14B.

Information for different departments that may be within the organization
havehas been itemized. However, if there are other sectors within the
organization, the Contractor shall provide those departments under the available
“Department #” and provide a description of the department.

In addition, the Contractor shall provide written explanations of any difference
between the total administrative expense from Table 19, and the data entered
into Table 14B.
Capitation Arrangements
Depending on the arrangement with providers, a Contractor shall include either
the entire portion of the capitation payment in a medical expense line, or it
will break out a portion of the capitation amount and report that in an
administrative expense line. Examples of services that may be capitated have
been provided. However, if there are other capitated services, the Contractor
shall include these services on the worksheet. Based upon the above information,
the Contractor shall complete Table 14C for each service that the Contractor
contracts with providers on a capitated basis.

      Date Effective: July 1, 20076   33

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Equipment and Systems
The Contractor shall provide a list of nonrecurring equipment and system
upgrades during SFY-end and the amount charged in the SFY-end Table 19, and
Medicaid/NJ FamilyCare program.
Non-Pharmacy Claim Processing
The Contractor shall provide the following information as it relates to the
administration of the Medicaid/NJ FamilyCare program:
§ If the Contractor outsources any portion of its non-pharmacy claims
processing?

  –   what components are outsourced and what components are maintained in-
house?     –   provide the total cost for outsourced claims processing in
SFY-end.

      Date Effective: July 1, 20076   34

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Appendix A
IBNR Methodology
IBNRs are difficult to estimate because the quantity of service and exact
service cost are not always known until claims are actually received. Since
medical claims are the major expenses incurred by the Contractors, it is
extremely important to accurately identify costs for outstanding unbilled
services. To accomplish this, a reliable claims system and a logical IBNR
methodology are required.
Selection of the most appropriate system for estimating IBNR claims expense
requires judgment based on a Contractor’s own circumstances, characteristics,
and the availability and reliability of various data sources. A primary
estimation methodology along with supplementary analysis usually produces the
most accurate IBNR estimates. Other common elements needed for successful IBNR
systems are:

§   An IBNR system must function as part of the overall financial management and
claims system. These systems combine to collect, analyze, and share claims data.
They require effective referral, prior authorization, utilization review, and
discharge planning functions. Also, the Contractor must have a full accrual
accounting system. Full accrual accounting systems help properly identify and
record the expense, together with the related liability, for all unpaid and
unbilled medical services provided to Contractor members.

§   An effective IBNR system requires the development of reliable lag tables
that identify the length of time between provision of service, receipt of
claims, and processing and payment of claims by major provider type (inpatient
hospital, physician, pharmacy, and other medical). Reliable claims/cash
disbursement systems generally produce most of the necessary data. Lag tables,
and the projections developed from them, are most useful when there is
sufficient, accurate claims history, which show stable claims lag patterns.
Otherwise, the

      Date Effective: July 1, 20076   36

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

tables will need modification, on a pro forma basis, to reflect corrections for
known errors or skewed payment patterns. The data included in the lag schedules
shall include all information received to date in order to take advantage of all
known amounts (i.e., RBUCs and paid claims).
Accurate, complete, and timely claims data shall be monitored, collected,
compiled, and evaluated as early as possible. Whenever practical, claims data
collection and analysis shall begin before the service is provided (i.e., prior
authorization records). This prospective claims data, together with claims data
collected as the services are provided, shall be used to identify claims
liabilities. Claims data shall also be segregated to permit analysis by major
rate code, region/county, and consolidated category of service.
Subcontractor agreements shall clearly state each party’s responsibility for
claims/encounter submission, prior notification, authorization, and
reimbursement rates. These agreements shall be in writing, clearly understood
and followed consistently by each party.
The individual IBNR amounts, once established, shall be monitored for adequacy
and adjusted as needed. If IBNR estimates are subsequently found to be
significantly inaccurate, analysis shall be performed to determine the reasons
for the inaccuracy. Such an analysis shall be used to refine a Contractor’s IBNR
methodology if applicable.
There are several different methods that can be used to determine the amount of
IBNRs. The Contractor shall employ the one that best meets its needs and
accurately estimates its IBNRs. If a Contractor is utilizing a method different
from the methods included herein, a detailed description of the process must be
submitted to DMAHS for approval. This process may be described in the “Notes to
Financial Reports” section. The IBNR methodology used by the Contractor must be
evaluated by the Contractor’s independent accountant or actuary for
reasonableness.
Case Basis Method
Accruals are based on estimates of individual claims and/or episodes. This
method is generally used for those types of claims where the amount of the cost
will be large, requiring prior authorization. The final estimated cost could be
made after the services have been authorized by the Contractor. For example, if
a Contractor knows how many hospital days were authorized for a certain time
period, and can incorporate the contracted reimbursement arrangement(s) with the
hospital(s), a reasonable estimate should be attainable. This is also the most
common and can be the most accurate method for small and medium sized
organizations.

      Date Effective: July 1, 20076   37

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Average Cost Method
As the name suggests, average costs of services are used to estimate total
expense. Two primary average cost methods are discussed below. It is important
to note that each method may be used by a Contractor to estimate different
categories of IBNRs (i.e., hospitalization vs. other medical). Also, either
method may be utilized in conjunction with other IBNR methodologies discussed in
this document.
PMPM Averages
Under this method the average costs are based on the population of each rate
code (or group of homogenous rate codes) over a given time period, in this case
one month. The average cost may cover one or more service categories and is
multiplied by the number of members in the specific population to estimate the
total expense of the service category. Any claims paid are subtracted from the
expense estimate that results in the IBNR liability estimate for that service
category.
Per Diem or Per Service Averages
Averages for this method are of specific occurrences known by the Contractor at
the time of the estimation. Therefore, it is first necessary to know how many
hospital days, procedures or visits were authorized as of the date for which the
IBNR is being estimated. Again, once the total expense has been estimated, the
amount of related paid claims shall be subtracted to get the IBNR liability.
This method is primarily used for hospitalization IBNRs as Contractors know the
amount of hospital days authorized at any given time.
Lag Tables
Lag tables are used to track historical payment patterns. When a sufficient
history exists and a regular claims submission pattern has been established,
this methodology can be employed. All Contractors shall use lag information as a
validation test for accruals calculated using other methods, if it is not the
primary methodology employed. Typically, the information on the schedules is
organized according to the month claims are incurred on the horizontal axis and
the month claims are paid by the Contractor on the vertical axis.

      Date Effective: July 1, 20076   38

 

--------------------------------------------------------------------------------

 

Contractor Financial Reporting Manual   State of New Jersey

Once a number of months becomes “fully developed” (i.e. claims submissions are
thought to be complete for the month of service), the information can be
utilized to effectively estimate IBNRs. Computing the average period over which
claims are submitted historically and applying this information to months that
are not yet fully developed does this.

      Date Effective: July 1, 20076   39

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

Appendix B
Key Utilization Definitions
The definitions of key utilization measures are provided below.

                      TYPE OF     CATEGORY OF       UTILIZATION/     SERVICE
MEASURE   MEASURE   PROXY FOR   DEFINITIONS  
Inpatient Hospital
  Inpatient Hospital Days   Quantity/Days   Days are calculated as follows:  
 
          Number of days between Admit and Discharge date (Exclude admit and
denied days. Include discharge day). If dates are equal, inpatient day is
counted as one (1).
 
           
 
          Days counted should be all paid days of service, regardless of year,
for each discharge that occurred in the year. If the admission and discharge do
not occur in the same year, all days are counted as occurring in the year in
which the discharge occurs.
 
           
 
          Include data for which you are both the primary payor and the
secondary payor.

      Date Effective: July 1, 20076   40

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

                      TYPE OF     CATEGORY OF       UTILIZATION/     SERVICE
MEASURE   MEASURE   PROXY FOR   DEFINITIONS  
Primary Care Services
  Primary Care Visits   Quantity/Services   A visit is defined as one or more
professional contacts between a patient and unique service provider on a unique
date of service.
 
           
Physician Specialty Services
  Physician Specialty Visits   Quantity/Services   A visit is defined as one or
more professional contacts between a patient and a unique service provider on a
unique date of service.
 
           
Emergency Room
  Emergency Room Visits   Quantity/Services   This measure summarizes
utilization of Emergency Department Visits and Observation Room Stays that
result in discharge. Observation and/or Emergency Room Stays resulting in an
inpatient admission should not be counted on this report.
 
           
 
          Each visit to an Emergency Department that does not result in an
admission should be counted once, regardless of the intensity of care required
during the stay or the length of stay. Patients admitted to the hospital from
the Emergency Department should not be included in counts of visits. Visits to
urgent care centers should be counted.
 
           
Dental
  Dental Visits   Claim Count/Visits   A visit is defined as one or more
professional contacts between a patient and a unique service provider on a
unique date of service.

      Date Effective: July 1, 20076   41

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

                      TYPE OF     CATEGORY OF       UTILIZATION/     SERVICE
MEASURE   MEASURE   PROXY FOR   DEFINITIONS  
Pharmacy
  Prescriptions   Claim
Count/Prescriptions   A prescription is defined as one fill of a prescription
that is filled by a pharmacist based on the written order to supply a particular
medication for a specific patient with instructions for its use.
 
           
Outpatient Facility
  Outpatient Facility Visits   Quantity/Services   A visit is defined as one or
more professional contacts between a patient and a unique service provider on a
unique date of service.
 
           
 
          The visit can be to a free standing or a hospital outpatient
department.
 
           
DME/Medical Supplies &
Orthotics/Prosthetics
  DME/Medical Supplies &
Orthotics/Prosthetics
Units   Claim Count/Claims   A unit is counted as one for each unique claim.
 
           
Home Health Care
  Home Health Care Services   Quantity/Services   A service is defined as one or
more professional contacts between a patient and a unique service provider on a
unique date of service.
 
           
Laboratory & Radiology
  Laboratory & Radiology
Units   Claim Count/Claims   A unit is counted as one for each unique claim.
 
           
Transportation
  Transportation Units   Claim
Count/Transports   A unit is counted as one for each unique claim.

Round trip transportation is considered one unit.
 
           
All Other Practitioners and Services
  All Other Practitioner and Services   Quantity/Services   A service is defined
as one or more professional contacts between a patient and a unique service
provider on a unique date of service.

      Date Effective: July 1, 20076   42

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

Appendix C
Managed Care Category of Service Codes
The definitions of managed care category of service codes are defined in a
matrix in the contract.

      Date Effective: July 1, 20076   43

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

Appendix D
Report Forms
12-Month Period End Reports Due Each Quarter
This section includes copies of the forms to be completed electronically by the
Contractor for each quarter end.

§   Certification Statement at Each Quarter End

§   Table 4: Claims Processing Lag Report

  –   Part A: Claims Processing Lag Report for Manually Submitted Claims     –  
Part B: Claims Processing Lag Report for Electronically Submitted Claims

§   Table 7: Stop Loss Summary   §   Table 10: Third Party Liability Collections
  §   Table 11: Utilization and Unit Cost Information   §   Table 14:
Supplemental Data   §   Table 19: Income Statement by Rate Cell Grouping for
Twelve Month-End and SFY End at June 30 with paid runout through September 30

  –   PartA-R2, U, V     –   Part S2: All Rate Cell Groupings for current
12 months — Statewide     –   Part S3: Reconciliations

      Date Effective: July 1, 20076   44

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

  –   Part T: Non-State Plan Services

§   Table 20: Lag Report

  –   Part A: Lag Report for Inpatient Hospital Payments Excluding MCSA
Populations     –   Part B: Lag Report for Physician Payments Excluding MCSA
Populations     –   Part C: Lag Report for Pharmacy Payments Excluding MCSA
Populations     –   Part D: Lag Report for Other Medical Payments Excluding MCSA
Populations     –   Part E: Lag Report for MCSA Populations

  §   Table 21: Maternity Outcome Counts   §   Notes to Financial Reports

Annual Supplemental Reports Due
This section includes copies of the forms to be completed electronically by the
Contractor for each September 30 quarter end.

§   Certification Statement at Each September 30 Quarter End   §   Table 11:
Utilization and Unit Cost Information   §   Table 14: Supplemental Data   §  
Table 19: Income Statement by Rate Cell Grouping for SFY- End at June 30 with
paid runout through September 30

  –   Part A-R2, U, V     –   Part S3: Reconciliations

§   Table 20: Lag Report

  –   Part A: Lag Report for Inpatient Hospital Payments Excluding MCSA
Populations

      Date Effective: July 1, 20076   45

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

  –   Part B: Lag Report for Physician Payments Excluding MCSA Populations     –
  Part C: Lag Report for Pharmacy Payments Excluding MCSA Populations     –  
Part D: Lag Report for Other Medical Payments

§   General Ledger for period ending June 30 Excluding MCSA Populations

–Part E: Lag Report for MCSA Populations   §   Notes to Financial Reports

      Date Effective: July 1, 20076   46

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

Appendix E
Certification Statement at Each Quarter End
The Certification Statement is located on the following pages.
The Certification Statement shall be submitted quarterly to David Moran, the
Director, HMO Financial Reporting, on the same due dates as required in the
General Instructions.
Certification Statement — Annual Reports
The Certification Statement is located on the following pages.
A Certification Statement shall be submitted annually to David Moran, the
Director, HMO Financial Reporting, -on the same due dates as required in the
General Instructions.

      Date Effective: July 1, 20076   47

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

CERTIFICATION STATEMENT AT EACH QUARTER END
OF
 
(Contractor Name)
TO THE
NEW JERSEY DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
FOR THE PERIOD ENDED
 
(Month/Day/Year)

     
Name of Preparer
   
 
   
 
   
Title
   
 
   
 
   
Phone Number
   
 
   

Please check which tables are included with this packet:

         
0 Table 4
  0 Table 19A-R, S2, S31   0 Notes 0 Table 20
0 Table 7
  0 Table 20 A-DE14   0 Table 21
0 Table 10
  0 Table 2119    

I hereby attest that the information submitted in the tables herein is current,
complete and accurate to the best of my knowledge. I understand that whoever
knowingly and willfully makes or causes to be made a false statement or
representation on the tables may be prosecuted under applicable state laws. In
addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate, or where
the entity already participates, a termination of a Contractor’s agreement or
contract with DMAHS.

         
 
       
Date
  Chief Financial Officer   Signature

      Date Effective: July 1, 20076   48

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

CERTIFICATION STATEMENT AT EACH SEPTEMBER 30 QUARTER END
OF
 
(Contractor Name)
TO THE
NEW JERSEY DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
FOR THE PERIOD ENDED
 
(Month/Day/Year)

     
Name of Preparer
   
 
   
 
   
Title
   
 
   
 
   
Phone Number
   
 
   

Please check which tables are included with this packet:

         
0 Table 11 A
  0 Table 14 B   0 Table 20 A-DE
0 Table 11 B
  0 Table 14 C   0 GL at 06/30
0 Table 14 A
  0 Table 19A-R, S3   0 Notes

I hereby attest that the information submitted in the tables herein is current,
complete and accurate to the best of my knowledge. I understand that whoever
knowingly and willfully makes or causes to be made a false statement or
representation on the tables may be prosecuted under applicable state laws. In
addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate, or where
the entity already participates, a termination of a Contractor’s agreement or
contract with DMAHS.

      Date Effective: July 1, 20076   49

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

         
Date
  Chief Financial Officer   Signature

      Date Effective: July 1, 20076   50

 

--------------------------------------------------------------------------------

 

      Contractor Financial Reporting Manual   State of New Jersey

NOTES TO FINANCIAL REPORTS
Any notes or further explanations of any items contained in any of the reports
or in the reporting of financial disclosures are to be noted here. Appropriate
references and attachments are to be used as necessary. Space is provided below
or you may use a separate page as necessary.

      Date Effective: July 1, 20076   51

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749704.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749705.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749706.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749707.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749708.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749709.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749710.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749711.gif]

 

--------------------------------------------------------------------------------

 

(Table) [w37497w3749712.gif]

 

--------------------------------------------------------------------------------

 

(Table) [w37497w3749713.gif]

 

--------------------------------------------------------------------------------

 

(Table) [w37497w3749714.gif]

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #19 — Part S3 — Income Statement by Rate Cell Grouping
Reconciliations

                 
FOR THE SFY ENDING 6-30-07
          FOR    
 
               
 
              (HMO Name)

Revenue Reconciliation

                                                      HIV /AIDS -Blood     Only
5 rows provided           Capitation   Maternity   Products   EPSDT (insert
additional row if needed)   Date   Cheek #   Premiums   Reimbursement  
Reimbursement   Premiums
1
      01/00/00   00000   $ —   $ —   $ —   $ —
2
      01/00/00   00000   $ —   $ —   $ —   $ —
3
      01/00/00   00000   $ —   $ —   $ —   $ —
4
      01/00/00   00000   $ —   $ —   $ —   $ —
5
      01/00/00   00000   $ —   $ —   $ —   $ —
6
  Totals Received from the State           $ —   $ —   $ —   $ —
7
  Unearned Premiums           $ —   $ —   $ —   $ —
8
  Change In Receivables / Unearned Premiums                        
9
  Other                        
10
  Total Premiums Reconciled to 19 S-2           $ —   $ —   $ —   $ —

 

Notes:   $ Cells with this shading are calculated fields and are not to be
filled out.   1- Detail any differences In the “Notes” section.

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED
CARE REPORTING ONLY
Table #19 — Part S3 — Income Statement by Rate Cell Grouping
Reconciliations

                 
FOR THE SFY ENDING 6-30-07
          FOR    
 
               
 
              (HMO Name)

Lag Triangle and Income Statement Reconciliation for Twelve Month End

                                                                         
Twelvemonth   Twelve month   Twelve-Month     Lag Report   Table #19 - Parts S1&
$2   Paid Claim   IBNR & RBUC   Total $ Lag                       Table #19 -
Part           Table #19 - Part           Table #19 - Part     Report #  
Medical Cost Grouping   Line #   Consolidated Category of Service   Lag Report  
S2   Difference1   Lag Report   S2   Difference1   Lag Report   S2   Difference1
 
Table #20
  Inpatient Hospital     9     Inpatient Hospital   $ —   $ —   $ —   $ —   $ —
  $ —   $ —   $ —   $ —
- Part A
                                                   
Table #20
  Physician     10     Primary Care   $ —   $ —   $ —   $ —   $ —   $ —   $ —  
$ —   $ —
- Part B
        11     Physician Specially Services                                    
Table #20
  Pharmacy     18     Pharmacy (not to include Reimbursable HIV/AIDS)   $ —   $
—   $ —   $ —   $ —   $ —   $ —   $ —   $ —
-Part C
        19     Reimbursable HIV/AIDS Drugs and Blood Products)                  
                 
 
        12     Outpatient Hospital (excludes ER)                                
   
 
        13     Other Professional Services                                    
 
        14     Emergency Room                                    
 
        15     DMB/Medical Supplies                                    
 
        16     Prosthetics & Orthotics                                    
 
        17     Covered Dental                                    
Table #20
  Other     20     Home Health, Hospice, & PDN                                  
 
- Part D
        21     Transportation   $ —   $ —   $ —   $ —   $ —   $ —   $ —   $ —  
$ —
 
        22     Lab & X-ray                                    
 
        23     Vision Care including Eyeglasses                                
   
 
        24     Mental Health/Substance Abuse                                    
 
        26     EPSDT Medical & PDN                                    
 
        27     EPSDT Dental -EPD                                    
 
        28     Family Planning                                    
 
        29     Other Medical                                      
 
  Total     30     Total   $ —   $ —   $ —   $ —   $ —   $ —   $ —   $ —   $ —  

 

Notes:   $ Cells with this shading are calculated fields and are not to be
filled out.   1 - Detail any differences In the “Notes” section.

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #19 — Part S3 — Income Statement by Rate Cell Grouping
Reconciliations

                 
FOR THE SFY ENDING 6-30-07
          FOR    
 
               
 
              (HMO Name)

Prior Period IBNR Reconciliation for Twelve Month End

              Incurred in Twelve Months Prior to
1 Claims Paid in Most Recent Twelve Month End
  $ —  
2 + IBNR as of Most Recent Twelve Months
(line 43 of #2A-D lag triangles)
  $ —  
3 - IBNR as of Prior Twelve Month End
  $ —  
4 + Subcapitation Payments, Pharmacy Rebates, Settlements as of Most Recent.
Twelve Months
(lines 39+40+41 of #20A-D lag triangles)
  $ —  
5 - Subcapitation Payments, Pharmacy Rebates, Settlements as of Prior Twelve
Month End
  $ —  
6 Prior Period IBNR Adjustment for Twelve Month End (lines 1+2-3+4-5)
  $ —  
7 Table #19 - Parts S2 Adjustment for prior period IBNR estimates (line 45 of
Table # 19S2)
  $ —  
8 Difference (lines 6-7)
  $ —  

 

Notes:   $   Cells with this shading are calculated fields and are not to be
filled out.       1 - Detail any differences in the “Notes” section.

 

--------------------------------------------------------------------------------

 

(Table) [w37497w3749715.gif]

 

--------------------------------------------------------------------------------

 

(Table) [w37497w3749716.gif]

 

--------------------------------------------------------------------------------

 

(Table) [w37497w3749717.gif]

 

--------------------------------------------------------------------------------

 

(Table) [w37497w3749718.gif]

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #11A — Cost & Utilization by AFDC Rate Cell Grouping
For Inpatient Hospital, Primary Care Services, Physician Specialty Services,
Emergency Room, Dental, Pharmacy (not to include Reimbursable HIV/AIDS Drugs and
Blood Products), Outpatient Facility, D Supplies, Home Health Care, Laboratory
and Radiology, Transportation, and All Other Practitioners & Services

                 
 
  FOR THE STATE FISCAL-ENDING AT 09/30:            
 
               
 
              (HMO Name)

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #11A — Cost & Utilization by AFDC Rate Cell Grouping
For Inpatisnt Hospital, Primary Care Services, Physician Specialty Services,
Emergency Room, Dental, Pharmacy (not to include Reimbursable HIV/AIDS Drugs and
Blood Products), Outpatient Facility, D Supplies, Home Health Care, Laboratory
and Radiology, Transportation, and All Other Practitioners & Services

                 
 
  FOR THE STATE FISCAL-ENDING AT 09/30:            
 
               
 
              (HMO Name)

Notes:
1.
This will be used for AFDC allocation in capitation rates.
2.
COS from Financials
  COS from this Submission  
Inpatient Hospital
  Inpatient Hospital  
Primary Care
  Primary Care Services  
Physician Specialty Services
  Physician Specialty Services  
Outpatient Hospital
  Outpatient Facility  
Other Professional Services
  All Other Practitioners and Services  
Emergency Room
  Emergency Room  
DME/Medical Supplies
  DME/Medical Supplies & Orthotics/Prosthetics  
Prosthetics & Orthotics
  DME/Medical Supplies & Orthotics/Prosthetics  
Dental
  Dental  
Pharmacy
  Pharmacy  
Home Health Care
  Home Health Care  
Transportation
  Transportation  
Lab & X-ray
  Laboratory & Radiology  
Vision Care
  All Other Practitioners and Services  
Menial Health/Substance Abuse
  All Other Practitioners and Services  
Other Medical
  All Other Practitioners and Services

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749719.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749720.gif]

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #11B- Cost — Utilization by FamilyCare Parents Rate Cell Grouping
For Inpatient Hospital, Primary Can Services, Physician Specialty Services,
Emergency Room, Dental, Pharmacy (not to Include Reimbursable HIV/AIDS Drugs and
Blood Products), Outpatient Facility, DME/Medical Supplies, Home Health Care,
Laboratory and Radiology, Transportation, and All Other Practitioners & Services

           
FOR THE STATE FISCAL-ENDING AT 09/30:
         
 
         
 
        (HMO Name)

                                                                     
Transportation             Previous   Previous   Previous   Current   Current  
Current             SFY-and @ 09/30   SFY-and @ 09/30   SFY-and @ 09/30  
SFY-and @ 09/30   SFY-and @ 09/30   SFY-and @ 09/30         COA   Member Months
  Incurred $   Units   Member Months   Incurred $   Units   1    
FamilyCare Parents/Adults 21-44.99 M
    —     $ —       —     —     $ —       —     2    
FamilyCare Parents/Adults 21-44.99 F
    —     $ —       —     —     $ —       —     3    
FamilyCare Parents/Adults 45+ M&F
    —     $ —       —     —     $ —       —   Subtotal  
FamilyCare Parents/Adults
    —     $ —       —     —     $ —       —  

                                                                      All Other
Presentation and Services             Previous   Previous   Previous   Current  
Current   Current             SFY-and @ 09/30   SFY-and @ 09/30   SFY-and @
09/30   SFY-and @ 09/30   SFY-and @ 09/30   SFY-and @ 09/30         COA   Member
Months   Incurred $   Services   Member Months   Incurred $   Services   1    
FamilyCare Parents/Adults 21-44.99 M
    —     $ —       —     —     $ —       —     2    
FamilyCare Parents/Adults 21-44.99 F
    —     $ —       —     —     $ —       —     3    
FamilyCare Parents/Adults 45+ M&F
    —     $ —       —     —     $ —       —   Subtotal  
FamilyCare Parents/Adults
    —     $ —       —       —     $ —       —  

Reconciliations to Table 19 A - C

                                              Rate Cell Total     Report Totals
    Difference  
New Jersay Family Care Parents/Adults
  Rate Cell M Total Medical Expense
                       

Notes:

1.   This will be used for FamilyCare Parents allocation In capitation rates.
2.
  COS from Financials   COS from this Submission
 
  Inpatient Hospital   Inpatient Hospital
 
  Primary Care   Primary Care Services
 
  Physician Specialty Services   Physician Specialty Services
 
  Outpatient Hospital   Outpatient Facility
 
  Other Professional Services   All Other Practitioners and Services
 
  Emergency Room   Emergency Room
 
  DME/Medical Supplies   DME/Medical Supplies & Orthotics/Prosthetics
 
  Prosthetics & Orthotics   DME/Medical Supplies & Orthotics/Prosthetics
 
  Dental   Dental
 
  Pharmacy   Pharmacy
 
  Home Health Care   Home Health Care
 
  Transportation   Transportation
 
  Lab & X-ray   Laboratory & Radiology
 
  Vision Care   All Other Practitioners and Services
 
  Mental Health/Substance Abuse   All Other Practitioners and Services
 
  Other Medical   All Other Practitioners and Services

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #14A — Member Months & Income Statement

             
FOR THE STATE FISCAL-ENDING AT 09/30:
           
 
           
 
      (HMO Name)    

MEMBER MONTHS

                                                                      Current
Calender Year YTD         Previous State Fiscal Year   Previous Calendar Year  
Current State Fiscal Year   (1st 3 quarters) Product Line/Line of Business  
Member Months   Member Months   Member Months   Member Months 1  
Medicaid/NJ FamilyCare At-Risk Population=
    —       —       —       —   2  
 
                                3  
Total Medicaid/NJ FamilyCare Member Months
    —       —       —       —      
All Other Lines of Business
                                4  
a — NJ Medicare/Commercial
    —       —       —       —   5  
b — Other States Medicaid
    —       —       —       —   6  
c — Other States Medicare/Commercial
    —       —       —       —   7  
Total Member Months
    —       —       —       —  

                                  Income Statement by Line of Business  
Previous Calendar Year             Revenue   Medical Expenses   Administration
Expenses   1    
NJ Medicaid/NJ FamilyCare
  $ —     $ —     $ —     2    
NJ Medicare/Commercial
  $ —     $ —     $ —     3    
Other States Medicaid
  $ —     $ —     $ —     4    
Other States Medicare/Commercial
  $ —     $ —     $ —  

Income Statement by Line of Business

                                              Current Calendar Year YTD (1st 3
quarters)             Revenue   Medical Expenses   Administration Expenses   1  
 
NJ Medicaid/NJ FamilyCare
  $ —     $ —     $ —     2    
NJ Medicare/Commercial
  $ —     $ —     $ —     3    
Other States Medicaid
  $ —     $ —     $ —     4    
Other States Medicare/Commercial
  $ —     $ —     $ —  

      Notes:       1.   Gray highlighted cells denotes calculation.   2.   CY
and SFY member month counts will overlap.

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749721.gif]

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #14C – Capitation Arrangements
Current State Fiscal Year End

             
FOR THE STATE FISCAL-ENDING AT 09/30:
           
 
           
 
      (HMO Name)    

CAPITATED SERVICES

                                                              Current State
Fiscal Year End             Provider at Full-Risk   Total Amount Reported as  
Reported Medical Expense   Total Amount Reported as   Reported Administrative
Expense Covered Series   (Yes or No)   Medical Expense   Line # on Report 2,
Table 19   Administrative Expense   Line # on Report 2, Table 19 1    
Vision
          $ —     $ —     $ —           2    
Dental
          $ —     $ —     $ —           3    
Lab/Radiology
          $ —     $ —     $ —           5    
Mental Health
          $ —     $ —     $ —           6    
Triage Services/Nurse Hotline
          $ —     $ —     $ —           7    
Primary Care Physicians
          $ —     $ —     $ —           8    
Other #1
          $ —     $ —     $ —           9    
Other #2
          $ —     $ —     $ —           10    
Other #3
          $ —     $ —     $ —           11    
Other #4
          $ —     $ —     $ —           12    
Other #5
          $ —     $ —     $ —           13    
Other #6
          $ —     $ —     $ —           14    
Other #7
          $ —     $ —     $ —           15    
Total
                                       

 

Notes:       1.   Gray highlighted cells denotes calculation.

 

--------------------------------------------------------------------------------

 

Attach Copy of the General Ledger for the period ending 6-30-XX

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
NOTES TO FINANCIAL REPORTS

             
FOR THE SFY ENDING 6-30-08
    FOR       
 
       
 
      (HMO Name)    

Any notes or further explanations of any items contained in any of the reports
or in the reporting of financial disclosures are to be noted here. Appropriate
references and attachments are to be used as necessary. Space is provided below
or you may use a separate page as necessary.

 
Table #11
– Part A — Cost and Utilization by AFDC Rate Cell Grouping
– Part B — Cost and Utilization by FamilyCare Parents/Adults Rate Cell Grouping
 
Table #14
– Part A — Member Months and Income Statement
– Part B — Administrative Cost Detail
– Part C — Capitation Arrangements
 
Table #19
– Parts A-S2 — Income Statement By Rate Cell Grouping
 
Table #20
– Part A — Lag Report for Inpatient Hospital Payments
– Part B — Lag Report for Physician Payments
– Part C — Lag Report for Pharmacy Payments
– Part D — Lag Report for Other Medical Payments

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749722.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749723.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749724.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749725.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749726.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749727.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749728.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749729.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749730.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749731.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749732.gif]

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #19 – Part S3 – Income Statement by Rate Cell Grouping
Reconciliations

                 
FOR THE TWELVE MONTHS ENDING
      FOR        
 
               
 
          (HMO Name)    

Revenue Reconciliation

                                                                               
      HIV/AIDS - Blood             Only 5 rows provided           Capitation  
Maternity   Products   EPSDT   (insert additional rows if needed)   Date   Check
#   Premiums   Reimbursement   Reimbursement   Premiums   1    
 
  01/00/00   00000   $ —     $ —     $ —     $ —     2    
 
  01/00/00   00000   $ —     $ —     $ —     $ —     3    
 
  01/00/00   00000   $ —     $ —     $ —     $ —     4    
 
  01/00/00   00000   $ —     $ —     $ —     $ —     5    
 
  01/00/00   00000   $ —     $ —     $ —     $ —     6    
Totals Received from the State
          $ —     $ —     $ —     $ —     7    
Unearned Premiums
          $ —     $ —     $ —     $ —     8    
Change in Receivables / Unearned Premiums
                                          9    
Other
                                          10    
Total Premiums Reconciled to 19 S-2
          $ —     $ —     $ —     $ —  

 

Notes:   $   Cells with this shading are calculated fields and are not be filled
out.   1 –   Detail any difference in the “Notes” section.

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #19 — Part $3 — Income Statement by Rate Cell Grouping
Reconciliations

                     
FOR THE TWELVE MONTHS ENDING
          FOR        
 
                   
 
              (HMO Name)    

                                                                               
              Lag Triangle and Income Statement Reconciliation for Twelve Month
End               Twelve-Month     Twelve-Month     Twelve-Month   Lag Report  
        Table #19 - Part $1 & 32   Paid Claims     IBNR & RBUC     Total $   Lag
                                                  Table #19 -Part              
      Table #19 -Part         Report B   Medical Cost Grouping   Line #    
Consolidated Category of Service   Lag Report     Table #19 -Part$2    
Difference 1     Lag Report     S2     Difference 1     Lag Report     S2    
Difference 1   Table #20 -Part A   Inpatient Hospital     9    
Inpatient Hospital
  $ —     $ —     $ —     $ —     $ —     $ —     $ —     $ —     $ —   Table
#20 -Part B   Physician     10     Primary Care                                
                                                  11     Physician Specialty
Services   $ —     $ —     $ —     $ —     $ —     $ —     $ —     $ —     $ —  
Table #20 -Part C   Pharmacy     18    
Pharmacy (not to include Reimbursable HIV/AIDS
  $ —     $ —     $ —     $ —     $ —     $ —     $ —     $ —     $ —          
  19    
Reimbursable HIV/AIDS Drugs and Blood Products
                                                                               
  12    
Outpatient Hospital (excludes ER)
                                                                               
  13    
Other Professional Services
                                                                               
  14    
Emergency Room
                                                                               
  15    
DME/Medical Supplies
                                                                               
  16    
Prosthetics & Orthotics
                                                                               
  17    
Covered Dental
                                                                               
  20    
Home Health, Hospice, & PDN
                                                                        Table
#20 -Part D   Other     21    
Transportation
  $ —     $ —     $ —     $ —     $ —     $ —     $ —     $ —     $ —          
  22    
Lab & X-ray
                                                                               
  23    
Vision Care including Eyeglasses
                                                                               
  24    
Mental Health/Substance Abuse
                                                                               
  26    
EPSDT Medical & PDN
                                                                               
  27    
EPSDT Dental -EPD
                                                                               
  28    
Family Planning
                                                                               
  29    
Other Medical
                                                                               
   
 
                                                          Total     30    
Total
  $ —     $ —     $ —     $ —     $ —     $ —     $ —     $ —     $ —          
   
 
                                                     

 

Note     $   - Cells with this shading are calculated fields and are not to be
filled out.       1 — Detail any differences in the “Notes” section.

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #19 — Part S3 — Income Statement by Rate Cell Grouping
Reconciliations

                     
FOR THE TWELVE MONTHS ENDING
          FOR        
 
                   
 
              (HMO Name)    

                  Prior Period IBNR Reconciliation for Twelve Month End    
Incurred in Twelve Months Prior to  
1
  Claims Paid in Most Recent Twelve Month End   $ —  
2
  + IBNR as of Most Recent Twelve Months (line 43 of #2A-D lag triangles)   $ —
 
3
  - IBNR as of Prior Twelve Month End   $ —  
4
  + Subcapitation Payments, Pharmacy Rebates, Settlements as of Most Recent
Twelve Months
(lines 39+40+41 of #20A-D lag triangles)   $ —  
5
  - Subcapitation Payments, Pharmacy Rebates, Settlements as of Prior Twelve
Month End   $ —  
6
  Prior Period IBNR Adjustment for Twelve Month End
(line 1+2-3+4-5)   $ —  
7
  Table #19 - Parts S2 Adjustment for prior period IBNR estimates
(line 46 of Table # 1952)   $ —  
8
  Difference (lines 6-7)   $ —  

 

Notes   $   - Cells with this shading are calculated fields and are not to be
filled out.       1 — Detail any differences in the “Notes” section.

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #19 — Part T — Non-State Plan Service Expenses by Rate Cell Grouping
          Non-State Plan Services1, 2

                     
FOR THE TWELVE MONTHS ENDING
          FOR        
 
                   
 
              (HMO Name)    

                                                                     
AFDC/NJCPW/NJ KidCare A -     AFDC/NJCPW/NJ KidCara A -     AFDC/NJCPW/NJ
KidCare A -     ABD With Medicare & Other       North     Central     South    
Dual Eligibles - DDD               Twelve-Month             Twelve-Month        
    Twelve-Month             Twelve-Month   Expenses   Twelve-Month $     Units
    Twelve-Month $     Units     Twelve-Month $     Units     Twelve-Month $    
Units  
EXPENSES:
                                                               
MEDICAL & HOSPITAL NON-STATE PLAN SERVICES
                                                               
1
  $ —       —     $ —       —     $ —       —     $ —       —  
2
  $ —       —     $ —       —     $ —       —     $ —       —  
3
  $ —       —     $ —       —     $ —       —     $ —       —  
4
  $ —       —     $ —       —     $ —       —     $ —       —  
5
  $ —       —     $ —       —     $ —       —     $ —       —  
6
  $ —       —     $ —       —     $ —       —     $ —       —  
7
  $ —       —     $ —       —     $ —       —     $ —       —  
8
  $ —       —     $ —       —     $ —       —     $ —       —  
9
  $ —       —     $ —       —     $ —       —     $ —       .  
10
  $ —       —     $ —       —     $ —       —     $ —       —  
11 TOTAL MEDICAL & HOSPITAL NON-STATE PLAN SERVICES (1 through 10)
  $ —       —     $ —       —     $ —       —     $ —       —  
ADMINISTRATION FOR NON-STATE PLAN SERVICES*
                                                               
12 TOTAL ADMINISTRATION
  $ —       —     $         —     $         —     $ —       —  
TOTAL EXPENSES FOR NON-STATE PLAN SERVICES
                                                               
 
                                               
13 TOTAL EXPENSES (11 + 12)
  $ —       —     $ —       —     $ —       —     $ —       —  
 
                                               

Notes:   1 —  All medical and administrative expenses must be reported using
actual incurred and paid data for the current period of the calendar year (no
reserves).

Non-State Plan Services Description
1
2
3
4
5
6
7
8
9
10
*if medical and hospital claim costs exist for non-State Plan services, then
must have some amount of administration for non-State Plan services

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #19 — Part T — Non-State Plan Service Expenses by Rate Cell Group
          Non-State Plan Services1, 2
FOR THE TWELVE MONTHS ENDING                                        &n
bsp;                    

                                                                      ABD With
Medicare & Other                                     ABD without Medicare - Non-
      Dual Eligibles - Non-DDD     Non-ABD - DDD     ABD without Medicare - DDD
    DDD               Twelve-Month             Twelve-Month            
Twelve-Month             Twelve-Month   Expanses   Twelve-Month $     Units    
Twelve-Month $     Units     Twelve-Month $     Units     Twelve-Month $    
Units  
EXPENSES:
                                                               
MEDICAL & HOSPITAL NON-STATE PLAN SERVICES
                                                               
1
  $ —       —     $ —       —     $ —       —     $ —       —  
2
  $ —       —     $ —       —     $ —       —     $ —       —  
3
  $ —       —     $ —       —     $ —       —     $ —       —  
4
  $ —       —     $ —       —     $ —       —     $ —       —  
5
  $ —       —     $ —       —     $ —       —     $ —       —  
6
  $ —       —     $ —       —     $ —       —     $ —       —  
7
  $ —       —     $ —       —     $ —       —     $ —       —  
8
  $ —       —     $ —       —     $ —       —     $ —       —  
9
  $ —       —     $ —       —     $ —       —     $ —       —  
10
  $ —       —     $ —       —     $ —       —     $ —       —  
11 TOTAL MEDICAL & HOSPITAL NON-STATE PLAN SERVICES (1 through 10)
  $ —       —     $ —       —     $ —       —     $ —       —  
ADMINISTRATION FOR NON-STATE PLAN SERVICES*
                                                               
12 TOTAL ADMINISTRATION
  $ —       —     $ —       —     $ —       —     $ —       —  
TOTAL EXPENSES FOR NON-STATE PLAN SERVICES
                                                               
 
                                               
13 TOTAL EXPENSES (11+12)
  $ —       —     $ —       —     $ —       —     $ —       —  
 
                                               

 

Notes:    1 —  All medical and administrative expenses must be reported using
actual incurred and paid data for the current period of the calendar year (no
reserves).

Non-State Plan Services Description
1
2
3
4
5
6
7
8
9
10
*If medical and hospital claim costs exist for non-State Plan services, then
must have some amount of administration for non-State Plan services

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #19 — Part T — Non-State Plan Service Expenses by Rate Cell Group
          Non-State Plan Services1, 2
FOR THE TWELVE MONTHS ENDING                                      &n bsp; 

                      NJ KIdCare B&C               Twelve-Month   Expanses  
Twelve-Month $     Units  
EXPENSES:
               
MEDICAL & HOSPITAL NON-STATE PLAN SERVICES
               
1
  $ —       —  
2
  $ —       —  
3
  $ —       —  
4
  $ —       —  
5
  $ —       —  
6
  $ —       —  
7
  $ —       —  
8
  $ —       —  
9
  $ —       —  
10
  $ —       —  
11 TOTAL MEDICAL & HOSPITAL NON-STATE PLAN SERVICES (1 through 10)
  $ —       —  
ADMINISTRATION FOR NON-STATE PLAN SERVICE
               
12 TOTAL ADMINISTRATION
  $ —       —  
TOTAL EXPENSES FOR NON-STATE PLAN SERVICES
               
 
           
13 TOTAL EXPENSES (11 + 12)
  $ —       —  
 
           

 

Notes:   1 — All medical and administrative expenses must be reported using
actual incurred and paid data for the current period of the calendar year (no
reserves).

Non-State Plan Services Description
1
2
3
4
5
6
7
8
9
10
*If medical and hospital claim costs exist for non-State Plan services, then
must have some amount of administration for non-state Plan services

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #19 — Part T — Non-State Plan Service Expenses by Rate Cell Group
          Non-State Plan Services1, 2
FOR THE TWELVE MONTHS ENDING                                        &n
bsp;                    

                                                                      NJ Family
Care Parents/     ABD with Medicare & Other       NJ KidCare D     Adults    
Dual Eligibles- AIDS               Twelve-Month             Twelve-Month        
    Twelve-Month   Expenses   Twelve-Month $     Units     Twelve-Month $    
Units     Twelve-Month $     Units  
EXPENSES:
                                               
MEDICAL & HOSPITAL NON-STATE PLAN SERVICES
                                               
1
  $ —       —     $ —       —     $ —       —  
2
  $ —       —     $ —       —     $ —       —  
3
  $ —       —     $ —       —     $ —       —  
4
  $ —       —     $ —       —     $ —       —  
5
  $ —       —     $ —       —     $ —       —  
6
  $ —       —     $ —       —     $ —       —  
7
  $ —       —     $ —       —     $ —       —  
8
  $ —       —     $ —       —     $ —       —  
9
  $ —       —     $ —       —     $ —       —  
10
  $ —       —     $ —       —     $ —       —  
11 TOTAL MEDICAL & HOSPITAL NON-STATE PLAN SERVICES (1 through 10)
  $ —       —     $ —             $ —       —  
ADMINISTRATION FOR NON-STATE PLAN SERVICES*
                                               
12 TOTAL ADMINISTRATION
  $ —       —     $ —       —     $ —       —  
TOTAL EXPENSES FOR NON-STATE PLAN SERVICES
                                               
 
                                   
13 TOTAL EXPENSES (11 + 12)
  $ —       —     $ —       —     $ —       —  
 
                                   

 

Notes: 1 —   All medical and administrative expenses must be reported using
actual incurred and paid data for the current period of the calendar year (no
reserves).

Non-State Plan Services Description
1
2
3
4
5
6
7
8
9
10
*If medical and hospital claim costs exist for non-State Plan services, then
must have some amount of administration for non-State Plan services

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #19 — Part T — Non-State Plan Service Expenses by Rate Cell Group
          Non-State Plan Services1, 2
FOR THE TWELVE MONTHS ENDING                                        &n
bsp;                    

                                                      Non-ABD-AIDS     Maternity
    Newborns               Twelve-Month             Twelve-Month            
Twelve-Month   Expenses   Twelve-Month $     Units     Twelve-Month $     Units
    Twelve-Month $     Units  
EXPENSES:
                                               
MEDICAL & HOSPITAL NON-STATE PLAN SERVICES
                                               
1
  $ —       —     $ —       —     $ —       —  
2
  $ —       —     $ —       —     $ —       —  
3
  $ —       —     $ —       —     $ —       —  
4
  $ —       —     $ —       —     $ —       —  
5
  $ —       —     $ —       —     $ —       —  
6
  $ —       —     $ —       —     $ —       —  
7
  $ —       —     $ —       —     $ —       —  
8
  $ —       —     $ —       —     $ —       —  
9
  $ —       —     $ —       —     $ —       —  
10
  $ —       —     $ —       —     $ —       —  
11 TOTAL MEDICAL & HOSPITAL NON-STATE PLAN SERVICES (1 through 10)
  $ —       —     $ —       —     $ —       —  
ADMINISTRATION FOR NON-STATE PLAN SERVICES*
                                               
12 TOTAL ADMINISTRATION
  $ —       —     $ —       —     $ —       —  
TOTAL EXPENSES FOR NON-STATE PLAN SERVICES
                                               
 
                                   
13 total expenses (11 + 12)
  $ —       —     $ —       —     $ —       —  
 
                                   

 

Notes: 1 —   All medical and administrative expenses must be reported using
actual incurred and paid data for the current period of the calendar year (no
reserves).

Non-State Plan Services Description
1
2
3
4
5
6
7
8
9
10
*If medical and hospital claim costs exist for non-State Plan services, then
must have some amount of administration for non-State Plan services

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
Table #21 — Maternity Outcome Counts 1

             
         FOR THE TWELVE MONTHS ENDING
     FOR       
 
           
 
      (HMO Name)    

                                              Current 12 Month Period       Live
Births             Newborn     Ratio MMs /       C-Section     Vaginal    
Non-live Births     Member Mo’s     Births 2  
NORTHERN REGION
                                       
AFDC/NJCPW/NJ KidCare A
                                       
 
                                       
CENTRAL REGION
                                       
AFDC/NJCPW/NJKidCare A
                                       
 
                                       
SOUTHERN REGION
                                       
AFDC/NJCPW/NJ KidCare A
                                       
 
                                        STATEWIDE
All Other                                        
 
                                       
TOTAL
                                       

 

Notes:   1 —   Only outcomes on or after the thirteenth week of gestation should
be included in this report, excluding elective abortions. 2 —   It is expected
that there shall be approximately 2.5 newborn member months reported for each
delivery as the newborn time period is on average 75 days. Any variation from
2.5 member months may suggest a reporting inconsistency.

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749733.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749734.gif]

 

--------------------------------------------------------------------------------

 

(TABLE) [w37497w3749735.gif]

 

--------------------------------------------------------------------------------

 

FOR MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
NOTES TO FINANCIAL REPORTS

                     
FOR THE TWELVE MONTHS ENDING
          FOR        
 
 
 
         
 
(HMO Name)    

      Any notes or further explanations of any items contained in any of the
reports or in the reporting of financial disclosures are to be noted here.
Appropriate references and attachments are to be used as necessary. Space is
provided below or you may use a separate page as necessary.
 
   
Table #4
   
- Part A — Claims Lag Report for Manually Submitted Claims
   
- Part B — Claims Lag Report for Electronically Submitted Claims
   
 
   
Table #7
   
- Parts A-C — Stop Loss Summary
   
 
   
Table #10
   
-Third Party Liability
   
 
   
Table #19
   
- Parts A-V — Income Statement By Rate Cell Grouping
   
 
   
Table #20
   
- Part A — Lag Report for Inpatient Hospital Payments
   
- Part B — Lag Report for Physician Payments
   
- Part C — Lag Report for Pharmacy Payments
   
- Part D — Lag Report for Other Medical Payments
   
 
   
Table #21
   
- Maternity Outcome Counts
   

 

--------------------------------------------------------------------------------

 

B.4.11 Special Child Health Services Network
The contractor shall utilize the following DHSS website to access an updated
list of Special Child Health Services County Case Management Units:
http://www.state.nj.us/health/fhs/socasemg.htmsch/sccase.shtml

 

--------------------------------------------------------------------------------

 

SECTION C
CAPITATION RATES

C-1

--------------------------------------------------------------------------------

 

STATE OF NEW JERSEY
FAMILYCARE
SFY08 CAPITATION RATES

    SFY08 Rates — Version 1.3a
Contract Period: 07/01/07 — 06/30/08

                      Category   Age/Sex   Northern   Central   Southern  
Statewide
AFDC / DYFS/ KidCare A / New Jersey Care Children
  Newborn                
AFDC / DYFS / KidCare A / New Jersey Care Children
  75 dys - 2yrs M&F                
AFDC / DYFS / KidCare A / New Jersey Care Children / NJCPW
  2 - 20.99 M&F                
AFDC / NJCPW
  21 - 44.99 Female                
AFDC
  21 - 44.99 Male                
AFDC / NJCPW
  45 + M&F                
Aged with Medicare
  All                
Blind/Disabled with Medicare and Other Dual Eligibles
  < 45 M&F                 Blind/Disabled with Medicare and Other Dual Eligibles
  45+ M&F   *****REDACTED*****

Maternity
  All                
ABD-DDD with Medicare and Other Dual Eligibles
  All                
ABD (including AIDS & DDD) without Medicare1
  All                
Non ABD-DDD
  All                
KidCare B&C
  Newborn                
KidCare B&C
  < 2 M&F                
KidCare B&C
  Youth                
KidCare D
  Newborn                
KidCare D
  < 2 M&F                
KidCare D
  Youth                
FamilyCare Parents 0-200% / FamilyCare Adults & Hlth Access / Adult Restricted
Aliens
  < 45 Female                
FamilyCare Parents 0-200% / FamilyCare Adults & Hlth Access / Adult Restricted
Aliens
  < 45 Male                
FamilyCare Parents 0-200% / FamilyCare Adults & Hlth Access / Adult Restricted
Aliens
  45+ M&F                
AIDS-ABD with Medicare and Other Dual Eligibles
  All                
AIDS-Non-ABD
  All                
AIDS-ABD with Medicare and Other Dual Eligibles DDD (incl. Behavioral Health
Add-On)
  All                
AIDS-Non-ABD DDD (including Behavioral Health Add-On)
  All                

 

--------------------------------------------------------------------------------

 

              (STATE OF NEW JERSEY LOGO) [w37497w3749701.gif]    

Jon S. Corzine
Governor   State of New Jersey
Department of Human Services
Division of Medical Assistance and Health Services
P.O. Box 712
Trenton, NJ 08625-0712
Telephone 1-800-356-1561  

Jennifer Velez
Acting Commissioner

                  John R. Guhl
Director

May 9, 2007
Peter D. Haytaian
President and CEO
AMERIGROUP New Jersey, Inc.
399 Thornall Street, 9th Floor
Edison, NJ 08837
Dear Mr. Haytaian:
Enclosed is an amendment to the managed care contract. This amendment, which
will become effective on July 1, 2007, will modify language regarding medical
cost ratio. The language change is necessary to appropriately reflect Division
intent and avoid the negative impact on the State’s collection of imposed taxes
and the proper assessment of insolvency deposits.
Please sign the five signature pages and return to our office by close of
business on May 18, 2007.

         
 
       
 
  Sincerely,    
 
  -s- Jill Simone, MD [w37497w3749703.gif]    
 
  Jill Simone, MD    
 
  Executive Director    
 
  Office of Managed Health Care    

JS:H:dv

c:   John Koehn
Jennifer Langer

New Jersey Is An Opportunity Employer

 

--------------------------------------------------------------------------------

 

STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
AND
AMERIGROUP NEW JERSEY, INC.
AGREEMENT TO PROVIDE HMO SERVICES
In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract
between AMERIGROUP New Jersey, Inc. and the State of New Jersey, Department of
Human Services, Division of Medical Assistance and Health Services (DMAHS),
effective date October 1, 2000, all parties agree that the contract shall be
amended, effective July 1, 2007, as follows:

1.   Article 8, “Financial Provisions,” Sections 8.4.1 and 8.4.3 shall be
amended as reflected in Article 8, Sections 8.4.1 and 8.4.3 attached hereto and
incorporated herein.

 

--------------------------------------------------------------------------------

 

Medical Cost Ratio Damages 7/2007
All other terms and conditions of the October 1, 2000 contract and subsequent
amendments remain unchanged except as noted above.
The contracting parties indicate their agreement by their signatures.

                     
 
                    AMERIGROUP
      State of New Jersey
   
 
                    New Jersey, Inc.
      Department of Human Services
   
 
                   
BY:
  /s/ Peter D. Haytaian       BY:   /s/ John R. Guhl    
 
                   
 
                    Peter D. Haytaian
              John R. Guhl
   
 
                    TITLE: President & CEO       TITLE: Director, DMAHS    
 
                    DATE: May 17, 2007       DATE:
                                            
 
                    APPROVED AS TO FORM ONLY                
 
                    Attorney General                
 
                    State of New Jersey                
 
                   
BY:
                   
 
 
 
               
 
  Deputy Attorney General                
 
                    DATE:                                                       
 

 

--------------------------------------------------------------------------------

 

  3.   Costs for activities required to achieve compliance standards for EPSDT
participation, lead screening, and prenatal care as specified in Article IV may
be considered direct medical expenditures. The contractor’s reporting shall be
based only on the approved Medical Cost Ratio — Direct Medical Expenditures Plan
(Report on Table 6).

Calculation of MCR. The calculation of MCR will be made using information
submitted by the contractor on the quarterly reports — Income Statement by Rate
Cell Grouping (Section A.7.21 of the Appendices, Table 19, ). The costs related
to 8.4.1.A 1-3 are to be reported on Table 6 and the allowable amount will be
added to the calculation of Medical and Hospital Expenses. The sum of all
applicable quarters in the SFY for which the MCR is calculated for Total Medical
and Hospital Expenses less Coordination of Benefits (COB) and less reinsurance
recoveries will be divided by the sum of all applicable quarters of Medicaid/NJ
FamilyCare premiums to arrive at the ratio. In addition, the DMAHS will allow
for any applicable premium adjustments in the MCR calculation. At its sole
discretion, the State reserves the right to recompute the MCR to determine
direct medical expenditures of eighty (80) percent for a period of up to three
(3) years prior to the close of the state fiscal year under review for MCR
determination and apply damages recover the underexpenditure as delineated in
Article 8.4.3.
8.4.2 RESERVED
8.4.3 DAMAGESDAMAGESRECOVERY OF UNDEREXPENDITURE
The Department shall have the right to impose damages on a contractor that has
failed to keep maintain the required MCR. recover tho amount of payments from
the State not spent on medical costs as defined above.
If at 180 days after the SFY end the MCR is below 80.0%, the State shall recover
100% of the underexpenditure. If the contractor fails to meet the MCR
requirement and a penalty is applied, recovery is made, a plan of corrective
action shall be required.
8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS