##### 



Jon S. CorzineGovernor
    
    (STATE OF NEW JERSEY LOGO)
State of New JerseyDepartment of Human ServicesDivision of Medical Assistance and Health Services
P.O. Box 712 
Trenton, NJ 08625-0712
Telephone 1-800-356-1561June 8, 2007
    
    Jennifer VelezActing CommissionerJohn R. GuhlDirector
 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,
 )
 Rita Hemingway
Director, Contract Relations
Office of Managed Health Care
 RH;dg
 Enclosure
 c:
    
    Jill Simone, MDJohn KoehnJennifer Langer
 New Jersey Is An Equal Opportunity Employer




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##### 



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




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##### 



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.




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##### 



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.




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##### 



AMERIGROUP
    
    State of New JerseyNew Jersey, Inc.
    
    Department of Human ServicesBY:
    
    /s/ Peter D. Haytaian

Peter D. Haytaian
    
    
    
    BY:
    
    /s/ John R. Guhl

John R. GuhlTITLE: President & CEO
    
    TITLE: Director, DMAHSDATE: 4/13/07
    
    date: 4/20/07APPROVED AS TO FORM ONLYAttorney GeneralState of New JerseyBY:
    
    [ILLEGIBLE]

Deputy Attorney GeneralDATE: 4/17/07




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##### 



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 Changes01/2007 Accepted
    
    I-19




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##### 



PSC
    
    PSC
    
    Race CodeCost Sharing
    
    No Cost Sharing
    
    No Cost Sharing301
    
    300
    
    3493
    
    380494
    
    497495
    
    700498
    
    763498
(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
    
    PSCCost Sharing
    
    No Cost Sharing498 (w/corresponding 
cap code) 
701
    
    380, 310, 320, 330, 410, 420,
430, 470, 497 (with
corresponding cap codes)700763
 7/2007 Changes01/2007 Accepted
    
    I-20




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##### 



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 Changes01/2007 Accepted
    
    I-27




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##### 



3.3
    
    PROVIDER SERVICESThe 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




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##### 



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 LISTSThe contractor shall provide federally qualified health centers with electronic
remittance advices and electronic capitation lists of enrollees. In addition, the
contractor shall provide electroniccopies of or aan electronicreport of the data
elements of the electronic remittance advices and capitation lists in Excel format to
the DMAHS by the45th 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 MANAGEMENTThe 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




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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; and3.
    
    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,whoare 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




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##### 



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 throughmailers,
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




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##### 



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 Assistants2.
    
    Preventive Health Care and Counseling and Health Promotion3.
    
    Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program ServicesFor 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 Care5.
    
    Inpatient Hospital Services including acute care hospitals, rehabilitation hospitals, and
special hospitals.6.
    
    Outpatient Hospital Services7.
    
    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 therapeutic9.
    
    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




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##### 



27.
    
    Mental Health/Substance Abuse Services for enrollees who are clients of the Division of
Developmental Disabilities. Exception  partial care and partial hospitalizationservices 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 type2.
    
    
    290.1
    
    
    Presenile dementia3.
    
    
    290.10
    
    
    Presenile dementia, uncomplicated4.
    
    
    290.11
    
    
    Presenile dementia with delerium5.
    
    
    290.12
    
    
    Presenile dementia with delusional features6.
    
    
    290.13
    
    
    Presenile dementia with depressive features7.
    
    
    290.2
    
    
    Senile dementia with delusional or depressive features8.
    
    
    290.20
    
    
    Senile dementia with delusional features9.
    
    
    290.21
    
    
    Senile dementia with depressive features10.
    
    
    290.3
    
    
    Senile dementia with delerium11.
    
    
    290.4
    
    
    Arteriosclerotic dementia12.
    
    
    290.40
    
    
    Arteriosclerotic dementia, uncomplicated13.
    
    
    290.41
    
    
    Arteriosclerotic dementia with delirium14.
    
    
    290.42
    
    
    Arteriosclerotic dementia with delusional features15.
    
    
    290.43
    
    
    Arteriosclerotic dementia with depressive features16.
    
    
    290.8
    
    
    Other specific senile psychotic conditions17.
    
    
    290.9
    
    
    Unspecified senile psychotic condition18.
    
    
    291.1
    
    
    Alcohol amnestic syndrome19.
    
    
    291.2
    
    
    Other alcoholic dementia20.
    
    
    292.82
    
    
    Drug induced dementia21.
    
    
    292.83
    
    
    Drug-induced amnestic syndrome22.
    
    
    292.9
    
    
    Unspecified drug induced mental disorders23.
    
    
    293.0
    
    
    Acute delirium24.
    
    
    293.1
    
    
    Subacute delirium25.
    
    
    293.8
    
    
    Other specific transient organic mental disorders26.
    
    
    293.81
    
    
    Organic delusional syndrome27.
    
    
    293.82
    
    
    Organic hallucinosis syndrome28.
    
    
    293.83
    
    
    Organic affective syndrome29.
    
    
    293.84
    
    
    Organic anxiety syndrome30.
    
    
    294.0
    
    
    Amnestic syndrome31.
    
    
    294.1
    
    
    Dementia in conditions classified elsewhere32.
    
    
    294.8
    
    
    Other specified organic brain syndromes (chronic)33.
    
    
    294.9
    
    
    Unspecified organic brain syndrome (chronic)34.
    
    
    305.1
    
    
    Non-dependent abuse of drugs  tobacco35.
    
    
    310.0
    
    
    Frontal lobe syndrome36.
    
    
    310.2
    
    
    Postconcussion syndrome37.
    
    
    310.8
    
    
    Other specified nonpsychotic mental disorder following
organic brain damage
 7/2007 Changes 1/2007 Accepted
    
    IV-7




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##### 



071100713007210
 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
hospitalizationservices 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 detoxification2.
    
    Costs for Methadone maintenance and its administration3.
    
    Mental Health Services
 a.
    
    Partial care and partial hospitalizationservices 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 CONTRACTORThe 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.
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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.
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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
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4.5
    
    ENROLLEES WITH SPECIAL NEEDS4.5.1
    
    INTRODUCTIONFor 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
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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.
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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-Levelof 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,
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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
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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; ande.
    
    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
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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 REQUIREMENTSThe 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 everyprovider 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:
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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 quarterlysemi
annualbasis or more frequently as may be required.C.
    
    The contractor shall provide the HBC with a full network on a monthlyquarterly
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 monthlyquarterlyprovider file shall include an identifier for every provider
including the SSN, tax ID# or professional license number.
 4.8.4
    
    PROVIDER DIRECTORY REQUIREMENTSThe 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.
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providers are willing, capable, and authorized (through licensure or certification)
to serve multiple counties or statewide.
 a.
    
    Medical Toxicologyb.
    
    Developmental & Behavioral Pediatricsc.
    
    Medical Geneticsd.
    
    Specialty Centers (Centers of Excellence)e.
    
    Other Specialty Centers/Providersf.
    
    DME providersg.
    
    Medical suppliersh.
    
    Prosthetists, orthotists, pedorthistsi.
    
    Hearing aid suppliersj.
    
    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.
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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.
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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 obtainaA 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.
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3.
    
    The need for the family to keep track of the cost-sharing amounts paid; and4.
    
    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;
andCCC.
    
    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 SERVICESThe 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




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##### 



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




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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.
    
    SanctionsViolations 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




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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.
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    VII-26




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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 Changes1/2007 Accepted
    
    VII-27




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##### 



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
 one hundred (100) ninety-nine and one half (99.5)
   7/2007 Changes1/2007 Accepted
    
    VII-28




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##### 



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 recordsat 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 receivedadjudicationby the contractor
and within one year plus seventy-five (75) days twelve (12) monthsfrom 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 Changes1/2007 Accepted
    
    VII-40




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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 GroupingThe 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 Changes1/2007 Accepted
    
    VII-41




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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.
    7.27.2 UNAUDITED FINANCIAL STATEMENTS (SAP)
 th
 7.28 FEDERAL APPROVAL AND FUNDING
  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.
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    VII-42




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8.4 MEDICAL COST RATIO
 8.4.1 MEDICAL COST RATIO STANDARD
  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 homevisitencounter 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 Changes1/2007 Accepted
    
    VIII-4




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based only on the approved Medical Cost Ratio  Direct
Medical Expenditures Plan (Report on Table 6).
 each the in the SFY for which the MCR is
calculated 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
 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. penalty
is applied recovery is made,
 8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS
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    VIII-5




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8.5.1 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
  8.5.2 MAJOR PREMIUM GROUPS
  8.5.2.1 AFDC/TANF, DYFS AND AGING OUT FOSTER CARE CHILDREN, NJC PREGNANT WOMEN, AND NJ FAMILYCARE
PLAN A CHILDREN
 DYFS and Aging Out Children in
Foster Care,
 8.5.2.2 NJ FAMILYCARE PLANS B & C
  8.5.2.3 NJ FAMILYCARE PLAN D CHILDREN
  8.5.2.4 NJ FAMILYCARE PLAN D PARENTS/CARETAKERS
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    VIII-6




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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
  8.5.2.7 ABD WITH MEDICARE AND OTHER DUAL ELIGIBLES
  8.5.2.8 CLIENTS OF DDD
  8.5.2.9 ENROLLEES WITH AIDS
  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
 th
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    VIII-7




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SECTION A
REPORTS
 with
prior DMAHS approval.
 /2007




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##### 



Contractor Financial Reporting Manual for Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 Contents
 1. Introduction
    
    
    12. General Instructions
    
    
    76673. 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)
    
    
    321130314. Appendix A Incurred But Not Reported (IBNR) Methodology
    
    
    36345. Appendix B  Key Utilization Definitions
    
    
    40386. Appendix C  Managed Care Category of Service Codes
    
    
    43417. Appendix D  Report Forms
    
    
    44428. Appendix E  Certification Statement at Each Quarter End
    
    
    4644
 Date Effective: July 1, 20076
    
    i




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Contractor Financial Reporting Manual
    
    State of New Jersey
 1
 Introduction
    §
    
    Rate cell grouping detail;
 §
    
    Regional detail;
 §
    
    IBNR calculation detail; and
 §
    
    Timing of submissions.
 Date Effective: July 1, 20076
    
    1




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Contractor Financial Reporting Manual
    
    State of New Jersey
  for
these reporting purposes (seventeen rate cell groupings for
 at risk populations and two rate
cell groupings for Managed Care Service Administrator (MCSA) populations).
 Rate Cell
    
    
    
    CapitationReference
    
    Rate Cell Grouping
    
    Code
    
    DescriptionAFDC/SSI/DDDTable #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




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Contractor Financial Reporting Manual
    
    State of New Jersey
 Rate Cell
    
    
    
    CapitationReference
    
    Rate Cell Grouping
    
    Code
    
    DescriptionTable #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 KidCareTable #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,
573995719957899,58499
    
    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




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Contractor Financial Reporting Manual
    
    State of New Jersey
 Rate Cell
    
    
    
    CapitationReference
    
    Rate Cell Grouping
    
    Code
    
    DescriptionTable # 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/DataTable #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.MCSATable #19
Part U
    
    NJ
FamilyCareAdults 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




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 Rate Cell
    
    
    
    CapitationReference
    
    Rate Cell Grouping
    
    Code
    
    DescriptionTable #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




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
   Northern (Region 1)
    
    Central (Region 2)
    
    Southern (Region 3)Bergen
    
    Essex
    
    AtlanticHudson
    
    Mercer
    
    BurlingtonHunterdon
    
    Middlesex
    
    CamdenMorris
    
    Union
    
    Cape MayPassaic
    
    
    
    CumberlandSomerset
    
    
    
    GloucesterSussex
    
    
    
    MonmouthWarren
    
    
    
    OceanSalem
 Date Effective: July 1, 20076
    
    6




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 2 2
 General Instructions
   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.
  Quarter Ending:
    
    Due Date:March 31
    
    May 15June 30
    
    August 15September 30
    
    November 15December 31
    
    February 15
  Quarter Ending:
    
    Due Date:September 30
    
    November 105
  Date Effective: July 1, 20076
    
    7




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
  David.Moran@dhs.state.nj.us
  Mike.Nordstrom@mercer.com
    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
         Date Effective: July 1 , 20076
    
    9




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 33
 Report Specifications
 -E  Submission Due at Each Quarter End
  excluding the Managed Care Service Administrator
(MCSA) rate cell
groupings.
 MedicalConsolidated
    
    Income Statement
    
    Cost
    
    Lag ReportCategory of Service
    
    Reference
    
    Grouping
    
    ReferenceInpatient Hospital
    
    Table #19  Part S2,
Line 9
    
    Inpatient
Hospital
    
    Table #20  Part APrimary Care
    
    Table #19  Part S2,
Line 10
    
    Physician
    
    Table #20  Part BPhysician Specialty 
Services
    
    Table #19  Part S2,
Line 11
    
    Physician
    
    Table #20  Part B
 Date Effective: July 1 , 20076
    
    10




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 MedicalConsolidated
    
    Income Statement
    
    Cost
    
    Lag ReportCategory of Service
    
    Reference
    
    Grouping
    
    ReferencePharmacy (not to
include Reimbursable
HIV/AIDS Drugs and Blood
Products)
    
    Table #19  Part S2, Line 18
    
    Pharmacy
    
    Table #20  Part CReimbursable HIV/AIDS Drugs
and Blood Products
    
    Table #19  Part S2, Line 19
    
    Pharmacy
    
    Table #20  Part COutpatient Hospital
(excludes ER)
    
    Table #19  Part S2, Line 12
    
    Other
    
    Table #20  Part DOther Professional Services
    
    Table #19  Part S2, Line 13
    
    Other
    
    Table #20  Part DEmergency Room
    
    Table #19  Part S2, Line 14
    
    Other
    
    Table #20  Part DDME/Medical Supplies
    
    Table #19  Part S2, Line 15
    
    Other
    
    Table #20  Part DProsthetics and Orthotics
    
    Table #19  Part S2, Line 16
    
    Other
    
    Table #20  Part DDental
    
    Table #19  Part S2, Line 17
    
    Other
    
    Table #20  Part DHome Health, Hospice,. &PDN
    
    Table #19  Part S2, Line 20
    
    Other
    
    Table #20  Part DTransportation
    
    Table #19  Part S2, Line 21
    
    Other
    
    Table #20  Part DLab & X-ray
    
    Table #19  Part S2, Line 22
    
    Other
    
    Table #20  Part DVision Care including 
Eyeglasses
    
    Table #19  Part S2, Line 23
    
    Other
    
    Table #20  Part DMental Health/ Substance Abuse
    
    Table #19  Part S2, Line 24
    
    Other
    
    Table #20  Part DEPSDT Medical & PDN
    
    Table #19  Part S2, Line 26
    
    Other
    
    Table #20  Part DEPSDT Dental
    
    Table #19  Part S2, Line 27
    
    Other
    
    Table #20  Part DFamily Planning
    
    Table #19  Part S2, Line 28
    
    Other
    
    Table #20  Part DOther 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




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 Do
not
      The amount in each column on this line must be updated each period.
 Date Effective: July 1, 20076
    
    12




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
   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




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 , U,
V
 Submission Due at Each Quarter End
  not
required
 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.
  DRG Codes:
 § or
 DRG Codes only with specific ICD-9 Diagnosis Codes:
 §
 Date Effective: July 1, 2007
6
    
    14




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 §
    
    DRG codes 460 through 469 plus one of the following ICD-9 codes, V27-V27.9
 DYFS
   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
    Date Effective: July 1, 2007
6
    
    15




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
   
 Date Effective: July 1, 20076
    
    16




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
  Revenue
   1
   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).
 f
 2d, 2e,
      Expenses
 Medical and Hospital
      Date Effective: July 1, 20076
    
    18




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
                Date Effective: July 1, 20076
    
    19




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
  
 Administration
 designated forms for the MCSA
populations (Parts U and V) and Except
for the MCSA rate cell groupings, t 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.
       Date Effective: July 1, 20076
    
    20




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
         a
reconciliation reconciliation
 Date Effective: July 1, 20076
    
    21




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
  Example for 12 Month Ending
    
    Example using06/30/20xx Reporting Period
    
    DollarsClaims 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
    
    - $
    450,000Claims incurred in the period
    
    Claims incurred in 12 Month
ending 06/30/20xx
    
    $
    50,050,000
 Date Effective: July 1, 20076
    
    22




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
  Incurred in 12Month Ending
    
    Incurred in06/30/20xx
    
    03/31/20XX & Prior
    
    TotalClaims 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
    
    
    $
    450,000Recognized in Qtr
Ending 06/30/20xx
    
    $
    50,450,000
    
    
    -$
    400,000
    
    
    $
    50,050,000
 #2S 19S2 3- 12
    Date Effective: July 1, 20076
    
    23




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 Submission Due at Each Quarter End
 2
  §
    
    Live births
 
    
    Cesarean Section deliveries
    
    Vaginal deliveries
 §
    
    Non-live births
  Rate Cell Grouping
    
    Geographic AreaAFDC/NJCPW/NJ KidCare A
    
    NorthernAFDC/NJCPW/NJ KidCare A
    
    CentralAFDC/NJCPW/NJ KidCare A
    
    SouthernAll Other
    
    Statewide
  
 2
    
    Still or live births at or after the thirteenth week of gestation, excluding
elective abortions. Date Effective: July 1, 20076
    
    24




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 Submission
Due at Each Quarter End
  Table 4A
 manually submitted
    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.
     Date Effective: July 1, 20076
    
    25




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
         Table 4B
 electronically submitted
   Date Effective: July 1, 20076
    
    26




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
             Date Effective: July 1, 20076
    
    27




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
   Date Effective: July 1, 20076
    
    28




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 Submission Due at Each Quarter End
  Date Effective: July 1, 20076
    
    29




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 Submission Due at Each Quarter End
  §
    
    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.
   Date Effective: July 1, 20076
    
    30




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 Annual Submission Due at September 30 Quarter End
   the first fiscal quarter
ending annual supplemental (September 30) Besides quarter ending September 30, this information is not required for any other quarter ending
time periods.
  first fiscal quarter
ending annual supplemental (September 30) Besides quarter ending September 30, this information is not required for any other quarter ending
time periods.
  Date Effective: July 1, 20076
    
    31




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 Annual Submission Due at September 30 Quarter End
    §
    
    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.
 Note: If there are no changes since last years submission, the
Contractor shall indicate as such and provide no additional information.
  Note: If there are no changes since
last years submission, the Contractor shall indicate as such
and shall not provide the contracts.
 §
    
    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.
   Administrative Cost Detail
  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.
    Date Effective: July 1, 20076
    
    33




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
     §
 
    
    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




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
  IBNR Methodology
   §
    
    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
      Case Basis Method
  Date Effective: July 1, 20076
    
    37




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 Average Cost Method
  PMPM Averages
  Per Diem or Per Service Averages
  Lag Tables
  Date Effective: July 1, 20076
    
    38




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
  Date Effective: July 1, 20076
    
    39




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
  Key Utilization Definitions
 TYPE OFCATEGORY OF
    
    
    
    UTILIZATION/SERVICE MEASURE
    
    MEASURE
    
    PROXY FOR
    
    DEFINITIONSInpatient 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 OFCATEGORY OF
    
    
    
    UTILIZATION/SERVICE MEASURE
    
    MEASURE
    
    PROXY FOR
    
    DEFINITIONSPrimary 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 OFCATEGORY OF
    
    
    
    UTILIZATION/SERVICE MEASURE
    
    MEASURE
    
    PROXY FOR
    
    DEFINITIONSPharmacy
    
    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
  Managed Care Category of Service Codes
  Date Effective: July 1, 20076
    
    43




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
  Report Forms
 12-Month Period End Reports Due Each Quarter
  §
    
    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




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##### 



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 PaymentsExcluding MCSA Populations
 Date Effective: July 1, 20076
    
    45




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
 
    
    Part B: Lag Report for Physician PaymentsExcluding MCSA Populations
    
    Part C: Lag Report for Pharmacy PaymentsExcluding MCSA Populations
    
    Part D: Lag Report for Other Medical Payments
 §
    
    General Ledger for period ending June 30Excluding MCSA Populations 
Part E: Lag Report for MCSA Populations§
    
    Notes to Financial Reports
 Date Effective: July 1, 20076
    
    46




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##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
  Certification Statement at Each Quarter End
   Certification Statement  Annual Reports
   Date Effective: July 1, 20076
    
    47




---



##### 



Contractor Financial Reporting Manual
    
    State of New Jersey
  OF
 
  TO THE
 NEW JERSEY DEPARTMENT OF HUMAN SERVICES 
DIVISION OF MEDICAL ASSISTANCE AND
HEALTH SERVICES
 FOR THE PERIOD ENDED
 
 (Month/Day/Year)
 Name of PreparerTitlePhone Number
 Please check which tables are included with this packet:
 0 Table 4
    
    0 Table 19A-R, S2, S31
    
    0 Notes
0 Table 200 Table 7
    
    0 Table 20 A-DE14
    
    0 Table 210 Table 10
    
    0 Table 2119
  Date
    
    Chief Financial Officer
    
    Signature
 Date Effective: July 1, 20076
    
    48




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##### 



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 PreparerTitlePhone Number
 Please check which tables are included with this packet:
 0 Table 11 A
    
    0 Table 14 B
    
    0 Table 20 A-DE0 Table 11 B
    
    0 Table 14 C
    
    0 GL at 06/300 Table 14 A
    
    0 Table 19A-R, S3
    
    0 Notes
  Date Effective: July 1, 20076
    
    49




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##### 



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
  Date Effective: July 1, 20076
    
    51




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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 -BloodOnly 5 rows provided
    
    
    
    
    
    Capitation
    
    Maternity
    
    Products
    
    EPSDT(insert additional row if needed)
    
    Date
    
    Cheek #
    
    Premiums
    
    Reimbursement
    
    Reimbursement
    
    Premiums1
    
    
    
    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 Premiums9
    
    Other10
    
    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
  FOR THE SFY ENDING 6-30-07
    
    
    
    
    
    FOR(HMO Name)
  Twelvemonth
    
    Twelve month
    
    Twelve-MonthLag Report
    
    Table #19 - Parts S1& $2
    
    Paid Claim
    
    IBNR & RBUC
    

Total $Lag
    
    
    
    
    
    
    
    
    
    
    
    Table #19 - Part
    
    
    
    
    
    Table #19 - Part
    
    
    
    
    
    Table #19 - PartReport #
    
    Medical Cost Grouping
    
    Line #
    
    Consolidated Category of Service
    
    Lag Report
    
    S2
    
    Difference1
    
    Lag Report
    
    S2
    
    Difference1
    
    Lag Report
    
    S2
    
    Difference1Table #20
    
    Inpatient Hospital
    
    
    9
    
    
    Inpatient Hospital
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ - Part ATable #20
    
    Physician
    
    
    10
    
    
    Primary Care
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ - Part B
    
    
    
    
    11
    
    
    Physician Specially ServicesTable #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 Services14
    
    
    Emergency Room15
    
    
    DMB/Medical Supplies16
    
    
    Prosthetics & Orthotics17
    
    
    Covered DentalTable #20
    
    Other
    
    
    20
    
    
    Home Health, Hospice, & PDN- Part D
    
    
    
    
    21
    
    
    Transportation
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 
    
    $ 22
    
    
    Lab & X-ray23
    
    
    Vision Care including Eyeglasses24
    
    
    Mental Health/Substance Abuse26
    
    
    EPSDT Medical & PDN27
    
    
    EPSDT Dental -EPD28
    
    
    Family Planning29
    
    
    Other MedicalTotal
    
    
    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.




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##### 



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)
  Incurred in Twelve Months Prior to1 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.




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FOR
MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
 Table #11A  Cost & Utilization by AFDC Rate Cell Grouping
  FOR THE STATE FISCAL-ENDING AT 09/30:(HMO Name)




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FOR
MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
 Table #11A  Cost & Utilization by AFDC Rate Cell Grouping
  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 SubmissionInpatient Hospital
    
    Inpatient HospitalPrimary Care
    
    Primary Care ServicesPhysician Specialty Services
    
    Physician Specialty ServicesOutpatient Hospital
    
    Outpatient FacilityOther Professional Services
    
    All Other Practitioners and ServicesEmergency Room
    
    Emergency RoomDME/Medical Supplies
    
    DME/Medical Supplies & Orthotics/ProstheticsProsthetics & Orthotics
    
    DME/Medical Supplies & Orthotics/ProstheticsDental
    
    DentalPharmacy
    
    PharmacyHome Health Care
    
    Home Health CareTransportation
    
    TransportationLab & X-ray
    
    Laboratory & RadiologyVision Care
    
    All Other Practitioners and ServicesMenial Health/Substance Abuse
    
    All Other Practitioners and ServicesOther Medical
    
    All Other Practitioners and Services




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Table
#11B- Cost  Utilization by FamilyCare Parents Rate Cell Grouping
  FOR
THE STATE FISCAL-ENDING AT 09/30:(HMO Name)
 TransportationPrevious
    
    Previous
    
    Previous
    
    Current
    
    Current
    
    CurrentSFY-and @ 09/30
    
    SFY-and @ 09/30
    
    SFY-and @ 09/30
    
    SFY-and @ 09/30
    
    SFY-and @ 09/30
    
    SFY-and @ 09/30COA
    
    Member Months
    
    Incurred $
    
    Units
    
    Member Months
    
    Incurred $
    
    Units1
    
    
    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 ServicesPrevious
    
    Previous
    
    Previous
    
    Current
    
    Current
    
    CurrentSFY-and @ 09/30
    
    SFY-and @ 09/30
    
    SFY-and @ 09/30
    
    SFY-and @ 09/30
    
    SFY-and @ 09/30
    
    SFY-and @ 09/30COA
    
    Member Months
    
    Incurred $
    

Services
    
    Member Months
    
    Incurred $
    
    Services1
    
    
    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
    
    
    DifferenceNew 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 SubmissionInpatient Hospital
    
    Inpatient HospitalPrimary Care
    
    Primary Care ServicesPhysician Specialty Services
    
    Physician Specialty ServicesOutpatient Hospital
    
    Outpatient FacilityOther Professional Services
    
    All Other Practitioners and ServicesEmergency Room
    
    Emergency RoomDME/Medical Supplies
    
    DME/Medical Supplies & Orthotics/ProstheticsProsthetics & Orthotics
    
    DME/Medical Supplies & Orthotics/ProstheticsDental
    
    DentalPharmacy
    
    PharmacyHome Health Care
    
    Home Health CareTransportation
    
    TransportationLab & X-ray
    
    Laboratory & RadiologyVision Care
    
    All Other Practitioners and ServicesMental Health/Substance Abuse
    
    All Other Practitioners and ServicesOther Medical
    
    All Other Practitioners and Services




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Table #14A  Member Months & Income Statement
 FOR THE STATE FISCAL-ENDING AT 09/30:(HMO Name)
  Current Calender Year YTDPrevious 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 Months1
    
    Medicaid/NJ
FamilyCare At-Risk Population=
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    23
    
    Total
Medicaid/NJ FamilyCare Member Months
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    All Other Lines of Business4
    
    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 YearRevenue
    
    Medical Expenses
    
    Administration Expenses1
    
    
    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 Expenses1
    
    
    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.




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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 EndProvider at Full-Risk
    
    Total Amount Reported as
    
    Reported Medical Expense
    
    Total Amount Reported as
    
    Reported Administrative ExpenseCovered Series
    
    (Yes or No)
    
    Medical Expense
    
    Line # on Report 2, Table 19
    
    Administrative Expense
    
    Line # on Report 2, Table 191
    
    
    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.




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




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NOTES TO FINANCIAL REPORTS
 FOR
THE SFY ENDING 6-30-08
    
    
    FOR(HMO Name)
  Table #11 Part A  Cost and Utilization by AFDC Rate Cell Grouping Part B  Cost and Utilization by FamilyCare Parents/Adults Rate Cell GroupingTable #14 Part A  Member Months and Income Statement Part B  Administrative Cost Detail Part C  Capitation ArrangementsTable #19 Parts A-S2  Income Statement By Rate Cell GroupingTable #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




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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 - BloodOnly 5 rows provided
    
    
    
    
    
    Capitation
    
    Maternity
    
    Products
    
    EPSDT(insert additional rows if needed)
    
    Date
    
    Check #
    
    Premiums
    
    Reimbursement
    
    Reimbursement
    
    Premiums1
    
    
    
    
    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 Premiums9
    
    
    Other10
    
    
    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-MonthLag Report
    
    
    
    
    
    Table #19 - Part $1 & 32
    
    Paid Claims
    
    
    IBNR & RBUC
    
    
    Total $Lag
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Table #19 -Part
    
    
    
    
    
    
    
    
    
    
    Table #19 -PartReport 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 1Table #20 -Part A
    
    Inpatient Hospital
    
    
    9
    
    
    Inpatient Hospital
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    Table #20 -Part B
    
    Physician
    
    
    10
    
    
    Primary Care11
    
    
    Physician Specialty Services
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    Table #20 -Part C
    
    Pharmacy
    
    
    18
    
    
    Pharmacy (not to include Reimbursable
HIV/AIDS
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    19
    
    
    Reimbursable HIV/AIDS Drugs and
Blood Products12
    
    
    Outpatient Hospital (excludes ER)13
    
    
    Other Professional Services14
    
    
    Emergency Room15
    
    
    DME/Medical Supplies16
    
    
    Prosthetics & Orthotics17
    
    
    Covered Dental20
    
    
    Home Health, Hospice, & PDNTable #20 -Part D
    
    Other
    
    
    21
    
    
    Transportation
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    22
    
    
    Lab & X-ray23
    
    
    Vision Care including Eyeglasses24
    
    
    Mental Health/Substance Abuse26
    
    
    EPSDT Medical & PDN27
    
    
    EPSDT Dental -EPD28
    
    
    Family Planning29
    
    
    Other MedicalTotal
    
    
    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 to1
    
    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 Services 1, 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 & OtherNorth
    
    
    Central
    
    
    South
    
    

Dual Eligibles - DDDTwelve-Month
    
    
    
    
    
    
    Twelve-Month
    
    
    
    
    
    
    Twelve-Month
    
    
    
    
    
    
    Twelve-MonthExpenses
    
    Twelve-Month $
    
    
    Units
    
    
    Twelve-Month $
    
    

Units
    
    
    Twelve-Month $
    
    
    Units
    
    
    Twelve-Month $
    
    
    UnitsEXPENSES:MEDICAL & HOSPITAL NON-STATE PLAN SERVICES1
    
    $
    
    
    
    
    
    
    
    $
    
    
    
    
    
    
    
    $
    
    
    
    
    
    
    
    $
    
    
    
    
    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 SERVICES13 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).




---



##### 



FOR
MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
 Table
#19  Part T  Non-State Plan Service Expenses by Rate Cell Group
 Non-State
Plan Services 1, 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
    
    
    DDDTwelve-Month
    
    
    
    
    
    
    Twelve-Month
    
    
    
    
    
    
    Twelve-Month
    
    
    
    
    
    
    Twelve-MonthExpanses
    
    Twelve-Month $
    
    
    Units
    
    
    Twelve-Month $
    
    
    Units
    
    
    Twelve-Month $
    
    
    Units
    
    
    Twelve-Month $
    
    

UnitsEXPENSES:MEDICAL & HOSPITAL NON-STATE PLAN SERVICES1
    
    $
    
    
    
    
    
    
    
    $
    
    
    
    
    
    
    
    $
    
    
    
    
    
    
    
    $
    
    
    
    
    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 SERVICES13 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).




---



##### 



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&CTwelve-MonthExpanses
    
    Twelve-Month $
    
    
    UnitsEXPENSES:MEDICAL & HOSPITAL NON-STATE PLAN SERVICES1
    
    $
    
    
    
    
    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 SERVICE12 TOTAL ADMINISTRATION
    
    $
    
    
    
    
    TOTAL EXPENSES FOR NON-STATE PLAN SERVICES13 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).




---



##### 



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 & OtherNJ KidCare D
    
    
    Adults
    
    
    Dual Eligibles- AIDSTwelve-Month
    
    
    
    
    
    
    Twelve-Month
    
    
    
    
    
    
    Twelve-MonthExpenses
    
    Twelve-Month $
    
    
    Units
    
    
    Twelve-Month $
    
    
    Units
    
    
    Twelve-Month $
    
    
    UnitsEXPENSES:MEDICAL & HOSPITAL NON-STATE PLAN SERVICES1
    
    $
    
    
    
    
    
    
    
    $
    
    
    
    
    
    
    
    $
    
    
    
    
    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 SERVICES13 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).




---



##### 



FOR
MEDICAID/NJ FAMILYCARE
MANAGED CARE REPORTING ONLY
 Table #19  Part T  Non-State Plan Service Expenses by Rate Cell Group
 Non-State
Plan Services 1, 2
 FOR THE TWELVE MONTHS ENDING  &n
bsp;
 Non-ABD-AIDS
    
    
    Maternity
    
    

NewbornsTwelve-Month
    
    
    
    
    
    
    Twelve-Month
    
    
    
    
    
    
    Twelve-MonthExpenses
    
    Twelve-Month $
    
    
    Units
    
    
    Twelve-Month $
    
    

Units
    
    
    Twelve-Month $
    
    
    UnitsEXPENSES:MEDICAL & HOSPITAL NON-STATE PLAN SERVICES1
    
    $
    
    
    
    
    
    
    
    $
    
    
    
    
    
    
    
    $
    
    
    
    
    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 SERVICES13 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).




---



##### 



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 PeriodLive Births
    
    
    
    
    
    
    Newborn
    
    
    Ratio MMs /C-Section
    
    
    Vaginal
    
    
    Non-live Births
    
    
    Member Mos
    
    
    Births 2NORTHERN REGIONAFDC/NJCPW/NJ KidCare ACENTRAL REGIONAFDC/NJCPW/NJKidCare ASOUTHERN REGIONAFDC/NJCPW/NJ KidCare ASTATEWIDE All OtherTOTAL
  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.




---



##### 








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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 ClaimsTable #7-Parts A-C  Stop Loss SummaryTable #10-Third Party LiabilityTable #19- Parts A-V  Income Statement By Rate Cell GroupingTable #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 PaymentsTable #21- Maternity Outcome Counts




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B.4.11 Special Child Health Services Network
  socasemg.htm




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SECTION C
CAPITATION RATES
 C-1




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SFY08 Rates  Version 1.3a
Contract Period: 07/01/07  06/30/08
 Category
    
    Age/Sex
    
    Northern
    
    Central
    
    Southern
    
    StatewideAFDC / DYFS/ KidCare A / New Jersey Care Children
    
    NewbornAFDC / DYFS / KidCare A / New Jersey Care Children
    
    75 dys - 2yrs M&FAFDC / DYFS / KidCare A / New Jersey Care Children / NJCPW
    
    2 - 20.99 M&FAFDC / NJCPW
    
    21 - 44.99 FemaleAFDC
    
    21 - 44.99 MaleAFDC / NJCPW
    
    45 + M&FAged with Medicare
    
    AllBlind/Disabled with Medicare and Other Dual Eligibles
    
    < 45 M&FBlind/Disabled with Medicare and Other Dual Eligibles
    
    45+ M&F
    
    *****REDACTED*****Maternity
    
    AllABD-DDD with Medicare and Other Dual Eligibles
    
    AllABD (including AIDS & DDD) without Medicare1
    
    AllNon ABD-DDD
    
    AllKidCare B&C
    
    NewbornKidCare B&C
    
    < 2 M&FKidCare B&C
    
    YouthKidCare D
    
    NewbornKidCare D
    
    < 2 M&FKidCare D
    
    YouthFamilyCare Parents 0-200% / FamilyCare Adults & Hlth Access / Adult Restricted Aliens
    
    < 45 FemaleFamilyCare Parents 0-200% / FamilyCare Adults & Hlth Access / Adult Restricted Aliens
    
    < 45 MaleFamilyCare Parents 0-200% / FamilyCare Adults & Hlth Access / Adult Restricted Aliens
    
    45+ M&FAIDS-ABD with Medicare and Other Dual Eligibles
    
    AllAIDS-Non-ABD
    
    AllAIDS-ABD with Medicare and Other Dual Eligibles DDD (incl. Behavioral Health Add-On)
    
    AllAIDS-Non-ABD DDD (including Behavioral Health Add-On)
    
    All




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(STATE OF NEW JERSEY LOGO)Jon S. CorzineGovernor
    
    State of New JerseyDepartment of Human ServicesDivision of Medical Assistance and Health Services

P.O. Box 712
Trenton, NJ 08625-0712
Telephone 1-800-356-1561
    
    Jennifer VelezActing Commissioner
 JohnR. GuhlDirector
  
    Sincerely,-s- Jill Simone, MDJill Simone, MDExecutive DirectorOffice of Managed Health Care
  c:
    
    John Koehn
Jennifer Langer
 New Jersey Is An Opportunity Employer




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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
  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.




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Medical Cost Ratio Damages 7/2007
   AMERIGROUP
    
    
    
    State of New JerseyNew Jersey, Inc.
    
    
    
    Department of Human ServicesBY:
    
    /s/ Peter D. Haytaian
    
    
    
    BY:
    
    /s/ John R. GuhlPeter D. Haytaian
    
    
    
    
    
    John R. GuhlTITLE: President & CEO
    
    
    
    TITLE: Director, DMAHSDATE: May 17, 2007
    
    
    
    DATE:APPROVED AS TO FORM ONLYAttorney GeneralState of New JerseyBY:Deputy Attorney GeneralDATE:




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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).
 apply damages
 8.4.2 RESERVED
 8.4.3 DAMAGES DAMAGESRECOVERY OF UNDEREXPENDITURE
 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.
 penalty is
applied, recovery is made,
 8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS