##### 








---



##### 



1.
    
    Article 1, Definitions section  for the following definition:
 1.
    
    Capitation Summary Record (new definition)
  2.
    
    Article 2, Conditions Precedent Sections H and K.1(b) shall be amended as reflected
in Article 2, Sections H and K.1(b) attached hereto and incorporated herein.3.
    
    Article 3, Managed Care Management Information System, Sections 3.2(C); 3.2.1(B);
3.2.5; 3.3.1(A); 3.3.3(A); 3.4.4 (new); 3.9(A); 3.9(C); 3.9.1(A) (new); 3.9.1(B); 3.9.1(C)
(deleted); 3.9.2(A); 3.9.2(B); 3.9.3(C); 3.9.3(D) (deleted), re-number remaining; 3.9.3(E)
(new); 3.9.4(A) and 3.9.4(B) shall be amended as reflected in Article 3, Sections 3.2(C),
3.2.1(B), 3.2.5, 3.3.1(A), 3.3.3(A), 3.4.4, 3.9(A), 3.9(C), 3.9.3(D), 3.9.3(E), 3.9.4(A)
and 3.9.4(B) attached hereto and incorporated herein.4.
    
    Article 4, Provision of Health Care Services Sections 4.1.1(G)4 (new); 4.1.2(A)18;
4.2.1(K)3 (new); 4.2.6(A)6 (deleted); 4.2.6(B)1(c); 4.2.6(B)7(f); 4.2.6(B)7(f)ii. 1);
4.3.3(A); 4.5.2(B); 4.5.4(B); 4.6.1(C)8 (new) 4.6.2(P); 4.6.2(X) (new) (deleted previous);
4.6.2(AA)1 (new); 4.6.4(C); 4.6.4(C)6(c); 4.6.4(C)6(d); 4.7.1(K) (new); 4.7.2(A)1; 4.8.3;
4.8.3(A), 4.8.3(A)3 (new); 4.8.3(C)1(new); 4.8.7(D) and 4.8.8(G)1 shall be amended as
reflected in Article 4, Sections 4.1.1(G)4, 4.1.2(A)18, 4.2.1(K)3, 4.2.6(A)6, 4.2.6(B)1(c),
4.2.6(B)7(f)ii.1), 4.3.3(A), 4.5.2(B), 4.5.4(B), 4.6.1(C)8, 4.6.2(P), 4.6.2(X), 4.6.2(AA)1,
4.6.4(C), 4.6.4(C)6(c), 4.6.4(C)6(d), 4.7.1(K), 4.7.2(A)1, 4.8.3, 4.8.3(A), 4.8.3(A)3,
4.8.3(C)1, 4.8.7(D) and 4.8.8(G)1 attached hereto and incorporated herein.5.
    
    Article 5, Enrollee Services Sections 5.8.2(S); 5.8.2(NN); 5.10.2(A)1; 5. 14.2(B)8
and 5.15.3(D) shall be amended as reflected in article 5, Sections 5.8.2(S), 5.8.2(NN),
5.10.2(A)1, 5.15.2(B)8 and 5.15.3(D) attached hereto and incorporated herein.6.
    
    Article 7, Terms and Conditions Sections 7.3(A); 7.16.4; 7.16.5; 7.16.7(B)2 (new);
7.16.7(B)3 (new); 7.26(F); 7.27.1(B) and 7.38.2(A)1 shall be amended as reflected in
Article 7,




---



##### 



Sections 7.3(A), 7.16.4, 7.16.5, 7.16.7(B)2, 7.16.7(B)3, 7.26(F), 7.27.1(B) and
7.38.2(A)1 attached hereto and incorporated herein.7.
    
    Article 8, Financial Provisions, Sections 8.4.1(A); 8.4.1(A)1; 8.4.1(A)2; 8.4.1(A)3;
8.5.2.1; 8.5.2.4; 8.5.4 (Heading) 8.5.8 (deleted) (Reserved) and 8.7(H)3 shall be amended
as reflected in Article 8, Sections 8.4.1(A), 8.4.1(A)1, 8.4.1(A)2, 8.4.1(A)3, 8.5.2.1,
8.5.2.4, 8.5.4, 8.5.5 and 8.7(H)3 attached hereto and incorporated herein.8.
    
    Appendix, Section A, Reports
    
    A.3.1  Reserved (deleted previous);
    
    A.4.1  Provider Network File: Attachment A, #13, #18, #19, #20, #21, #22, #33, #36
(new); Attachment B, #16, #18 (new); Attachment E (revised);
    
    A.4.3  Network Accessibility Analysis for New Jersey Medicaid/NJ FamilyCare, B.3 #1, 2,
3, 8, 10, 11, 12 (footnote added to define na);
    
    A.7.1  Certifications, A.7.1(A); A.7.1(B); A.7.1(C) revised language; A.7.1(E) (new);
    
    A.7.2  Fraud and Abuse (deleted Section C);
    
    A.7.3  Table 1; (revised);
    
    A.7.4  Reserved (deleted previous);
    
    A.7.6  Reserved (Table 4 moved to HMO Financial Reporting Manual);
    
    A.7.7  Table 5; narrative revised;
    
    A.7.8  Table 6: 6a, 6b, 6d and 6e moved to HMO Financial Reporting Manual; 6c renamed;
    
    A.7.9  Reserved (Table 7 moved to HMO Financial Reporting Manual);
    
    A.7.10  Reserved (deleted previous);
    
    A.7.11  Table 9: Semi-Annual Utilization and Medical Expenditure Summary (new),
(deleted previous);
    
    A.7.13  Reserved (deleted previous);
    
    A.7.16  Reserved (deleted previous);
    
    A.7.18  Table 16 (revised);
    
    A.7.21  HMO Financial Reporting Manual for Medicaid/NJ FamilyCare Rate Cell Grouping
Costs, (revised) (moved from B.7.3, incorporates revised Table 19;




---



##### 




    
    A.7.22  Reserved (Table 20 moved to Financial Reporting Manual);
    
    A.7.23  Reserved (Table 21 moved to Financial Reporting Manual);
    
    A.8.3  Estate Referral Form  (report separated from previous A.8.2)
  9.
    
    Appendix, Section B, Reference Materials
    
    B.3.1  Reserved (deleted previous);
    
    B.3.2  Data Files Resources Guide (new) (deleted previous);
    
    B.4.6  School-Based Youth Services Programs  list replaced with web site address;
    
    B.4.7  Local Health Departments  list replaced with web site address;
    
    B.4.9  Mental Health/Substance Abuse Screening Tool
    
    B.4.11Special Child Health Services Network  list replaced with web site address;
    
    B.4.13  Statewide Family Centered HIV Care network (Ryan White Title IV)  list
replaced with web site address;
    
    B.5.2  Cost sharing Requirements for NJ FamilyCare Plan H:#4 deleted, renumber remaining;
    
    B.57.3  Reserved (previous moved to A.7.21), and
    
    B.7.4  Reserved
  10.
    
    Appendix, Section C, Capitation Rates shall be revised as reflected in SFY 2005
Capitation Rates attached hereto and incorporated herein.11.
    
    Appendix, Section E, Managed Care Service Administrator (MCSA) Administrative Fees
shall be revised as reflected in the SFY 2005 Administrative Fees attached hereto and
incorporated herein.




---



##### 



12.
    
    All other terms and conditions of the October 1, 2000 contract and subsequent amendments
remain unchanged except as noted above.
  Amerigroup
New Jersey, Inc
    
    State of New Jersey
Department of Human ServicesBY:
    
    /s/      TBD
    
    BY:

    
    /s/ Ann Clemency KohlerTITLE: President and CEO
    
    TITLE: Director, DMAHSDATE: /s/ April 28, 2005
    
    DATE: /s/ 5/2/05APPROVED AS TO FORM ONLY
Attorney General
State of New JerseyBY:
    
    /s/      TBDDeputy Attorney GeneralDATE: /s/ 4/29/05




---



##### 



Automatic Assignment
 Basic Service Area
 Beneficiary
 Benefits Package
 Bilingual Multilingual
 Bonus
 Capitated Service
 Capitation
 Capitation Payments




---



##### 



Capitation Rate
 Capitation Summary Record




---



##### 




    
    The region and names of the counties targeted for expansion;
    
    Anticipated dates of the submission of the COA modification to DOBI and DHSS (with
copies to DMAHS);
    
    Anticipated date of approval of the COA;
    
    Anticipated date for full operations in the region;
    
    Anticipated date for initial beneficiary enrollment in each county
 that June 30, 2004




---



##### 



1.
    
    A contractor shall establish and maintain:
 a.
    
    An office in New Jersey, andb.
    
    Premium and claims accounts in a New
Jersey qualified bank with a principal office in New Jersey as
approved by DOBI.
 2.
    
    The contractor shall have a fiscally sound operation as demonstrated
by:
 a.
    
    Maintenance of a minimum net worth in
accordance with DOBI requirements (total line of business) and the
requirements outlined in G and J above and Article 8.2.b.
    
    Maintenance of a net operating surplus
for Medicaid/NJ FamilyCare line of business. If the contractor fails
to earn a net operating surplus during the most recent calendar year
or does not maintain minimum net worth requirements on a quarterly
basis, it shall submit a plan of action to DMAHS within the time
fram especified by the Department. The plan is subject to the
approval of DMAHS. It shall demonstrate how and when minimum net
worth will be replenished and present marketing and financial
projections. These shall be supported by suitable back-up material.
The discussion shall include possible alternate funding sources,
including invoking of corporate parental guarantee. The plan will
include:
 i.
    
    A
detailed marketing plan with enrollment
projections for the next two years.ii.
    
    A
projected balance sheet for the next two years.iii.
    
    A
projected statement of revenues and expenses on an
accrual basis for the next two years.




---



##### 



iv.
    
    A
statement of cash flow projected for the next two
years.v.
    
    A
description of how to maintain capital
requirements and replenish net worth.vi.
    
    Sources and timing of capital shall be
specifically identified.
 3.
    
    The contractor may be required to obtain prior to this contract and
maintain Stop-Loss insurance, pursuant to provisions in Article 8.3.2.




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##### 








---



##### 



A.
    
    Capture and maintain contractor enrollment data electronically.B.
    
    Provide information so that the contractor can send plan materials and
information to enrollees.C.
    
    Capture electronically the Primary Care Provider (PCP) selections name
provided by enrollees as well as enrollee health profiles from the Health Benefits
Coordinator and/or the State.D.
    
    Provide contractor enrollment and Medicaid information to providers.E.
    
    Maintain an enrollee complaint and grievance tracking system for
Medicaid and NJ FamilyCare enrollees.F.
    
    Produce the required enrollee data reports.
    a weekly file (the managed care register files; See section B.3.2 of the
Appendices)




---



##### 



4.
    
    The system shall capture and maintain all of the data elements provided
by the Department on the weekly update files.




---



##### 



2.
    
    Generation of correspondence to enrollees based on variable criteria., including PCP and
demographic information.




---



##### 



The contractor shall provide the State with a monthly file of enrollees (see section A.3.1 of the
Appendices). The States fiscal agent will reconcile this file with the States Recipient File. The
contractor shall provide for reconciling any differences and taking the appropriate corrective
action




---



##### 



and/or




---



##### 








---



##### 








---



##### 








---



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##### 



via diskette, tape
or electronic transmission, Divisions Electronic Media Claims (EMC) Manual will be distributed with
regular updates www.wpc-edi.com/hipaa www.njmmis.com
     with dates of service on or after
October 16, 2003.
  and no more frequently than
monthly




---



##### 



All Types of Claims. The contractor shall
capture all required encounter data elements for each of the eight claim types: Inpatient,
Outpatient, Professional, Home Health, Transportation, Vision, Dental, and Pharmacy.
 are provided in Section A.7.11. note that New Jersey specific Medicaid
codes are required in some fields. Provides shall be identified using the providers EIN or
tax-identification number.
 Contractor Encounter. The contractor shall submit encounter data for claims and encounter
received by the contractor. The contractor shall identify a capitated arrangement versus a fee for
service arrangement for its network providers. For noncapitated arrangements, the contractor shall
report the actual payment made to the provider for each encounter. For capitated arrangements the
contractor may reports a zero payment for each encounter. However, a monthly Capitation Summary
Record shall be required for each provider type, beneficiary capitation category, and service
month combination. The specifications for the submission of monthly capitation summary records is
further detailed in the EMC Manual issued by the Division.
  EMC Manual issued by the
Division.




---



##### 



via diskette, tape, or electronic
transmission Electronic Media Claims Manual issued by the Division
 The contractor shall be responsible for passing a two-phased test for each encounter claim type.
The first phase requires that each submitted file follows the prescribed format that header and
trailer records are present and correctly located within the file, and that the key fields are
present. The second phase requires that the required data elements are present and properly valued
 Following each submission and error report will be forwarded to the contractor identifying the file
and record location of each error encountered for both testing phases. The contractor shall analyze
the report, complete the necessary corrections, and re-submit the encounter data test file(s)




---



##### 



Two-Phased The first phase requires each submitted file follow the prescribed format, that header and trailer
records are present and correctly located within the file and that the key fields are present. The
second phase requires that the required data elements are present and
properly valued.
 D. Phase One Errors. If all or part of a production encounter file(s) rejects during phase one, an
error report will be forwarded to the contractor identifying the file and record location of each
error encountered. The contractor shall analyze the report, complete the necessary corrections, and
re-submit the rejected encounter production data within forty-five (45) calendar days from the
date the contractor receives the notice of error(S).
 E.
   specifications listed in the Divisions EMC Manual The Remittance Advice File is produced on magnetic tape and contains all submitted




---



##### 



encounter
data that passed phase one testing.
  as full record adjustments the Divisions
EMC Manual




---



##### 








---



##### 



19.
    
    Hospice Services  are covered in the community as well as in institutional settings.
Room and board services are included only when services are delivered in an institutional
(non-private residential) setting.20.
    
    Durable Medical Equipment (DME)/Assistive Technology Devices in accordance with
existing Medicaid regulations.21.
    
    Medical Supplies22.
    
    Prosthetics and Orthotics including certified shoe provider23.
    
    Dental Services24.
    
    Organ Transplants  includes donor and recipient costs. Exception: the contractor will
not be responsible for transplant-related donor and recipient inpatient hospital costs for
an individual placed on a transplant list while in the Medicaid FFS program prior to
initial enrollment into the contractors plan.




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##### 



25.
    
    Transportation Services for any contractor-covered service or non-contractor covered
service including ambulance, mobile intensive care units (MICUs) and invalid coach
(including lift equipped vehicles)26.
    
    Post-acute Care




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##### 








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##### 



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
from problems identified through the EPSDT exams. Reasonable outreach shall be
documented and must consist of: mailers, certified mail as necessary; use of MEDM
system provided by the State; and contact with the Medical Assistance Customer Center
(MACC), DDD, or DYFS regional offices in the case of DYFS enrollees to confirm
addresses and/or to request assistance in locating an enrollee.5.
    
    PCP Notification. The contractor shall provide each PCP, on a calendar quarter
basis, as list of the PCPs enrollees who have not had an encounter during the past
year and/or who have not complied with the EPSDT periodicity and immunization schedules
for children. Primary care sites/PCPs and/or the contractor shall be required to
contact these enrollees to arrange an appointment. Documentation of the outreach
efforts and responses is required.
 4.2.6.A.6. Reporting Standards. The contractor shall submit quarterly reports, hard copy
and on diskette, of the EPSDT services. See Section A.7.16 of
the Appendices (Table 14).




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##### 




    
    Vision and hearing screening;
    
    Dental inspection; and
    
    Nutritional assessment
 (See Section B.4.3 of the Appendices)
  
    
    Hemoglobin/hematocrit/EP
    
    Urinalysis
    
    Tuberculin test  intradermal, administered annually and when medically indicated
    
    Lead screening using blood lead level determinations must be
done for every Medicaid-eligible and NJ FamilyCare child:
 o
    
    between nine (9) months and eighteen (18)
months, preferably at twelve (12) months of ageo
    
    at 18-26 months, preferably at twenty-four (24)
months of ageo
    
    test any child between twenty-seven (27) to
seventy-two (72) months of age not previously tested




---



##### 




    
    Additional laboratory tests may be appropriate and medically; indicated
(e.g., for ova an parasites) and shall be obtained as necessary.




---



##### 



3
  3
 3
 3




---



##### 








---



##### 



ees fro a list of SBYSPs




---



##### 








---



##### 



Medical Information form Medical Information form




---



##### 








---



##### 



Medical Information form




---



##### 








---



##### 








---



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---



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##### 



HEDIS
    
    Report PeriodReporting Set Measures
    
    by Contract Year*Childhood Immunization Status
    
    Annually*Adolescent Immunization Status
    
    Annually*Well-Child visits in first 15 months of life
    
    Annually* Well-Child visits in the 3rd,
4th, 5th, and 6th
year of life
    
    annuallyAdolescent Well-Care Visits
    
    annually*Prenatal and Postpartum care
    
    annuallyBreast Cancer Screening
    
    annuallyCervical Cancer Screening
    
    annually*Use of Appropriate Medication for People with Asthma
    
    annuallyComprehensive Diabetes Care
    
    annually




---



##### 



Childhood & Adolescent Immunization




---



##### 








---



##### 



X. Focus Groups. The State will annually conduct four focus groups with enrolled populations
identified by the State and communicated in writing to the contractor. Objectives for the focus
groups will be collaboratively developed by the State and the contractor. For the first contract
year, two focus groups each will be conducted with enrollees who have communication affecting
disorders and with enrollees who are elderly.
 Focus groups results will be reported by the State. The contractor shall identify opportunities for
improvement identified through the focus groups, specify additional measurement or intervention
efforts developed to address the opportunities for improvement, and a timeline, subject to State
approval., indicating when such activities will be completed. A status report on the additional
measurement or intervention efforts shall be submitted annually to the State by a date specified by
DMAHS.




---



##### 








---



##### 








---



##### 



covered




---



##### 








---



##### 








---



##### 








---



##### 



Instructions and formats for this report are specified in Section B.3.3 of the
Appendices of this contract.




---



##### 



by hard copy and computer diskette
 on computer diskette




---



##### 








---



##### 




    
    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 services 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.




---



##### 



A list of Child Abuse Regional Diagnostic Centers is in Section B.4.16 of the
Appendices.




---



##### 








---



##### 



list found in Appendices




---



##### 








---



##### 








---



##### 



status survey enrollee




---



##### 








---



##### 








---



##### 



An




---



##### 



access the process at any time




---



##### 



(Within that timeframe, the
enrollee may file an appeal or request a State fair hearing).




---



##### 




    
    A designated administrative liaison for the Medicaid/NJ FamilyCare contract who shall be
the main point of contact responsible for coordinating all administrative activities for
this contract (contractors Representative; See also Article 7.5 below)
    
    A medical director who shall be a New Jersey licensed physician (M.D. or D.O).
    
    A dental service coordinator
    
    Financial Officer(s) or accounting and budgeting officer




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##### 








---



##### 








---



##### 



6




---



##### 








---



##### 








---



##### 








---



##### 



reported by hard copy and diskette 21 th After a grace period of five (5) days, for each calendar day after a due date the DMAHS
has not yet received at a prescribed location a report that fulfills the requirements of any one
item, assessment for damages equal to one half months negotiated blended capitation rate that
would normally be owed by the DMAHS to the contractor for one recipient shall be applied. The
damages shall be applied as an offset to the subsequent payments to the contractor.




---



##### 








---



##### 



Costs
 Guide for B7.3 standard Agreed Upon Procedures
 agreed upon
procedures a




---



##### 



Cost Reports




---



##### 



or to recover funds attempting to recover
funds




---



##### 








---



##### 








---



##### 



s 6a and 6b6
 s 6a and 6b6 of
Revenues and Expenses 3029 for
 c
 c




---



##### 



c
 of Revenues and
Expenses 8 6a, 6b and 6c c (lines 28) (line 6) (line 7) (line 4)
    ACTUAL MCR
    
    1st OFFENSE
    
    2ND OFFENSE80% or above
    
    NONE
    
    NONE78.00%  79.99%
    
    .15 times
underexpenditure
    
    .15 times
underexpenditure75.00  77.99%
    
    .50 times
underexpenditure
    
    .50 times
underexpenditure74.99 or below
    
    .90 times
underexpenditure
    
    .90 times
underexpenditure




---



##### 



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




---



##### 








---



##### 



th th




---



##### 



ADMINISTRATIVE COSTS
 The capitation rates, effective July 1, 2003 recognize costs for anticipated contractor
administrative expenditures due to Balanced Budge Act regulations.




---



##### 








---



##### 








---



##### 








---



##### 



Monthly HMO Reconciliation Rile
 The following is submitted by the contractor to DMAHS fiscal agent.




---



##### 



State of New Jersey
 Department of Human Services
 Division of Medical Assistance and Health Services
 Office of Management Information Systems
 File Layout
 HMO Reconciliation File
    
    Effective DateFile Name
 Data Set Name
    
    Record Size  Bytes

    Block Size
 Element
    
    Field Name
    
    Chars
    
    Bytes
    
    Bytes # rel to 1
    
    Format
    
    Cobol Picture
    
    Description and/or Remarks1
    
    Medicaid Number
    

    12
    
    12
    
    1-12
    
    Num
    
    9(12)
    
    Enrollees Medicaid
Number2
    
    Last Name
    

    12
    
    12
    
    13-24
    
    AN
    
    X(12)

    
    Enrollees Last Name3
    
    First Name
    
    7
    
    7
    
    25-31
    
    AN
    
    X(7)
    
    Enrollees First Name4
    
    DOB
    

    8
    
    8
    
    32-39
    
    Num
    
    9(8)
    
    Enrollees Date of Birth5
    
    SSN
    

    9
    
    9
    
    40-48
    
    An
    
    X(9)
    
    Enrollees Social
Security No.6
    
    Effect Enrollee
    

    8
    
    8
    
    49-56
    
    Num
    
    9(8)
    
    Effective date of
enrollment mmddyyyy
format7
    
    Disenroll Date
    

    8
    
    8
    
    57-64
    
    Num
    
    9(8)
    
    Disenrollment Date
mmddyyyy format8
    
    Filler
    
    33
    
    33
    
    65-97
    
    An
    
    X(33)
    
    As Needed/If Needed9
    
    Plan Code
    
    3
    
    3
    
    98-100
    
    An
    
    X(3)
    
    ###(078-098)
 
 Format: Num  NumericAn  alpha numericPD = Packed Decimal




---



##### 



BI = Binary




---



##### 



WhenField
    
    Field Name
    
    Size
    
    Required
    
    Definition
    
    Example1
    
    Last Name
    
    
    22
    
    
    
    A
    
    
    Individual Providers Surname; may include R. or
III. Name of group or medical school is
unacceptable
    
    Jones, Jr.2
    
    First Name
    
    
    15
    
    
    
    A
    
    
    Providers First Name. should include middle
initial. Name of group or medical schools is
unacceptable
    
    Tom T.3
    
    SSN
    
    
    9
    
    
    
    A
    
    
    Providers Social Security Number. Do not use
hyphens or spaces
    

    1509999994
    
    Tax ID
    
    
    9
    
    
    
    B
    
    
    Providers Tax ID Number. Do not use hyphens or
spaces
    
    2299999995
    
    Degree
    
    
    5
    
    
    
    A
    
    
    MD, DO, etc. Do not use periods
    
    DO6
    
    Primary
    
    
    1
    
    
    
    A
    
    
    Is this a primary care provider? (y Or N)
Do not indicate Y for dental providers
    

    Y7
    
    Practice Name
    
    
    45
    
    
    
    B
    
    
    Name of Practice if different than providers
last name
    
    Jones Family
Practice8
    
    Address 1
    
    
    60
    
    
    
    A
    
    
    Place where services are rendered. Always start
with street number if one is contained in the
actual address of the practice. Serving This
Area is not acceptable.
    
    225 Main St9
    
    Address 2
    
    
    30
    
    
    
    B
    
    
    Building Name, PO Box etc.
    
    Suite 310
    
    City
    
    
    22
    
    
    
    A
    
    
    Proper Name for Municipality in which practice
office is located. No abbreviations
    
    South Orange11
    
    State
    
    
    2
    
    
    
    A
    
    
    Two Character State Abbreviation, NJ or other
with rare exceptions
    
    NJ12
    
    Zip
    
    
    5
    
    
    
    A
    
    
    5 digit zip code
    

    0888813
    
    Phone
    
    
    15
    
    
    
    A
    
    
    For service address, include Area Code, prefix,
and Number No spaces or dashes.
    

    609588270514
    
    County
    
    
    2
    
    
    
    A
    
    
    Two digit code for county in which office is
actually located
    

    0715
    
    Office Hours
    
    
    60
    
    
    
    A
    
    
    List days and hours when patients can be seen at
this site.
    
    M9-5, T1-5, Th1-716
    
    Specialty Code
    
    
    3
    
    
    
    A
    
    
    See List. List only one per record
    

    21317
    
    Age Restrictions
    
    
    4
    
    
    
    B
    
    
    Speciality code in string field 16,
1st 2 = min age, 2nd 2 = max
age, 0000 if none for a specialty. Omit if no
specialty is limited
    

    123418
    
    Hosp Affl1
    
    
    355
    
    
    
    B
    
    
    Code for Hhospital where provider has admitting
privileges. *required for physicians, podiatrists
&Oral Surgeons.
    
    Newark-Beth Israel
A123419
    
    Hosp Affl2
    
    
    355
    
    
    
    B
    
    
    If more than One
    

    A123420
    
    Hosp Affl3
    
    
    355
    
    
    
    B
    
    
    If more than Two
    

    A123421
    
    Hosp Affl4
    
    
    355
    
    
    
    B
    
    
    If more than Three
    

    A1234




---



##### 



WhenField
    
    Field Name
    
    Size
    
    Required
    

    Definition
    
    Example22
    
    Hosp Affl5
    
    
    355
    
    
    
    B
    
    
    If more than Four
    

    A123423
    
    Languages
    
    
    10
    
    
    
    A
    
    
    Must be at least one, even if English; See code
list. No spaces/commas/Slashes/Hyphens, etc
    
    EFG924
    
    Plan Code
    
    
    3
    
    
    
    1
    
    
    Three digit plan code
    

    09925
    
    Panel Status
    
    
    1
    
    
    
    A
    
    
    O = Open, F = Frozen (no new patients)
    

    O26
    
    Specialty Name
    
    
    30
    
    
    
    A
    
    
    Show one narrative specialty name per record
    
    Family Practice27
    
    Panel Capacity
    
    
    4
    
    
    
    B
    
    
    Potential Number of Members: PCPs & General
Dentists, should not exceed 1500 unless
authorized by DMAHS
    

    150028
    
    Members Assigned
    
    
    4
    
    
    
    B
    
    
    Actual number of Members Assigned; PCPs & Dentists
    

    90029
    
    Record Type
    
    
    3
    
    
    
    B
    
    
    a = addition of record to file (excludes d)
d = deletion of record from file (excludes a & c)
s = multiple listing of provider, unique specialty
l = multiple listing of provider, unique location
Use all that apply. No commas. Spaces allowed.
    

    s a30
    
    Date
    
    
    10
    
    
    
    A
    
    
    Fill with date Network Update File
or Application Network
File was submitted to DMAHS mm/dd/yyyy
    

    06/01/200031
    
    Servicing County
    
    
    4
    
    
    
    B
    
    
    If other than actual county; include a record for
each county served. Out-of-county physicians may
not be considered in applications except where
specified in the contract32
    
    Total Hours
    
    
    2
    
    
    
    A
    
    
    Total number of hours for record. Round down
    

    2033
    
    Medicaid ID
    
    
    7
    
    
    
    A
    
    
    Providers Medicaid assigned ID
    

    123456734
    
    Special Needs
Indicator
    
    
    5
    
    
    
    A
    
    
    Indicates provider has expertise serving specific
populations. Use all OMHS special needs codes
that apply to provider.35
    
    Handicapped
Accessible
    
    
    1
    
    
    
    C
    
    
    Use Y if facility is Handicapped Accessible36
    
    Taxonomy Coe
    
    
    10
    
    
    
    B
    
    
    Health Care Provider Taxonomy Code
    
    Alpha-Numeric
according to
instructions.
 
 A = Always RequiredB = Required When ApplicableC = Optional




---



##### 



ATTACHMENT B
 
 WhenField
    
    Field Name
    
    Size
    
    Required
    
    Definition
    
    Example1
    
    Provider Name
    
    
    45
    
    
    A
    
    
    
    Docs Drugs2
    
    Provider Type
    
    
    30
    
    
    A
    
    
    
    Pharmacy3
    
    Provider Tax ID
    
    
    9
    
    
    A
    
    Providers Tax ID Number
    

    229999994
    
    Address 1
    
    
    60
    
    
    A
    
    Always start with street number if one is
contained in the actual address of the
practice. Serving This Area is not
acceptable.
    
    22 Main St.5
    
    Address 2
    
    
    30
    
    
    B
    
    Building Name, PO Box, Etc
    
    Suite 36
    
    City
    
    
    22
    
    
    A
    
    Proper Name for Municipality in which
practice office is located. No
abbreviations
    
    South Orange7
    
    State
    
    
    2
    
    
    A
    
    Two Character State Abbreviation, NJ or
other with rare exceptions
    
    NJ8
    
    Zip
    
    
    5
    
    
    A
    
    5 digit zip code
    
    088889
    
    Phone
    
    
    15
    
    
    A
    
    For service address, include Area Code,
prefix, and Number No spaces or dashes.
    
    609588270510
    
    County
    
    
    2
    
    
    A
    
    Two digit code for county in which office
is actually located
    

    0711
    
    Plan Code
    
    
    3
    
    
    A
    
    Three Digit Plan Code
    
    09912
    
    Specialty Code
    
    
    3
    
    
    A
    
    See Code List. Use one.
    
    50013
    
    Servicing County
    
    
    4
    
    
    B
    
    If other than actual county; Include a
record for each county served.
Out-of-county institutions may not be
considered in application except where
specified in the contract.14
    
    Date
    
    
    10
    
    
    A
    
    Fill with date Network Update File or
Application Network File was submitted to
DMAHS mm/dd/yyyy
    

    06/01/200015
    
    Record Type
    
    
    1
    
    
    B
    
    A = addition of record to file (excludes d)D = Deletion of record from file
(excludes a)
    

    a16
    
    Medicaid Id
    
    
    7
    
    
    B
    
    Providers Medicaid assigned Id
    
    123456717
    
    Hospital Code
    
    
    5
    
    
    B
    
    Unique Hospital Code
    

    9999918
    
    Taxonomy code
    
    
    10
    
    
    B
    
    Health care Provider Taxonomy Code
    
    Alpha Numeric
according to
specifications.
 
 A = Always requiredB = Required when applicable




---



##### 



Hospital Name
    
    County Location
    
    CodesAncora Psychiatric Hospital
    
    Atlantic
    
    P0101Atlantic City Medical Center  City Division
    
    Atlantic
    
    H0102Atlantic City Medical Center  Mainland Division
    
    Atlantic
    
    H0103Bacharach Institute for Rehabilitation
    
    Atlantic
    
    R0104Shore Medical Hospital
    
    Atlantic
    
    H0105William B. Kessler Memorial Hospital
    
    Atlantic
    
    R0106Bergen Regional Medical Center
    
    Bergen
    
    H0201Christian Health Care Center
    
    Bergen
    
    P0202Englewood Hospital and Medical Center
    
    Bergen
    
    H0203Hackensack University Medical Center
    
    Bergen
    
    H0204Holy Name Hospital
    
    Bergen
    
    H0205Kessler Institution for Rehabilitation  Kessler North
    
    Bergen
    
    R0206Pascack Valley Hospital
    
    Bergen
    
    H0207The Valley Hospital
    
    Bergen
    
    H0208Lourdes Medical Center of Burlington County
    
    Burlington
    
    H0301Deborah Heart and Lung Center
    
    Burlington
    
    S0302Hampton Behavioral Health Center
    
    Burlington
    
    P0303Marlton Rehabilitation Hospital
    
    Burlington
    
    R0304Virtua Memorial Hospital Burlington
    
    Burlington
    
    H0305Virtua-West Jersey Hospital Marlton
    
    Burlington
    
    H0306Weisman Childrens Rehabilitation Hospital
    
    Burlington
    
    R0307The Cooper Health System
    
    Camden
    
    H0401Kennedy Memorial Hospital  UMC Cherry Hill
    
    Camden
    
    H0402Kennedy Memorial Hospital  UMC Stratford
    
    Camden
    
    H0403Our Lady of Lourdes Medical Center
    
    Camden
    
    H0404Virtua West Jersey Hospital  Berlin
    
    Camden
    
    H0405Virtua West Jersey Hospital  Voorhees
    
    Camden
    
    H0406Burdette Tomlin Memorial Hospital
    
    Cape May
    
    H0501




---



##### 



Hospital Name
    
    County Location
    
    CodesRehabilitation Hospital of South Jersey
    
    Cumberland
    
    R0601South Jersey Healthcare  Regional Medical Center
    
    Cumberland
    
    H0602Clara Maas Medical Center
    
    Essex
    
    H0701Columbus Hospital
    
    Essex
    
    H0702East Orange General Hospital
    
    Essex
    
    H0703Irvington General Hospital
    
    Essex
    
    H0704Kessler Institution for Rehabilitation  Kessler East
    
    Essex
    
    R0705Kessler Institution for Rehabilitation  Kessler West
    
    Essex
    
    R0706Newark Beth Israel Medical Center
    
    Essex
    
    H0707St. Barnabas Medical Center
    
    Essex
    
    H0708St. James Hospital
    
    Essex
    
    H0709St. Michaels Medical Center
    
    Essex
    
    H0710The Mountainside Hospital
    
    Essex
    
    H0711UMDNJ  University Hospital
    
    Essex
    
    H0712VA New Jersey Health care System  East Orange
    
    Essex
    
    V0713Kennedy Memorial Hospitals  UMC Washington Township
    
    Gloucester
    
    H0801Underwood Memorial Hospital
    
    Gloucester
    
    H0802Bayonne Medical Center
    
    Hudson
    
    H0901Christ Hospital
    
    Hudson
    
    H0902Hudson County Meadowview Hospital
    
    Hudson
    
    P0903Liberty Health Care System  Greenview Hospital Campus
    
    Hudson
    
    H0904Liberty Health Care System  Jersey City Medical Center
Campus
    
    Hudson
    
    H0905Liberty Health Care System  Meadowlands Hospital Campus
    
    Hudson
    
    H0906Palisades Medical Center  New York Presbyterian Health
Care System
    
    Hudson
    
    H0907St. Marys Hospital
    
    Hudson
    
    H0908Hunterdown Medical Center
    
    Hunterdon
    
    H1001Senator Garrett W Hagedorn Gero-Psychiatric Hospital
    
    Hunterdon
    
    P1002Capital Health System  Fuld Campus
    
    Mercer
    
    H1101




---



##### 



Hospital Name
    
    County Location
    
    CodesCapital Health System  Mercer Campus
    
    Mercer
    
    H1102University Medical Center at Princeton
    
    Mercer
    
    H1103Robert Wood Johnson University Hospital At Hamilton
    
    Mercer
    
    H1104St. Francis Medical Center
    
    Mercer
    
    H1105St. Lawrence Rehabilitation center
    
    Mercer
    
    R1106Trenton Psychiatric Hospital
    
    Mercer
    
    P1107JFK Medical Center
    
    Middlesex
    
    H1201Raritan Bay Medical Center  Old Bridge
    
    Middlesex
    
    H1212Raritan Bay Medical Center  Perth Amboy
    
    Middlesex
    
    H1203Robert Wood Johnson University Hospital  New Brunswick
    
    Middlesex
    
    H1204St. Peters University Hospital
    
    Middlesex
    
    H1205JFK Johnson Rehabilitation Hospital
    
    Middlesex
    
    R1206University Behavioral HealthCare
    
    Middlesex
    
    P1207Bayshore Community Hospital
    
    Monmouth
    
    H1301CentraState Healthcare System
    
    Monmouth
    
    H1302Jersey Shore University Medical Center
    
    Monmouth
    
    H1303Monmouth Medical Center
    
    Monmouth
    
    H1304Riverview Medical Center
    
    Monmouth
    
    H1305HEALTHSOUTH Rehabilitation Hospital at Tinton Falls
    
    Monmouth
    
    R1306Chilton Memorial Hospital
    
    Morris
    
    H1401Morristown Memorial Hospital
    
    Morris
    
    H1402St. Clares Health Services  Denville
    
    Morris
    
    H1403Greystone Park Psychiatric Hospital
    
    Morris
    
    P1404Kessler Institute for Rehabilitation
Corporation-Kessler Welkind
    
    Morris
    
    R1405St. Clares Hospital Boonton Township
    
    Morris
    
    P1406Community Medical Center
    
    Ocean
    
    H1501Kimball Medical Center
    
    Ocean
    
    H1502Meridian Health Ocean Medical Center
    
    Ocean
    
    H1503Southern Ocean County Hospital
    
    Ocean
    
    H1504HEALTHSOUTH Rehabilitation Hospital of Toms River
    
    Ocean
    
    H1505




---



##### 



Hospital Name
    
    County Location
    
    CodesSt. Barnabas Behavioral Health Network
    
    Ocean
    
    P1506Barnert Hospital
    
    Passaic
    
    H1601Passaic Beth Israel Regional Health Network
    
    Passaic
    
    H1602St. Josephs Hospital and Medical Center  Paterson
    
    Passaic
    
    H1603St. Josephs Wayne Hospital
    
    Passaic
    
    H1604St. Marys Hospital Passaic
    
    Passaic
    
    H1605South Jersey Healthcare  Elmer Hospital
    
    Salem
    
    H1701The Memorial Hospital of Salem county
    
    Salem
    
    H1702Carrier Clinic
    
    Somerset
    
    P1801The Matheny School and Hospital
    
    Somerset
    
    S1802Somerset Medical Center
    
    Somerset
    
    H1803VA New Jersey Health Care System Lyons
    
    Somerset
    
    V1804Newton Memorial Hospital
    
    Sussex
    
    H1901St. Clares Hospital /Sussex
    
    Sussex
    
    H1902Muhlenburg Regional Medical Center
    
    Union
    
    H2001Overlook Hospital
    
    Union
    
    H2002Robert Wood Johnson University Hospital at Rahway
    
    Union
    
    H2003Trinitas Hospital Williamson Street Campus
    
    Union
    
    H2004Union Hospital
    
    Union
    
    H2005Childrens Specialized Hospital
    
    Union
    
    R2006Runnells Specialized Hospital
    
    Union
    
    S2007Summit Hospital
    
    Union
    
    P2008Hackettstown Community Hospital
    
    Warren
    
    H2101Warren Hospital
    
    Warren
    
    H2102




---



##### 



HOSPITAL NAME
    
    COUNTY LOCATION
    
    CODESAncora Psychiatric Hospital
    
    Atlantic
    
    P0101Atlantic City Medical Center  City Division
    
    Atlantic
    
    H0102Atlantic City Medical Center  Mainland Division
    
    Atlantic
    
    H0103Bacharach Institute for Rehabilitation
    
    Atlantic
    
    R0104Shore Medical Hospital
    
    Atlantic
    
    H0105William B. Kessler Memorial Hospital
    
    Atlantic
    
    R0106Bergen Regional Medical Center
    
    Bergen
    
    H0201Christian Health Care Center
    
    Bergen
    
    P0202Englewood Hospital and Medical Center
    
    Bergen
    
    H0203Hackensack University Medical Center
    
    Bergen
    
    H0204Holy Name Hospital
    
    Bergen
    
    H0205Kessler Institution for Rehabilitation  Kessler North
    
    Bergen
    
    R0206Pascack Valley Hospital
    
    Bergen
    
    H0207Valley Health System  The Valley Hospital
    
    Bergen
    
    H0208Lourdes Medical Center of Burlington County
    
    Burlington
    
    H0301Deborah Heart and Lung Center
    
    Burlington
    
    S0302Hampton Hospital
    
    Burlington
    
    P0303Mediplex Rehabilitation Hospital
    
    Burlington
    
    R0304Virtua Health  Virtua Memorial Hospital Burlington
    
    Burlington
    
    H0305Virtua Health  Virtua West Jersey Hospital Marlton
    
    Burlington
    
    H0306Voorhees Pediatric Rehabilitation Hospital
    
    Burlington
    
    R0307The Cooper Health System
    
    Camden
    
    H0401Kennedy Memorial Hospital- Cherry Hill
    
    Camden
    
    H0402Kennedy Memorial Hospital- Stratford
    
    Camden
    
    H0403Lourdes Health System-Our Lady of Lourdes Medical
Center
    
    Camden
    
    H0404Virtua West Jersey Hospital  Berlin
    
    Camden
    
    H0405Virtua West Jersey Hospital   Voorhees
    
    Camden
    
    H0406Burdette Tomlin Memorial Hospital
    
    Cape May
    
    H0501South Jersey Health System- South Jersey Hospital
Bridgeton
    
    Cumerland
    
    H0601




---



##### 



HOSPITAL NAME
    
    COUNTY LOCATION
    
    CODESSouth Jersey Health system South Jersey Hospital - Vineland
    
    Cumberland
    
    H0602Clara Maas Medical Center
    
    Essex
    
    H0701Columbus Hospital
    
    Essex
    
    H0702East Orange General Hospital
    
    Essex
    
    H0703Hospital Center at Orange
    
    Essex
    
    H0704Irvington General Hospital
    
    Essex
    
    H0705Kessler Institution for Rehabilitation  Kessler East
    
    Essex
    
    R0706Kessler Institution for Rehabilitation  Kessler West
    
    Essex
    
    R0707Newark Beth Israel Medical Center
    
    Essex
    
    H0708St. Barnabas Medical Center
    
    Essex
    
    H0709St. James Hospital
    
    Essex
    
    H0710St. Michaels Medical Center
    
    Essex
    
    H0711The Mountainside Hospital
    
    Essex
    
    H0712UMDNJ  University Hospital
    
    Essex
    
    H0713VA New Jersey Health care System  East Orange
    
    Essex
    
    V0714Essex County Hospital Center
    
    Essex
    
    P0715Kennedy Memorial Hospitals  UMC Washington Township
    
    Gloucester
    
    H0801Underwood Memorial Hospital
    
    Gloucester
    
    H0802Bayonne Medical Center
    
    Hudson
    
    H0901Christ Hospital
    
    Hudson
    
    H0902Liberty Health Care System  Greenview Hospital Campus
    
    Hudson
    
    H0903Liberty Health Care System  Jersey City Medical Center
Campus
    
    Hudson
    
    H0904Liberty Health Care System  Meadowlands Hospital
Campus
    
    Hudson
    
    H0905Palisades Medical Center  New York Presbyterian Health
Care System
    
    Hudson
    
    H0906St. Marys Hospital
    
    Hudson
    
    H0907West Hudson Hospital
    
    Hudson
    
    H0908Hunterdon Medical Center
    
    Hunterdon
    
    H1001Senator Garrett W Hagedorn Gero-Psychiatric Hospital
    
    Hunterdon
    
    P1002Capital Health System  Fuld Campus
    
    Mercer
    
    H1101Capital Health System  Mercer Campus
    
    Mercer
    
    H1102




---



##### 



HOSPITAL NAME
    
    COUNTY LOCATION
    
    CODESThe Medical Center at Princeton
    
    Mercer
    
    H1103Robert Wood Johnson University Hospital Hamilton
    
    Mercer
    
    H1104St. Francis Medical Center
    
    Mercer
    
    H1105St. Lawrence Rehabilitation center
    
    Mercer
    
    R1106Trenton Psychiatric Hospital
    
    Mercer
    
    P1107JFK Medical Center
    
    Middlesex
    
    H1201Raritan Bay Medical Center  Old Bridge
    
    Middlesex
    
    H1212Raritan Bay Medical Center  Perth Amboy
    
    Middlesex
    
    H1203Robert Wood Johnson University Hospital  New
Brunswick
    
    Middlesex
    
    H1204St. Peters University Hospital
    
    Middlesex
    
    H1205JFK Johnson Rehabilitation Hospital
    
    Middlesex
    
    R1206University Behavioral HealthCare
    
    Middlesex
    
    P1207Bayshore Community Hospital
    
    Monmouth
    
    H1301CentraState Healthcare System
    
    Monmouth
    
    H1302Jersey Shore University Medical Center
    
    Monmouth
    
    H1303Monmouth Medical Center
    
    Monmouth
    
    H1304Riverview Medical Center
    
    Monmouth
    
    H1305HEALTHSOUTH Rehabilitation Hospital at Tinton Falls
    
    Monmouth
    
    R1306Chilton Memorial Hospital
    
    Morris
    
    H1401Morristown Memorial Hospital
    
    Morris
    
    H1402St. Clares Health Services  Denville
    
    Morris
    
    H1403Greystone Park Psychiatric Hospital
    
    Morris
    
    P1404Kessler Rehabilitation Corporation- Kessler Welkind
    
    Morris
    
    R1405St. Clares Health Services Boonton
    
    Morris
    
    P1406St Barnabas Health Care System Community Medical Center
    
    Ocean
    
    H1501St Barnabas Health Care System Kimbal Medical Center
    
    Ocean
    
    H1502Meridian Health Ocean Medical Center
    
    Ocean
    
    H1503Southern Ocean County Hospital
    
    Ocean
    
    H1504HEALTHSOUTH Rehabilitation Hospital of Toms River
    
    Ocean
    
    H1505St. Barnabas Behavioral Health Network
    
    Ocean
    
    P1506Barnert Hospital
    
    Passaic
    
    H1601




---



##### 



HOSPITAL NAME
    
    COUNTY LOCATION
    
    CODESBeth Israel Hospital
    
    Passaic
    
    H1602St. Josephs Hospital and Medical Center  Paterson
    
    Passaic
    
    H1603St. Josephs Wayne Hospital
    
    Passaic
    
    H1604St. Marys Hospital Passaic
    
    Passaic
    
    H1605The General Hospital Center At Passaic
    
    Passaic
    
    H1606South Jersey Healthcare  Elmer Hospital
    
    Salem
    
    H1701The Memorial Hospital of Salem county
    
    Salem
    
    H1702Carrier Clinic
    
    Somerset
    
    P1801The Matheny School and Hospital
    
    Somerset
    
    S1802Somerset Medical Center
    
    Somerset
    
    H1803VA New Jersey Health Care System VA Medical Center
    
    Somerset
    
    V1804Newton Memorial Hospital
    
    Sussex
    
    H1901St. Clares Health Services/Sussex
    
    Sussex
    
    H1902Solaris Health System  Muhlenburg Regional Medical
Center
    
    Union
    
    H2001Atlantic Health System Overlook Hospital
    
    Union
    
    H2002Rahway Hospital
    
    Union
    
    H2003RJW Health Systems Childrens Specialized Hospital
    
    Union
    
    H2003Runnells Specialized Hospital
    
    Union
    
    S2007Summit Hospital
    
    Union
    
    P2008Hackettstown Community Hospital
    
    Warren
    
    H2101Warren Hospital
    
    Warren
    
    H2102




---



##### 



B  Report Specifications
  Beneficiaries - Include all AFDC, DYFS, NJ FamilyCare, SSI-ABDProvider Type
    
    All Ages
    
    Children under 21
    
    Adults 21 and upAdult PCPs (FP, FP,
IM OB/GYN-women
only
    
    
    
    
    
    Page Codes 1-9Pediatric PCPs (FP,
Ped., GP)General Dentists
    
    Page Codes 1-9Hospitals
    
    Page Codes 1-10 & 12Blood Drawing
Centers and Labs
that Draw Blood
    
    Page Codes 11 & 12
   Page
    
    AccessCode
    
    Standard
    
    Description1
    
    na*
    
    This cover page of each report includes plan name, county
beneficiary group and date.2
    
    na*
    
    This page uses a graph to illustrate the percentage of
beneficiaries who have access to a group of providers at various
distances. It includes a table showing the average distances to
the nearest choices of one, two, three, four and five providers.3
    
    na*
    
    This page shows, by zip code, the average distance for
beneficiaries to two providers and the percentage of
beneficiaries having two providers within 2, 6, 10 and 15 miles4
    
    A
    
    This page shows the number of providers, the number of
beneficiaries with access to two providers and the average
distance to up to five providers for beneficiaries with access.
It also analyzes beneficiary accessibility in ten key cities.5
    
    A
    
    This page shows, by zip code, the number and percentage of
beneficiaries who do not have access to a choice of two
providers and the average distance to one and two providers.6
    
    B
    
    This page shows the number of providers the number of
beneficiaries with access to one provider and the average
distance to up to five providers for beneficiaries with access.
It also analyzes beneficiary




---



##### 



Page
    
    AccessCode
    
    Standard
    
    Descriptionaccessibility in ten key cities.7
    
    B
    
    This page shows, by zip code, the number and percentage of
beneficiaries who do not have access to one provider and their
average distance to one provider.8
    
    na*
    
    This includes documentation about the report and its data sources9
    
    A
    
    This county map shows beneficiary locations for those who do not
have access to two providers. Use 2 point black circles for
beneficiaries.10
    
    na*
    
    This county map shows provider locations. Use 12 point light
gray circles for individual and 12 point black triangles for
multiple provider locations.11
    
    na*
    
    This county map shows all beneficiaries and a five mile radius
circle around each provider location. The map should show only
Radius 1 which should be transparent. Use provider and
beneficiary symbol specifications from page codes 9 and 10.12
    
    na*
    
    This should be a hard copy of the geocoded provider file, which
must include name, specialty/type, address, zip code, individual
capacity (where applicable), geographic coordinates and
geocoding method return code.
 
 * na = no access standard applicable; information required   Field Name
    
    DescriptionNAME1
    
    Last name for individual providers (include suffix, e.g., Jr. Sr.)
Entire name for institutionNAME2
    
    First name and middle initial with period for individualsADDRESS1
    
    Street number first then street name where medical care is actually providedADDRESS2
    
    Additional information (e.g., suite #, building)STDCITY
    
    Standard city name according to geocoder output fieldSTATE
    
    StateZIP
    
    Full zip codes in character or text format to show leading zerosSPECIALTY
    
    Primary specialty only for individual providers Provider type for institutionsLONGITUDE
    
    Geocoded LongitudeLATITUDE
    
    Geocoded LatitudeGEOMETHOD
    
    Return codes from geocoderCAPACITY
    
    Individual capacity used for access analysis when applicable




---



##### 



A.7.1.A CERTIFICAION OF ENROLLMENT INFORMATION RELATING TO PAYMENT UNDER THE Medicaid/NJ FAMILYCARE
PROGRAM.




---



##### 



Sample
 proposed
 CERTIFICATION OF ENROLLMENT INFORMATION RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM
 CERTIFICATION
 name of managed
care organization (MCO insert Plan identification number(s) here
  (Name of MCO) has reported to the DHS for the month of (indicate month and
year) all new enrollments, disenrollments, and any changes in the enrollees status.
(Name of MCO) has reviewed the monthly membership report for the month of
(indicate month and year) and I, (enter Name of Chief Financial Officer, Chief
Executive Officer or Name of Person who Reports Directly to and Who is Authorized to Sign
for Chief Financial Officer or Chief Executive Officer) attest that based on best knowledge,
information, and belief as of the date indicated below, all information submitted to DHS in
this report is accurate, complete, and truthful, and I hereby certify that NO MATERIAL FACT
HAS BEEN OMITTED FROM THIS FORM AND/OR THE DATA SUBMISSION.




---



##### 



I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who
Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief
Executive Officer), ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT THE
CALCULATION OF PAYMENTS TO (Name of MCO). I UNDERSTAND THAT I MUST COMPLY WITH ALL
APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR
CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF THIS
SUBMISSION.
 (INDICATE NAME AND TILTECFO, CEO OR DELGATE))On behalf of(INDICATE NAME OF BUSINESS ENTITY)DATE




---



##### 








---



##### 



Sample
 proposed
 CERTIFICATION OF ENCOUNTER INFORMATION RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM
 CERTIFICATION
 name of managed
care organization (MCO insert Plan identification number(s) here Name of MCO
  (Name of MCO) has reported to the DHS for the month of (indicate month and
year) all new encounters, (indicate type of data  inpatient hospital, outpatient hospital,
physician, etc.). (Name of MCO) has reviewed the encounter data for the month of
(indicate month and year) and I, (enter Name of Chief Financial Officer, Chief
Executive Officer or Name of Person who Reports Directly to and Who is Authorized to Sign
for Chief Financial Officer or Chief Executive Officer) attest that based on best knowledge,
information, and belief as of the date indicated below, all information submitted to DHS in
this report is accurate, complete, and truthful, and I hereby certify that NO
MATERIAL FACT HAS BEEN OMITTED FROM THIS FORM AND/OR THE DATA SUBMISSION.




---



##### 



I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who
Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief
Executive Officer), ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT THE
CALCULATION OF PAYMENTS TO (Name of MCO). I UNDERSTAND THAT I MUST COMPLY WITH ALL
APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR
CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF THIS
SUBMISSION.
 (INDICATE NAME AND TILTECFO, CEO OR DELGATE))On behalf of(INDICATE NAME OF BUSINESS ENTITY)DATE




---



##### 








---



##### 



Sample
 proposed
 CERTIFICATION OF ANY INFORMATION REQUIRED BY THE STATE AND CONTAINED IN CONTRACTS, PROPOSALS, AND RELATED DOCUMENTS RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM
 CERTIFICATION
 name of managed
care organization (MCO insert Plan identification number(s) here
  (Name of MCO) has reported to the DHS for the period of (indicate dates) all
information required by the State and contained in contracts, proposals, and related
documents submitted. (Name of MCO) has reviewed the monthly membership report for
the period of (indicate dates) and I, (enter Name of Chief Financial Officer,
Chief Executive Officer or Name of Person who Reports Directly to and Who is
Authorized to Sign for Chief Financial Officer or Chief Executive Officer) attest that
based on best knowledge, information, and belief as of the date indicated below, all
information submitted to DHS in this report is




---



##### 



accurate, complete, and truthful, and I hereby certify that NO MATERIAL FACT HAS BEEN
OMITTED FROM THIS FORM AND/OR THE DATA SUBMISSION.
 I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who
Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief
Executive Officer), ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT
THE CALCULATION OF PAYMENTS TO (Name of MCO). I UNDERSTAND THAT I MUST COMPLY WITH ALL
APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR
CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF THIS
SUBMISSION.
 (INDICATE NAME AND TILTECFO, CEO OR DELGATE))On behalf of(INDICATE NAME OF BUSINESS ENTITY)DATE




---



##### 



Certification of HIV/AIDS/Hemophilia




---



##### 



Month of CertificationRun Date
 
 
   
 Name of HMO




---



##### 



Beginning of month
    
    Added during the month
    
    Completed/Closed
    
    End of MonthProvider
    
    Enrollee
    
    Provider
    
    Enrollee
    
    Provider
    
    Enrollee
    
    Provider
    
    Enrollee# of CasesTotals




---



##### 



C. The contractor must submit quarterly the following report of FTE hours devoted solely
to DMAHS related fraud and abuse cases, reviews and initiatives. The contractor shall report
the data by employee.
 TOTAL HOURSDEVOTEDDMAHS RELATED FRAUD AND
    
    SOLELY TOABUSE CASE(S), REVIEWS, AND
    
    DMAHSEMPLOYEE
    
    INITIATIVE(S0
    
    FRAUD/ABUSEName/Description(Listeach case, review orinitiative separately,along with hoursdevoted solely toLast Name
    
    First Name
    
    DMAHS for each)
    
    Sub total Hours
    
    Total Hours




---



##### 



Medicaid Enrollment by Primary Care Providers  at the end of the prior quarter and and any member months for the quarter.




---



##### 



STATE OF NEW JERSEYPlan Name
    
    Quarter Ending
 
 Primary Care ProvidersList, by type of provider,alphabetically by lastname with one line for
    
    
    
    
    
    # of Enrollees
    
    Total # of
    
    Total Membereach county in which
    
    
    
    
    
    at End of Prior
    
    Enrollees for
    
    Months forprovider practices
    
    Specialty
    
    County
    
    Quarter
    
    Reporting Period
    
    QuarterPrimary Care PhysiciansDentistsCNP/CNSsPhysician AssistantsTotalTotal # PCPsTotal # PCPs with EnrolleesTotal # PCPs without EnrolleesTotal # DentistsTotal # Dentists with EnrolleesTotal # Dentists without EnrolleesTotal # CNP/CNSsTotal # CNP/CNSs with EnrolleesTotal # CNP/CNSs without Enrollees




---



##### 



Primary Care ProvidersList, by type of provider,alphabetically by lastname with one line for
    
    
    
    
    
    # of Enrollees
    
    Total # of
    
    Total Membereach county in which
    
    
    
    
    
    at End of Prior
    
    Enrollees for
    
    Months forprovider practices
    
    Specialty
    
    County
    
    Quarter
    
    Reporting Period
    
    QuarterTotal # PasTotal # PAs with EnrolleesTotal # PAs without Enrollees




---



##### 



Table 2 Disenrollment Form Plan
 The contractor shall aggregate the disenrollment from the plan of the number of enrollees
(not cases/families) by eligibility category and reason for disenrollment by identifying
involuntary (Section A) and voluntary (Section B) disenrollments. All reasons must be
explained in the appropriate space provided.
 NJ FamilyCare in this and other tables includes Plans B, C, D and H.




---



##### 



Plan Name                                                            Quarter Ending
 TABLE 2
DISENROLLMENT FORM PLAZN
 A. Involuntary Disenrollment By Reason
 A
    
    D
    
    SSI
    
    NJ
    
    TFDC
    
     YFS
    
    ABD
    
    FamilyCare
    
    QTALDeathInstitutionalizedMoved from Enrollment AreasLoss of Medicaid EligibilityChange in Medicaid Aid CategoryTermination By PlanOther*TOTAL
 
 *Explanation of Other
 B. Voluntary Disenrollment By Reason
 A
    
    D
    
    SSI
    
    NJ
    
    TFDC
    
    YFS
    
    ABD
    
    FamilyCare
    
    QTALClosed Panel of ProvidersEmergency Treatment ProceduresDelay in securing AppointmentsDissatisfaction with PCPOther*TOTAL
 
 *Explanation of Other




---



##### 



Reserved
 Table 4 Claims Lag Report




---



##### 



A.7.6  Table 4 Claims Lag Report  Table 4A
 Note: Use this form to report manually submitted claims that were processed
during the quarterly period. Claims submitted and processed electronically must be reported
separately on Table 4B. Manual claims submission shall be processed within 40 days of
receipt.
 Report amounts for each category of service and total listed in column 1 in
the following columns:
 Non-Processed Claims from Prior Quarters (column 2). Enter the number of
manually submitted claims on hand that were unprocessed as of the closing date of the last
quarterly period. The number should be the same as was reported in Column 16 of the prior
quarterly report.
 Claims Recd During Quarter (Column 3) Enter the amount of all manually
submitted claims that were received during the quarterly period being reported.
 Total Claims (Column 4). Enter the total of Columns 2 and 3.
 Claims Processed This Quarter (Column 5)  Enter the amount of all manually
submitted claims processed (both paid and denied) during the quarterly period being
reported. Do not count pended claims.
 1-40 Days (Column 6) Enter the number of manually submitted claims that were processed
(either paid or denied) within 40 days of their receipt. Note: The number of days required
to process a claim is calculated by comparing the date the claim was received by the
contractor to the date the claim was paid or denied by the contractor (See Article 7.16.5 of
this contract for further details.).
 % of Total (Column 7) Enter the percentage of manually submitted claims
processed within 40 days (Compared to the total claims processed. Divide Column 6 by Column
5 to arrive at percent).
 41-60 Days (Column 8) Enter the number of manually submitted claims that were
processed (either paid or denied) between 41-60 days of their receipt




---



##### 



% of Total (Column 9) Enter the percentage of manually submitted claims
processed within between 41-60 days (Compared to the total claims processed. Divide Column 8
by Column 5 to arrive at percent).
 61-90 Days (Column 10) Enter the number of manually submitted claims that were
processed (either paid or denied) between 61-90 days of their receipt
 % of Total (Column 11) Enter the percentage of manually submitted claims processed within
between 61-90 days (Compared to the total claims processed. Divide Column 12 by Column 5 to
arrive at percent).
 91-120 Days (Column 8) Enter the number of manually submitted claims that were
processed (either paid or denied) between 90-120 days of their receipt
 % of Total (Column 9) Enter the percentage of manually submitted claims
processed within between 90-120 days (Compared to the total claims processed. Divide Column
14 by Column 5 to arrive at percent).
 Non Processed Claims on Hand at End of Quarter (Column 16). Enter the number
of manually submitted claims on hand that were not processed as of closing date of the last
report period. (Should be the difference of Column 4 minus Column 5). Same number should
match number of claims entered in column 2 of next quarter reports.
 % of Claims Not Processed at End of Quarter (Column 17). Divide Column 16 by
Column 4 to arrive at percent.




---



##### 



>120 Days (Column 8) Enter the number of manually submitted claims that
were processed (either paid or denied) after 120 days of their receipt




---



##### 



Table 4B
 Note: Use this form to report electronically submitted claims that were
processed during the quarterly period. Claims submitted and processed electronically must be
reported separately on Table 4A. Electronic Claims submission shall be processed within 30
days of receipt.
 Report amounts for each category of service and total listed in Column 1 in
the following columns:
 Non-Processed Claims from Prior Quarters (Column 2). Enter the number of
electronically submitted claims on hand that were unprocessed as of the closing date of the
last quarterly period. The number should be the same as was reported in Column 16 of the
prior quarterly report.
 Claims Recd During Quarter (Column 3) Enter the amount of all electronically
submitted claims that were received during the quarterly period being reported.
 Total Claims (Column 4). Enter the total of Columns 2 and 3.
 Claims Processed This Quarter (Column 5)  Enter the amount of all
electronically submitted claims processed (both paid and denied) during the quarterly period
being reported. Do not count pended claims.
 1-30 Days (Column 6) Enter the number of electronically submitted claims that
were processed (either paid or denied) within 30 days of their receipt. Note: The number of
days required to process a claim is calculated by comparing the date the claim was received
by the contractor to the date the claim was paid or denied by the contractor (See Article
7.16.5 of this contract for further details.).
 % of Total (Column 7) Enter the percentage of electronically submitted claims
processed within 30 days (Compared to the total claims processed. Divide Column 6 by Column
5 to arrive at percent).
 31-60 Days (Column 8) Enter the number of electronically submitted claims that
were processed (either paid or denied) between 31-60 days of their receipt
 % of Total (Column 9) Enter the percentage of electronically submitted claims
processed within between 31-60 days (Compared to the total claims processed. Divide Column 8
by Column 5 to arrive at percent).
 61-90 Days (Column 10) Enter the number of electronically submitted claims
that were processed (either paid or denied) between 61-90 days of their receipt




---



##### 



% of Total (Column 11) Enter the percentage of electronically submitted claims
processed within between 61-90 days (Compared to the total claims processed. Divide Column
12 by Column 5 to arrive at percent).
 91-120 Days (Column 8) Enter the number of electronically submitted claims
that were processed (either paid or denied) between 91-120 days of their receipt
 % of Total (Column 9) Enter the percentage of electronically submitted claims
processed within between 91-120 days (Compared to the total claims processed. Divide Column
14 by Column 5 to arrive at percent).
 Non Processed Claims on Hand at End of Quarter (Column 16). Enter the number
of electronically submitted claims on hand that were not processed as of closing date of the
last report period. (Should be the difference of Column 4 minus Column 5). Same number
should match number of claims entered in column 2 of next quarter reports.
 % of Claims Not Processed at End of Quarter (Column 17). Divide Column 16 by
Column 4 to arrive at percent.




---



##### 



STATE OF NEW JERSEY
 Plan Name
    

Quarter
Ending
 Table 4A  CLAIMS LAG REPORT FOR MANUALLY SUBMITTED CLAIMS
 1
    
    2
    
    
    3
    
    
    4
    
    
    5
    
    
    Claims Processed During QuarterNonProcessed
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Non
    
    
    % of Claimsclaims
    
    
    Claims
    
    
    Total
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Processed
    
    
    notfrom
    
    
    Recd
    
    
    Claims
    
    
    Claims processed this
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Claims on
    
    
    Processedprior
    
    
    During
    
    
    (cols
    
    
    quarter (cols
    
    
    1-40
    
    
    Of
    
    
    1-60
    
    
    Of
    
    
    1-90
    
    
    0f-1-120
    
    
    Of
    
    
    120
    
    
    Of
    
    
    Hand at End
    
    
    at End ofCategory of services
    
    quarter
    
    
    Quarter
    
    
    2+3)
    
    
    6+8+10+12+14)
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    of Quarter
    
    
    QuarterInpatient HospitalPrimary CarePhysician Specialty ServicesHospital OutpatientOther Professional ServicesEmergency RoomDME/Medical SuppliesProstheticsDentalPharmacy




---



##### 



1
    
    2
    
    
    3
    
    
    4
    
    
    5
    
    
    Claims Processed During QuarterNonProcessed
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Non
    
    
    % of Claimsclaims
    
    
    Claims
    
    
    Total
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Processed
    
    
    notfrom
    
    
    Recd
    
    
    Claims
    
    
    Claims processed this
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Claims on
    
    
    Processedprior
    
    
    During
    
    
    (cols
    
    
    quarter (cols
    
    
    1-40
    
    
    Of
    
    
    1-60
    
    
    Of
    
    
    1-90
    
    
    0f-1-120
    
    
    Of
    
    
    120
    
    
    Of
    
    
    Hand at End
    
    
    at End ofCategory of services
    
    quarter
    
    
    Quarter
    
    
    2+3)
    
    
    6+8+10+12+14)
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    of Quarter
    
    
    QuarterAIDS/HIV Reimbursable DrugsHome Health CareTransportationLab and X-RayVision Care & EyeglassesMental Health/Substance AbuseOther MedicalTotal




---



##### 



STATE OF NEW JERSEY
 Plan Name
    

Quarter
Ending
 Table 4B  CLAIMS LAG REPORT FOR ELECTRONICALLY SUBMITTED CLAIMS
 1
    
    2
    
    
    3
    
    
    4
    
    
    5
    
    
    Claims Processed During QuarterNonProcessed
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Non
    
    
    % of Claimsclaims
    
    
    Claims
    
    
    Total
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Processed
    
    
    notfrom
    
    
    Recd
    
    
    Claims
    
    
    Claims processed this
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Claims on
    
    
    Processedprior
    
    
    During
    
    
    (cols
    
    
    quarter (cols
    
    
    1-30
    
    
    Of
    
    
    1-60
    
    
    Of
    
    
    1-90
    
    
    0f-1-120
    
    
    Of
    
    
    120
    
    
    Of
    
    
    Hand at End
    
    
    at End ofCategory of services
    
    quarter
    
    
    Quarter
    
    
    2+3)
    
    
    6+8+10+12+14)
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    of Quarter
    
    
    QuarterInpatient HospitalPrimary CarePhysician Specialty ServicesHospital OutpatientOther Professional ServicesEmergency RoomDME/Medical SuppliesProstheticsDentalPharmacy




---



##### 



1
    
    2
    
    
    3
    
    
    4
    
    
    5
    
    
    Claims Processed During QuarterNonProcessed
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Non
    
    
    % of Claimsclaims
    
    
    Claims
    
    
    Total
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Processed
    
    
    notfrom
    
    
    Recd
    
    
    Claims
    
    
    Claims processed this
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Claims on
    
    
    Processedprior
    
    
    During
    
    
    (cols
    
    
    quarter (cols
    
    
    1-30
    
    
    Of
    
    
    1-60
    
    
    Of
    
    
    1-90
    
    
    0f-1-120
    
    
    Of
    
    
    120
    
    
    Of
    
    
    Hand at End
    
    
    at End ofCategory of services
    
    quarter
    
    
    Quarter
    
    
    2+3)
    
    
    6+8+10+12+14)
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    etal
    
    
    ays
    
    
    of Quarter
    
    
    QuarterAIDS/HIV Reimbursable DrugsHome Health CareTransportationLab and X-RayVision Care & EyeglassesMental Health/Substance AbuseOther MedicalTotal




---



##### 








---



##### 



hard copy and
          www.state.nj.us/health/hcsa/hospitalsearch/index.html




---



##### 



Statement of Revenues and Expenses
  The contractor shall report revenues and expenses for all Medicaid premium
groups on an accrual basis for each quarter of the calendar year (Table 6A). A cumulative
year to date report is also required in the second, third, and fourth quarters of the
calendar year (Table 6B).
 Note: Shaded blocks are not required to be completed.
 1. Member months
 REVENUE
 2. Capitated Premiums  Revenue recognized on a prepaid basis for enrollees
for provision of a specified range of health services over a defined period of time,
normally one month. If Advance payments are made to the plan for m ore than one reporting
period, the portion of payment that has not been earned must be treated as a liability
(unearned Premiums).
 3. Supplemental Premiums  Revenue paid to the pal in addition to capitated
premiums for certain services provided. .See a, b and c below.
 a. Maternity (See Article 8)
 b. HIV/AIDS Reimbursable Drugs
 c. Other  Any other revenue paid by DMAHS to the plan in addition to
capitation for covered services that is not a or b above.
 4. Total Premium  All Medicaid premiums paid to the plan reported on lines 2,
3a, 3b and 3c.
 5 . Interest  Interest earned from all sources including escrow and reserve
accounts.
 6. COB Income from Coordination of Benefits and Subrogation
 7. Reinsurance Recoveries  income from the settlement of claims resulting
from a policy with a private reinsurance carrier.
 8. Other Revenue. Revenue from sources not covered in the previous revenue
accounts
 9. Total Revenue  Total revenue (the sum of lines 2 through 8).




---



##### 



EXPENSES: Report total actual expense on an accrual basis for each of the
medical and hospital categories below in column d. Report the applicable amounts for each of
the categories in columns a, b, and c as defined below.
 Paid Claims (Column a)  Enter amounts of paid claims (claims for which checks
have actually been mailed) during the quarter for each medical and hospital category.
 Reported by Unpaid Claims (RBUSs) (Column b) Enter the amount of all claims
which are received during the quarter by the plan for which a check has not yet been issued
for services during the quarter.
 Incurred But Not Reported (IBNR) (column c) Enter estimated amounts of the
obligation for claims which have not yet been received by the plan for services rendered
during the quarter.
 Actual PMPM (Column e). Enter the actual cost per member per month for each
line category. Divide the amount in column d by total member months online1 to arrive a the
dollar and cents number (use two decimal places, e.g. $14.25)
 Medical and Hospital
 10. Inpatient Hospital  Inpatient hospital costs including ancillary services
for enrollees while confined to an acute care hospital, including out of area
hospitalization.
 11. Primary care  Includes all costs associated with medical services
provided in any setting by a primary care provider, including physicians and other
practitioners
 12. Physician specialty services  All costs associated with medical services
provided by a physician other than a primary care physician.
 13. Outpatient Hospital. Includes the facility component of the outpatient
visit. The visit can be free standing or a hospital outpatient department. The professional
component should be billed separately and reported in the appropriate service category line
item, e.g., physician specialty services.
 14. Other Professional Services  Compensation paid by the contractor to non
physician providers engaged in the delivery of medical services.
 15. Emergency Room  Includes the facility component of the emergency room
visit asd well as out of area emergency room costs. Professional components that are billed
separately should be reported in the appropriate service category line item.
 16. DME/Medical Supplies ___include the cost of durable medical equipment and
supplies




---



##### 



17. Prosthetics and Orthotics  includes the cost of Prosthetics and Orthotics
 18. Dental Expenses for all dental services provided.
 19. Pharmacy  Expenses for legend and non-legend pharmacy services provided
that includes both ingredient costs and dispensing fees. Excludes expenses reported as
HIV/AIDS Reimbursable Drugs on line 20.
 20. HIV/AIDS Reimbursable Drugs
 21. Home Health Care  Expenses for home health services provided including
nurses, aides, hospice costs private duty nursing.
 22. Transportation  Expenses for all ambulance, medical intensive care Units
(MICUs) and invalid coach services.
 23. Lab & X-Ray. The cost of all laboratory and radiology (diagnostic
andtherpeutic) services for which the contractor is separately billed.
 24. Vision Care including Eyeglasses  The cost of routine exams (by
non-physicians) and dispensing glasses to correct eye defects. This category includes the
cost of eyeglasses but excludes ophthalmologist costs related to the treatment of disease or
injury to the eye: the latter should be included in physician specialty or Other
professional Services.
 25. Mental Health/Substance Abuse  Include the cost of all mental health and
substance abuse services including inpatient, physician services, outpatient hospital, other
professional services and other services associated with mental health or substance abuse
treatment.
 26. Reinsurance Expense  Expenses for reinsurance or stop loss insurance
 27. Incentive Pool Adjustment  A reduction to medical expense for adjusting
the full medial expenses reported.
 28. Other Medical  medical expenses not included in lines 10-27.
 29Total Medical and Hospital   The total of all medical and hospital expenses
(the sum of lines 10 through 28).
 ADMINISTRATION: Costs associated with the overall management and operation of
the plan including the following components:
 30. Compensation ___all expenses for administrative services including
compensation and fringe benefits for personnel time devoted to or in direct support of
administration. Include expenses for management contracts. Do not include marketing expenses
here.
 31. Interest Expense  Interest on loans paid during the period.




---



##### 



32. Occupancy, Depreciation, and Amortization
 33. Education and Outreach  Expenses incurred for education and outreach
activities
 34. Marketing  Expenses directly related to marketing activities including
advertising, printing, marketing, salaries, and fringe benefits, commissions, broker fees,
travel, occupancy, and other expenses allocated to the marketing activity.
 35. Other. Costs which are not appropriately assigned to the health plan
administration categories defined above.
 36. Total Administration- The total of costs of administration ( the sum of
lines 30 through 35).
 37. Total Expenses: the sum of Total Medical and Hospital Expenses (line 29)
and total Administration (line 36)
 38. Operation Income (Loss)  Excess or deficiency of Total Revenu (line 9)
minus Total Expenses (line 37).
 39. Extraordinary Item  A non-recurring gain or loss
 40. Adjustments for prior period IBNR estimates  should include a
reconciliation and explanation of prior period (BNY estimates. A contra expense would be
reported if IBNR estimates exceeded actual expenses. )
 42. Net Income (loss)  Operation Income (Loss) (line 38) minus lines 39, 40
and 41.




---



##### 



STATE OF NEW JERSEY
 Plan Name
    
    Quarter
Ending
 MEDICAID DATA ONLY
 TABLE 6A
 Quarter Only
 STATEMENT OF REVENUES AND EXPENSES
 Summary of All Eligibility groups on Claims Incurred
 During the Current Quarter
 PAIDCLAIMS
    
    
    RBUCs
    
    
    IBNRFor services received
    
    
    
    
    
    
    ACTUALduring this quarter
    
    
    ACTUAL TOTAL
    
    
    PMPMMember MonthsREVENUE:2. Capitated Premiums3. Supplemental Premiumsa. Maternityb.
HIV/AIDs Reimbursable Drugsc. Other4. Total Premiums5. Interest6. COB7. Reinsurance Recoveries8. Other RevenueTotal REVENUEEXPENSES:Medical & Hospital10. Inpatient Hospital11. Primary Care12. Physician Specialty13. Outpatient Hospital14. Other Professional Service15. Emergency Room16.
DME/Medical supplies17. Prosthetics & Orthotics18. Dental19. Pharmacy20. HIV/AIDS Reimbursable Drugs21. Home Health care22. Transportation23. Labs & X-ray24. Vision Care25 Mental Health/Substance Abuse26. Reinsurance Expenses27. Incentive Pool Adjustment28. Other Medical29. TOTAL MEDICAL AND HOSPITALADMINISTRATION




---



##### 



PAIDCLAIMS
    
    
    RBUCs
    
    
    IBNRFor services received
    
    
    
    
    
    
    ACTUALduring this quarter
    
    
    ACTUAL TOTAL
    
    
    PMPM30. Compensation31. Interest Expense32. Occupancy, Depre. & Amortiz.33. Education and outreach34. Marketing35. Other36.TOTAL ADMINISTRATION37.TOTAL EXPENSES38. OPERATION INCOME (LOSS)39. Extraordinary Item40 Provision for Taxes41. Adj for Prior period IBNR est.42. NET INCOME (LOSS)




---



##### 



STATE OF NEW JERSEY
 Plan Name
    
    Quarter Ending
 MEDICAID DATA ONLY
 TABLE 6B
 STATEMENT OF REVENUES AND EXPENSES
 Summary of All Eligibility groups on Claims Incurred
 Year to Date
 PAIDCLAIMS
    
    
    RBUCs
    
    
    IBNR
    
    
    ACTUAL TOTAL
    
    
    ACTUALFor services received yearto dateMember MonthsREVENUE:2. Capitated Premiums3. Supplemental Premiumsa. Maternityb. HIV/AIDs Reimbursable Drugsc. Other4. Total Premiums5. Interest6. COB7. Reinsurance Recoveries8. Other RevenueTotal REVENUEEXPENSES:Medical & Hospital10. Inpatient Hospital11. Primary Care12. Physician Specialty13. Outpatient Hospital14. Other Professional Service15. Emergency Room16. DME/Medical supplies17. Prosthetics & Orthotics18. Dental19. Pharmacy20. HIV/AIDS Reimbursable Drugs21. Home Health care22. Transportation23. Labs & X-ray24. Vision Care25 Mental Health/Substance Abuse26. Reinsurance Expenses27. Incentive Pool Adjustment28. Other Medical29. TOTAL MEDICAL AND HOSPITALADMINISTRATION30. Compensation




---



##### 



PAIDCLAIMS
    
    
    RBUCs
    
    
    IBNRFor services received year
    
    
    
    
    
    
    ACTUALto date
    
    
    ACTUAL TOTAL
    
    
    PMPM31. Interest Expense32. Occupancy, Depre. & Amortiz.33. Education and outreach34. Marketing35. Other36.TOTAL ADMINISTRATION37.TOTAL EXPENSES38. OPERATION INCOME (LOSS)39. Extraordinary Item40 Provision for Taxes41. Adj for Prior period IBNR est.42. NET INCOME (LOSS)




---



##### 



c
     Category(Care Management,Face-to-face,Employee Name
    
    
    
    
    
    
    
    
    
    
    
    
    
    Compliance withOr Number
    
    Employee Title
    
    
    Salary This quarter
    
    
    Allowable Amount
    
    
    EPSDT, et.al)
    
    
    %Total*(attach
additional sheets,
if necessary)
  (Signature)Name and Title




---



##### 



Table 7 Stop Loss Summary
 The contractor shall identify reinsurance coverage in effect during the quarterly
report period. For each of the designated eligibility categories, the contractor shall report the
total number of enrollees that exceeded the stop loss threshold and the total net expenditures
exceeding the stop loss threshold during the period.




---



##### 



STATE OF NEW JERSEY  Plan Name                 Quarter Ending
 Medicaid Data Only  Table 7  STOP LOSS SUMMARY   A. COVERAGE
 Maximum
    
    
    IncludesAggregate
    
    Maximum
    
    
    Aggregate
    
    
    Insolvency
    
    
    
    
    
    
    Cost ofStop Loss
    
    Per Enrollee
    
    
    Lifetime Per
    
    
    Insurance
    
    
    
    
    
    
    Premiumsthreshold
    
    Per Year
    
    
    Enrollee
    
    
    (Y/N)
    
    
    Deductable
    
    
    PMPM
 Policy Expiration Date
 B.
 Category of Eligibility
    
    AFDC/TA NF
    
    
    DYFS
    
    
    ABD
    
    
    NJ FamilyCare
    
    
    TOTALNumber
of Enrollees
Exceeding Stop
LossNet
Expenditures
Above Stop
Loss
 C. List Details for Each Individual (Name or ID Not Required)
 Net Expenditures Above Stop Loss
    
    Primary Diagnosis/Major Procedure123456789101112131415




---



##### 



A.7.10 reserved  Table 8 Medicaid Claims Analysis
 Part A. Claims Incurred During Current Period (quarter).
 Total Expense (Column A): Enter the accrued amounts in each respective medical
expense category in Column A. Amount reported as line 6. Total should agree with Table 6a, line 29.
total medical and Hospital Expenses. Column A  amounts should equal the sum of Columns B, C,and D
for each respective medical expense category.
 Claims Paid (Column B): Enter the amount of all claims actually processed (checks
mailed) related to services incurred during the quarter. Prior period claims processed during this
quarter but related to services incurred during prior quarters must be reflected in Part B, Column
B.
 Claims Reported  But Not Paid (Column C): Enter the amount of claims received by the
contractor related to services incurred during the quarter but for which checks have not yet been
issued. Do not include amounts for claims paid or IBNY amounts in this column
 Claims Incurred  but not Reported (Column D): Enter the amount estimated for
services incurred during the quarter for which the contractor has not yet received a claim. (Should
be same as Part A, Column D).
 Part B: Unpaid Claims
 Reported Claims that are Unpaid:
 On Claims Incurred During Prior Periods (Column A): Enter the amount of claims
received by the contractor related to services incurred during all periods prior to this quarter
for which checks have not yet been issued.
 On Claims Incurred During Current Period (Column B): Enter the amount of claims
received by the contractor related to services incurred during the quarter for which checks have
not been issued.
 Incurred  but not Reported
 On Claims Incurred During Prior Periods (Column C): Enter the amount estimated for
services incurred during all periods prior to this quarter for which the contractor has not yet
received a claim.
 On Claims Incurred During Current Period (Column D) Enter the amount estimated for
services incurred during the quarter for which the contractor has not yet received a claim.
 (Should be the same as Part A, Column D).
 Total Unpaid Claims (Column E): Enter the sum of Part B, Columns A, B, C, and D.




---



##### 



Plan
Name                                                 
                                                                           STATE OF NEW JERSEY
 Quarter Ending  TABLE 8  MEDICAID CLIAMS ANALYSIS
 A. Claims incurred during Current Period
 (D)(C)
    
    
    Claims IncurredCategory of Service
    
    
    
    
    
    
    
    
    
    Claims
    
    
    But NotRevenue & Expense
    
    (A)
    
    
    (B)
    
    
    Reported But
    
    
    ReportedStatement (Table 6a)
    
    Total Expenses
    
    
    Claims Paid
    
    
    Not Paid
    
    
    (IBNR)1.
Inpatient.... (line
10)2.
Primary Care ...
(line
11)3.
Physician Specialty
Services
(line12)4.
Emergency Room
(line
15)5.
All other medical
services (line
28)6.
TOTAL (line
29)
 B. Claims Unpaid
 (A)
    
    
    (B)
    
    
    (C)
    
    
    (D)
    
    
    (E)Reported Claims that are Unpaid
    
    

Incurred But Not ReportedOn Claims
    
    
    On ClaimIncurred
    
    
    On Claims
    
    
    On ClaimsIncurredIncurred
    
    
    During
    
    
    Incurred
    
    
    During
    
    
    Total UnpaidDuring Prior
    
    
    Current
    
    
    During Prior
    
    
    Current
    
    
    ClaimsCategory of Service
    
    Periods
    
    
    Period
    
    
    Periods
    
    
    Period
    
    
    (A+B+C+D)1.
Inpatient2.
Primary Care3.
Physician Specialty
Services4.
Emergency Room5.
All other medical
services6.
TOTAL




---



##### 



A.7.11Table 9 Health
Care Data Elements




---



##### 








---



##### 



The contractor must report encounter data at least quarterly and no more
frequently than monthly. The data shall be enrollee specific, listing all encounter data elements
of the services provided. The data reporting medium shall be a tape or diskette in a configuration
specified by DMAHS. Encounter report files will be used to create a data base which can be used in
a manner similar to fee for service history files to analyze plan utilization, reimburse the
contractor for supplemental payments (e.g. Pregnancy outcome) and calculate capitation premiums.
DMAHS will edit the data to assure consistency and readability. If data 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. All enrollee specific encounter data must be
submitted in accordance with the EMC manual.
The encounter list indicates the required data elements for Inpatient and Ambulatory Care
encounters. In addition, optional data elements are also listed. These elements are optional in
the sense that they can be used to custom fit the reporting to the needs of a particular program,
enhance data validity checking, or allow more flexibility in the use of mandatory data elements.




---



##### 



Medical Center
    
    Medical Center DOS
    
    Unduplicated
    
    Units/Days/Prescri
    
    
    
    Capitation
    
    Other AmountCOS Code
    
    DESC
    
    Enrollees Served
    
    ptions
    
    FFS Amount Paid
    
    Amount
    
    Paid01
    
    Inpatient Hospital04N
    
    Outpatient Hospital- Not ER04E
    
    Outpatient Hospital- ER08D
    
    EPSDT-PDNEPM
    
    EPSDT- MedicalEPD
    
    EPSDT- Dental09
    
    Optical Appliances10P
    
    Primary Care Physician,
Nurse Practitioner,
Physician Assistant10S
    
    Specialty Physician11
    
    Dental13
    
    Optomestrist Services14
    
    Chiropractic Services15S
    
    Nurse Practitioner -
Specialty17
    
    Podiatrist Services18
    
    Prosthetics and Orthotics20H
    
    Pharmacy, HIV/AIDS Drugs20N
    
    Pharmacy, Not HIV/AIDS Drugs30
    
    Medical supplies




---



##### 



Medical Center
    
    Medical Center DOS
    
    Unduplicated
    
    Units/Days/Prescri
    
    
    
    Capitation
    
    Other AmountCOS Code
    
    DESC
    
    Enrollees Served
    
    ptions
    
    FFS Amount Paid
    
    Amount
    
    Paid31
    
    DME32
    
    Hearing Aids40
    
    Home HealthPDN
    
    Private Duty Nursing  Not
EPSDT50
    
    Hospice Services60
    
    Lab65
    
    Radiology70
    
    TransportationFP
    
    Family PlanningMH
    
    Mental HealthPAS
    
    Physician Assistant SpecialtySA
    
    Substance AbuseXM
    
    Other Medical




---



##### 



TABLE 9
HEALTH CARE ELEMENTS
 Professional
    
    Dental
    
    Transportation
    
    Vision
    
    DescriptionCOMMON
DATAHMO ID
    
    X
    
    
    
    X
    
    
    
    HMO ID number assigned by
MedicaidRecord
ID
    
    X
    
    
    
    X
    
    
    
    HMO Number assigned to
the recordPatient
Medicaid ID
    
    X
    
    
    
    X
    
    
    
    Recipient ID
NumberWorkers
Comp
    
    X
    
    
    
    X
    
    
    
    Y/N indicator that
service is subject to workers
comp or relatedPayment
amount
    
    X
    
    
    
    X
    
    
    
    Total amount paid by
HMOPatient
DOB
    
    O
    
    
    
    X
    
    
    
    Patients DOBDate Claim
received
    
    X
    
    
    
    X
    
    
    
    Date Claim received by
HMODate of
payment
    
    X
    
    
    
    X
    
    
    
    Date of payment by
HMOStatus
code
    
    X
    
    
    
    X
    
    
    
    Status code p = paid, d =
deniedDETAIL
AREA
    
    X
    
    
    
    X0
    
    Capitation
Service
Category
    
    X
    
    
    
    X
    
    
    
    Classification of
services according to list1
    
    Service Date
From
    
    X
    
    
    
    X
    
    
    
    Date service
started2
    
    Service Date to
    
    X
    
    
    
    
    
    
    
    Date Service
Ended3
    
    Procedure
Code
    
    X
    
    
    
    X
    
    
    
    HCPCS procedure
code4
    
    1 Procedure
Code Modifier
    
    X
    
    
    
    
    
    
    
    First modifier, if
applicable5
    
    2 Procedure
Code modifier
    
    X
    
    
    
    
    
    
    
    Second modifier, if
applicable6
    
    Place of
Service
    
    X
    
    
    
    
    
    
    
    Place of Service
1=Office, 2=inpatient hospital, 3
= outpatient hospital/ER7.
    
    Diagnosis
Codes
    
    X
    
    
    
    
    
    
    
    ICD 9 CM diagnosis
code8
    
    Units of
Service
    
    X
    
    
    
    X
    
    
    
    Units of service
rendered9
    
    Servicing
Provider Number
    
    X
    
    
    
    X
    
    
    
    Provider SSN or Tax
ID0
    
    Referring
Provider Number
    
    X
    
    
    
    X
    
    
    
    Individual group from who
the patient was referred
 X = Required
O= Optional




---



##### 



TABLE 9B
HEALTH CARE ELEMENTS
 Inpatient
    
    Outpatient
    
    Home Health
    
    DescriptionCOMMON DATAHMO ID
    
    X
    
    X
    
    
    
    HMO ID number assigned by
MedicaidRecord ID
    
    X
    
    X
    
    
    
    HMO Number assigned to the
recordPatient Medicaid ID
    
    X
    
    X
    
    
    
    Recipient ID NumberWorkers Comp
    
    X
    
    X
    
    
    
    Y/N indicator that service is
subject to workers comp or
relatedPayment amount
    
    X
    
    X
    
    
    
    Total paid by HMOCapitation Service Category
    
    O
    
    O
    
    
    
    Classification of service,
according to listPatient DOB
    
    X
    
    X
    
    
    
    Patients DOBAdmit Date/Service From Date
    
    X
    
    X
    
    
    
    Date admitted to hospitalDischarge Date
    
    X
    
    X
    
    
    
    Date discharged from hospital0
    
    DRG Code
    
    X
    
    
    
    
    
    DRG Code1
    
    Patient Status
    
    X
    
    
    
    
    
    Status of patient at end of
stay 1= discharged to home,
2=discharged to LTC facility, 3=death,
4=otherSurgery Data (Up to 3 times)2
    
    Procedure Code
    
    X
    
    
    
    
    
    CPT/HCPCS Codes3
    
    Surgery Date
    
    X
    
    
    
    
    
    Surgery Date, if
applicable4
    
    Admitting Diagnosis Code
    
    X
    
    
    
    
    
    ICD 9CM diagnosis on
admittance5
    
    Discharge Diagnosis
    
    X
    
    
    
    
    
    ICD 9CM diagnosis on
discharge6
    
    Attending Physician Code
    
    X
    
    
    
    
    
    Attending Physician SSN or Tax
ID7
    
    Servicing provider Number
    
    X
    
    
    
    
    
    Facility/agency rendering care
tax id8
    
    Referring provider number
    
    X
    
    
    
    
    
    Individual/group from whom the
patient was referred, SSN or tax
id9
    
    Date claim received
    
    X
    
    
    
    
    
    Date Claim received by
HMO0
    
    Date of Payment
    
    X
    
    
    
    
    
    Date of payment by HMO1
    
    Status Code
    
    X
    
    
    
    
    
    Status code p = paid, d =
deniedDETAIL AREA2
    
    Capitation Service Category
    
    
    
    
    
    
    
    Classification of services
according to list3
    
    Service Date From
    
    
    
    
    
    
    
    Date service started4
    
    Service Date to
    
    
    
    
    
    
    
    Date Service Ended5
    
    Procedure Code
    
    
    
    
    
    
    
    HCPCS procedure code6
    
    Procedure Code Modifier
    
    
    
    
    
    
    
    modifier, if
applicable7
    
    Units of Service
    
    
    
    
    
    
    
    Units of service
rendered8
    
    Revenue Code
    
    
    
    
    
    
    
    Identifies the services
rendered in these settings9
    
    Clinic Code
    
    
    
    
    
    
    
    Identifies specialty clinic in
the outpatient hospital
setting
 X = Required
O= Optional




---



##### 



TABLE 9C 
HEALTH CARE DATA ELEMENTS
 DRUGHMO ID
    
    X
    
    HMO ID number assigned by MedicaidRecord ID
    
    X
    
    HMO Number assigned to the recordPatient Medicaid ID
    
    X
    
    Recipient ID NumberWorkers Comp/Accident
    Ind
    
    X
    
    Y/N indicator that service is subject to
workers comp or relatedPayment amount
    
    X
    
    Total paid by HMOPharmacy Number
    
    X
    
    Pharmacy provider SSN or Tax IDPrescribing Provider
    Number
    
    X
    
    Prescribing provider SSN or Tax IDRecipient DOB
    
    X
    
    Patient date of birthDate Dispersed
    
    X
    
    Date drug was dispersedNDC Number
    
    X
    
    NDC code of the substance dispensedMetric Quantity
    
    X
    
    Quantity of the substance dispensed and the
units of measureDays Supply
    
    X
    
    Days supply of the drug dispensedRefill Indicator
    
    X
    
    Number of available refills after the
dispensing dateCapitation Service
    Category
    
    X
    
    Classification of service according to
listDate Claim Received
    
    X
    
    Date claim received by HMODate of Payment
    
    X
    
    Date payment made by HMOStatus code
    
    X
    
    Status code p=paid, d= denied
 TABLE 9D
CAPITATION SERVICE CATEGORY LIST
 0
1A
    
    PRIMARY Care Physician, Nurse
Practitioners, Physician Assistant01b
    
    Specialty Physician02
    
    EPSDT03
    
    Inpatient Hospital04
    
    Outpatient Hospital05
    
    Laboratory06
    
    Radiology07
    
    Prescription Drugs08
    
    Family Planning09
    
    Outpatient Therapies10
    
    Podiatrist Services11
    
    Chiropractic Services12
    
    Optometrist Services13
    
    Optical Appliances14
    
    Hearing Aids15
    
    Home Health Agency Services16
    
    Hospice Services




---



##### 



17
    
    Durable Medical Equipment18
    
    Medical Supplies19
    
    Prosthetics and
Orthotics20
    
    Dental Services21
    
    Transportation




---



##### 



A.7.12 Reserved
 Table 10 Third Party Liability Collections
 The contractor shall report quarterly the categories of all third party liability
collections to DMAHS and shall include a complete disclosure demonstrating its efforts to obtain
payment from liable third parties and the amounts and nature of all third party payments recovered
for Title XIX and NJ FamilyCare enrollees including but not limited to payments for services ad
condition which are:
 
    
    · Covered through coordination of benefits;
    
    Employment related injuries or illnesses;
    
    Related to motor vehicle accidents, whether injured
as pedestrians, drivers, passengers or bicyclists; and
    
    Contained in diagnosis Codes 800 through 999 (ICD9CM)
with the exception of Code 994.6.




---



##### 



STATE OF NEW JERSEY
 PLAN
NAME                                                                                                                                                      Quarter Ending
 TABLE 10
THIRD PARTY LIABILITY COLLECTIONS *
 Casualty Insurance
    Health InsuranceEmployment
    
    Motor VehicleEligibility Category
    
    Related
    
    Related
    
    OtherAFDC **DYFSSSI AGED W/MEDICARE+SSI AGED W/O MEDICARE+SSI DISABLED & BLIND W/ MEDICARESSI DISABLED & BLIND W/O MEDICARENJ FAMILYCARETotal
 
 *
    
    Enter total amount collected for each eligibility category,**
    
    Include New Jersey care children and pregnant women+
    
    Include essential spouses




---



##### 



Reserved
 Table 11 Provider Additions and Deletions
 The contractor shall report, on a quarterly and annual basis, all additions and deletions to the
provider network as well as closed panels. Report closed panels under the deletions portion of the
table and state under the Reason for change column: Closed Provider Panel. Include the names
and locations of all new providers and subcontractors; decreases in the provider network;
identified by provider type, name and location; an all PCPs, PCDs, CNPs/CNSs, physician assistants,
physician specialists, and other subcontractors who are not accepting new patients. The contractor
shall not allow enrollment freezes for any provider unless the same limitations apply to all
commercially insured members as well or contract capacity limits have been reached.




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##### 



STATE OF NEW JERSEY
 Plan
Name
                       
                       
                       
               
               Quarter Ending
 TABLE 11
PROVIDER ADDITIONS AND DELETIONS
 A) Total Physicians at Start of Quarterb)Total Additions this quarterc) Total Deletions this Quarterd) Total Physicians at End of Quarter
 Recruitment Rate
    
    %Disenrollment Rate
    
    %Growth Rate
    
    %
 =a+b+c
 A. Listing of changes in Non Hospital Providers During Quarter
 Name of Additions
    
    Provider Type
    
    Address & City
    
    County
    
    Reason for ChangeTotal AdditionsName of DeletionsTotal Deletions
 B. Listing of Contracted Hospital Changes
 Name of Additions
    
    Address & City
    
    Reason for ChangeTotal AdditionsName of DeletionsTotal Deletions




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##### 



Table 14 EPSDT Services
 1. EPSDT Services
 the following EPSDT Services reports sorted by age group (0-11.99 months, 1-2 years, 3-5
years, 6-9 years, 10-14 years, 15-18 years, and 19-20 years) and separated by Medicaid/NJ
FamilyCare Plan A and Medicaid/NJ FamilyCare Plans B, C, and D must
be submitted quarterly:
 a. Number of Enrollees Receiving at least One Initial or Periodic Screening Services. This
is an unduplicated count of individual who received one or more documented initial or
periodic screenings during the quarter.
 b. Actual Number of Initial and Periodic Screening Services by Age. This includes combined
number of initial and periodic EPSDT child health screening examinations during the quarter.
Do not enter data for incomplete or inter-periodic screenings, or for vision, dental, or
hearing services.
 2. Referrals to Specialists
 a. Number of Referrals for Vision Assessments
 b.
Number of Referrals for Dental Assessments
 c.
Number of Referrals for Hearing Assessments
 d. Number of Referrals for Mental Health Assessments
e. Number of Referrals for Other Health Assessments
 3. Appropriate Immunizations according to Age (Report only newly identified Cases).
Number of enrollees Receiving Immunizations Sorted by Age Group (0-11.99 months, 1-2 years, 3-5
years, 6-9 years, and 10+ years).
 4. Lead Screenings and Treatments
 a. total number of enrollees screened for Lead Toxicity (all ages).
 b. Number of enrollees Screened Sorted by Age Group (9-18 months, 19-26 months, and 27-72 months).
 c. Number of newly identified Lead Positive Enrollees with Blood Lead Level Between 10-14 μg/dl
(low Toxicity).
 d. Number of newly identified Lead Positive Enrollees with Blood Lead Level Between 15-19 μg/dl
(Mild Toxicity).
 e. Number of newly identified Lead Positive Enrollees with Blood Lead Level 20 μg/dl and Over
(Moderate, High and Severe Toxicity).
 f. Number of Enrollees Referred to Local Health Departments with Blood Lead level of 10 μg/dl and
over
 g. Number of Enrollees Receiving Treatments with chelation.
 h. Number of Enrollees with Blood Lead level of 10 μg/dl and over placed in HMO Case Management
Program.




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##### 



STATE OF NEW JERSEY
 Plan
Name
                       
                       
                       
               
               Quarter Ending
 TABLE 14
EPSDT SERVICES
 Medicaid/NJ1. EPSDT Services

    
    FamilyCare A
    
    FamilyCare B, C & Dunduplicated count of children screenedb.
Number of screens by
age:                                                                     
<11-23-56-910-1415-1819-20Total number of screens
 Medicaid/NJ
    
    FamilyCare B, C2. Referrals to Specialist
    
    FamilyCare A
    
    & Da. Vision referralsb. Dental referralsc. Hearing referralsd. Mental health referralse. Other referrals
 Medicaid/NJ
    
    FamilyCare B, C3. Appropriate Immunizations According to Age
    
    FamilyCare A
    
    & Da. Number of enrollees receiving immunizations by
age:       <111-23-56-910+Total number of enrollees receiving immunizations
 4. Lead screenings and Treatments
    
    Medicaid/NJ
    
    FamilyCare B, CReport only newly identified Cases
    
    FamilyCare A
    
    & Da. Total No. of enrollees screened (all ages)b. No. of enrollees screened by age:19-18 months19-26 months27-72 monthsc No. of enrollees with low toxicity (BLL 10-14 μg/dl)
Ages19-18 months19-26 months27-72 monthsc No. of enrollees with mild toxicity (BLL 15-19 μg/dl)
Ages19-18 months




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##### 



4. Lead screenings and Treatments
    
    Medicaid/NJ
    
    FamilyCare B, CReport only newly identified Cases
    
    FamilyCare A
    
    & D19-26 months27-72 monthse No. of enrollees with high toxicity (BLL = 20 μg/dl)
Ages19-18 months19-26 months27-72 monthsf. no. of enrollees referred to LHDs (BLL = 10 μg/dl)g. . no. of enrollees being treated with chelationh. . no. of enrollees with BLL = 10 μg/dl placed in HMO case management
 NOTE: if a response is 0, provide explanation




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##### 








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##### 



Number of PAs
    
    Number of PAsCategory of Service
    

requested
    

denied
    
    % of PAs DeniedInpatient HospitalPrimary CarePhysician Specialty ServicesOutpatient HospitalOther Professional ServicesEmergency RoomDME/Medical SuppliesProsthetics & OrthoticsDentalPharmacyFormularyOff-FormularyHIV/AIDS Reimbursable DrugsHome Health CareTransportationLab & X-RayVision Care & EyeglassesMental HealthSubstance AbuseHospicePrivate Duty NursingOther MedicalTotal




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##### 



HMO Financial Reporting Manual for Medicaid/NJ FamilyCare Rate Cell Grouping Costs Table 19A, Parts A through V.




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##### 



Guide  Reporting
 Revised Date: March  January 2004
Effective Date: State Fiscal Year 2005




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##### 



1. Introductions
    
    
    22. General Instructions
    
    
    73. Report Guidelines Specifications
    
    

    9
 
    
    Report # 1: Lag Report (Table 20, Parts AE)
9
    
    Report # 2: Income Statements by Rate Cell Grouping (Table
19, Parts AV) 16 13
 o
    
    Table 19, Parts AS3: Medicaid/NJ FamilyCare At-Risk Groupingso
    
    Table 19, Part T: Non-State Plan Serviceso
    
    Table 19, Parts U and V: Managed Care Service Administrator Groupings
 
    
    Report # 3: Maternity Outcome Counts (Table 21)
    2922424
 
    
    Report # 4: Claims Processing Lag Reports (Parts
AB)
    302525
 
    
    Report # 7: Stop Loss Summary (Parts AC)
    352929
 
    
    Report # 10: Third Party Liability Collections
    363030
 
    
    Report # 3: Maternity
Outcome            Counts
(Table
21)

22
 4. Incurred  But Not Reported (IBNR) Methodology
    
    Appendix A5. Report Forms
    
    Appendix B
 HMO Financial Guide forReporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Introduction
  Guide Guide should Guide
 Guide Guide
 
    
    Rate cell grouping detail;
    
    Regional detail;
    
    IBNR calculation detail;
    
    Timing of submissions.
 Rate Cell Groupings
 Guide  a should
 HMO Financial Guide forReporting Specifications

    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



CapitationRate Cell Reference
    
    Rate Cell Grouping
    
    Code
    
    DescriptionTable # 19  Parts A, B, C
    
    AFDC/NJCPW/NJ KidCare A
 (Excluding AIDS)
    
    125R1-125R3
143R1-143R3
171R1-171R3
172R1-172R3
183R1-183R3
    
    Individual 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
    
    DFYS Clients
(Excluding AIDS)
    
    
    32599,34399
    
    
    Individuals eligible through the Division of
Youth and Family services (DYFS),
also known as
including Foster Care children and children
with Adoption Assistance, excluding
individuals with AIDS.Table # 19  Part E
    
    ABD with Medicare  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
Non- DDD
(Excluding AIDS)
    
    711R1-711R3
813R1-813R3
823R1-823R3
    
    ABD individual who receive Medicare and are
not eligible for services through the DDD,
excluding individuals with AIDS.Table # 19  Part G
    
    Non-ABD   DDD
(Excluding AIDS)
    
    47399
    
    Non-ABD individual eligible for services
through the DDD, excluding individuals with
AIDS.Table # 19  Part H
    
    ABD without Medicare 
DDD
(including AIDS)
    
    
    49399
    
    
    ABD individuals not receiving Medicare and
eligible for services through the DDD,
including individuals with AIDS.Table # 19  Part I
    
    ABD without Medicare 
Non-DDD
(including AIDS)
    
    
    71099, 81099
    
    
    ABD individuals not receiving Medicare and
not eligible for services through the DDD,
including individuals with AIDSTable # 19  Part J
    
    NJ KidCare B7C
(excluding AIDS)
    
    
    62599, 6399
    
    
    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 above 201% and up to and including
350% FPL, excluding individuals with AIDS.Table # 19  Part M
    
    NJ FamilyCare Parents
0-133% FPL (excluding
AIDS)
    
    57199, 57899,
58499
    
    Parents with dependent children with family
income between 0 and 133% FPL, excluding
individuals with AIDSTable # 19  Part O
    
    NJ FamilyCare Parents
134-2050% FPL (excluding
AIDS)
    
    
    95499, 97499,
98499
    
    
    Parents with dependent children with family
income between 134% and 200% FPL,
Parents/Caretakers with children below 23,
and children from the age of 19 through 22
years who are fulltime students who do not
qualify for AFDC Medicaid with family incomes
up to and including 250% of FPL, excluding
individuals with AIDS.
 HMO
Financial Guide forReporting Specifications


State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



CapitationRate Cell Reference
    
    Rate Cell Grouping
    
    Code
    
    Description250% of FPL, excluding individuals
with AIDS.Special Populations DataTable # 19  Part P
    
    ABD with Medicare 
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, DYFS, 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 Report # 2R1
and#3(Table 21)
in the Report Guidelines
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 Report # 2R2, in the Report
Guidelines
Specifications section.Table # 19  Part U
    
    NJ Familycare Adults
0100% FPL (excluding
AIDS)
    
    65499, 67499, 
68499
    
    Single Adults and couples without dependent
children with family income between 0% and
100% FPL, adults and couples without
dependent children under the age of 23 with
family incomes up to and including 250% FPL,
excluding individuals with AIDS. Includes
Health Access individuals without dependent
children.Table # 19  Part V
    
    Adult Restricted Aliens
    
    40199, 40299,
40399
    
    Classification based on restricted alien
status PSCs 310330, 410-47
30, 470 and 380 over the age of 20, or NJ
FamilyCare PSCs 763, and 497 and 498 with
corresponding cap codes.
 HMO Financial Guide forReporting Specifications


    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Guide
 Northern (Region 1)
    
    Central (Region 2)
    
    Southern (Region 3)Bergen
    
    Essex
    
    AtlanticHudson
    
    Mercer
    
    BurlingtonHunterdon
    
    Middlesex
    
    CamdenMorris
    
    Union
    
    Cape MayPassaic
    
    
    
    CumberlandSomerset
    
    
    
    GloucesterSussex
    
    
    
    MonmouthWarren
    
    
    
    OceanSalem
 HMO Financial Guide forReporting Specifications

    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



general guideline
  should
  Quarter Ending:
    
    Due DateMarch 31
    
    May 15June 30
    
    August 15September 30
    
    November 15December 31
    
    February 15
  Daved.Moran@dhs.state.nj.us  andTanti.Dararutana@dhs.state.nj.us       Mike.Nordstrom@mercer.com
  versions of these
reports
 HMO Financial Guide forReporting Specifications

    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



current
DMAHS
  should
 should should should
  should should
 can
 HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Guidelines Specifications
  helpful
 see below for services that are included in
 Consolidated
    
    Income Statement
    
    Managed Care Category
    
    Medical Cost
    
    Lag ReportCategory of Service
    
    Reference
    
    of Service Codes
    
    Grouping
    
    ReferenceDescriptionInpatient Hospital
    
    Table # 19  Parts
S1 & S2, Line 9
    
    Inpatient hospital costs
including ancillary services for
enrollees while confined to an acute
care hospital , including out of area
(OOA) hospitalization.
01
    
    Inpatient Hospital
    
    Table # 20  Part APrimary Care
    
    Table # 19  parts
S2 & S2, Line 10
    
    All costs associated with
medical services provided in any
setting by a primary care provider,
including physicians and other
practitioners.
10P
    
    Physician
    
    Table # 20  Part BPhysician Specialty Services
    
    Table # 19  parts
S2 & S2, Line 11
    
    All costs associated with
medical services provided by a
physician other than a primary care
physician (PCP)
10S
    
    Physician
    
    Table # 20  Part BPharmacy
(not to include
Reimbursable HIV/AIDS Drugs
and Blood Products)
    
    Table # 19  parts
S2 & S2, Line 18
    
    Expenses for legend and
non-legend drugs provided that include
both ingredient costs and dispensing
fees. Exclude expense reported to Human
Immunodeficiency Virus (HIV/AIDS
Reimbursable Drugs
20N
    
    Pharmacy
    
    Table # 20  Part C
 HMO Financial Guide for Reporting Specifications
    
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Consolidated
    
    Income Statement
    
    Managed Care Category
    
    Medical Cost
    
    Lag ReportCategory of Service
    
    Reference
    
    of Service Codes
    
    Grouping
    
    ReferenceDescriptionReimbursable HIV/AIDS Drugs
and Blood Products
    
    Table # 19  parts
S2 & S2, Line 19
    
    Specifically, protease
inhibitors and certain other
anti-retrovirals and factor VIII and IX
blood clotting factors.
20H
    
    Pharmacy
    
    Table # 20  Part COutpatient Hospital
(excludes ER)
    
    Table # 19  parts
S2 & S2, Line 12
    
    The facility component of
the outpatient visit. The visit can be
to a free standing clinic or to a
hospital outpatient department
04N
    
    Pharmacy
    
    Table # 20  Part DOther
Professional Services
    
    Table # 19  parts
S2 & S2, Line 13
    
    Compensation paid by the
HMO to non-physician providers engaged
in the delivery of medical
services
14, 15S, 17, PAS
    
    Other
    
    Table # 20  Part DEmergency
Room
    
    Table # 19  parts
S2 & S2, Line 14
    
    The facility component of
the emergency room visit as well as OOA
emergency rooms costs.
04E
    
    Other
    
    Table # 20  Part DDME/Medical
Supplies
    
    Table # 19  parts
S2 & S2, Line 15
    
    The cost of durable
medical Equipment (DME) and supplies
30, 31, 32.
    
    Other
    
    Table # 20  Part DProsthetics
and Orthotics
    
    Table # 19  parts
S2 & S2, Line 16
    
    The cost of Prosthetics
and Orthotics
    
    Other
    
    Table # 20  Part DDental
    
    Table # 19  parts
S2 & S2, Line 17
    
    Expenses for all dental
services provided
    
    Other
    
    Table # 20  Part DHome
Health, Hospice, and
PDN
Care
    
    Table # 19  parts
S2 & S2, Line 20
    
    Expenses for home health
services provided, including nurses,
aides and hospice costs and private
duty nursing (PDN
). 40, 50, PDN
    
    Other
    
    Table # 20  Part DTransportation
    
    Table # 19  parts
S2 & S2, Line 21
    
    Expenses for all
ambulance, medical intensive care units
(MICUs) and invalid coach
services
    
    Other
    
    Table # 20  Part DLab
& X-ray
    
    Table # 19  parts
S2 & S2, Line 22
    
    The cost of all
laboratory and radiology (diagnostic
and therapeutic) services for which the
HMO is separately billed.
60, 65.
    
    Other
    
    Table # 20  Part D
 HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Consolidated
    
    Income Statement
    
    Managed Care Category
    
    Medical Cost
    
    Lag ReportCategory of Service
    
    Reference
    
    of Service Codes
    
    Grouping
    
    ReferenceDescriptionVision Care including
eyeglasses
    
    Table # 19  parts
S2 & S2, Line 23
    
    The cost of routine exams
(by non-physicians) and dispensing
glasses to correct eye defects. This
category includes the cost of
eyeglasses but excludes ophthalmologist
costs related to the treatment of
disease or injury to the eye.
09, 13.
    
    Other
    
    Table # 20  Part DMental Health/substance
Abuse
    
    Table # 19  parts
S2 & S2, Line 24
    
    The cost of mental health
and substance abuse services including
inpatient, physician services,
outpatient hospital, other professional
services, and other services associated
with mental health or substance abuse
treatment.
MH, SA.
    
    Other
    
    Table # 20  Part DEPSDT Medical and PDN
    
    Table # 19  parts
S2 & S2, Line 26a
    
    08D, EPM
    
    Other
    
    Table # 20  Part DEPSDT Dental
    
    Table # 19  parts
S2 & S2, Line 26b
    
    EPD
    
    Other
    
    Table # 20  Part DFamily
Planning
    
    Table # 19  parts
S2 & S2, Line 27
    
    The cost of family
planning services, including medical
history and physical examinations
(including pelvic and breast),
diagnostic and laboratory tests, drugs
and biologicals, medical supplies and
devices, counseling, continuing
medical supervision, continuity of care
and genetic counseling
, FP
    
    Other
    
    Table # 20  Part DOther Medical
    
    Table # 19  parts
S2 & S2, Line 28
    
    Medical expenses not
included above.
XM
    
    Other
    
    Table # 20  Part D
  HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



should
  should should should should
  should should with
 should
 The amount in each column on this line must be updated each period.
   should
 HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Guidelines
  seventeen
  should should
   
    
    640.01, 640.81, 640.91
    
    641.01, 641.11, 641.21, 641.31, 641.81, 641.91,
    
    642.01, 642.11, 642.21, 642.21, 642.31, 642.41, 642.51, 642.64, 642.71, 642.91, 642.02,
642.12, 642.22, 642.21, 642.31, 642.41, 642.51, 642.61, 642.71, 642.91, 642.92
    
    643.01, 643.11, 643.21, 643.81, 643.91,
    
    645.01
    
    646.01, 646.11, 646.12, 646.21, 646.22, 646.31, 646.41, 646.42, 646.51, 646.52, 646.61,
646.62, 646.71, 646.81, 646.82, 646.91
 HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 




    
    647.01, 647.11, 647.21, 647.31, 647.41, 647.51, 647.61, 647.61, 647.81, 647.91, 647.02,
647.12, 647.11, 647.21, 647.32, 647.42, 647.52, 647.62, 647.82, 647.92
    
    648.01, 648.11, 648.21, 648.31, 648.41, 648.51, 648.61, 648.71, 648.81, 648.91, 648.02,
648.12, 648.22, 648.32, 648.62, 648.52, 648.62, 648.82, 648.92
    
    650 (and any or no trailing characters)
    
    651.01, 651.11, 651.21, 651.31, 651.41, 651.51, 651.61, 651.81, 651.91
    
    652.01, 652.11, 652.21, 652.31, 562.41, 652.51, 652.61, 652.71, 652.81, 652.91
    
    653.01, 653.11, 653.21, 653.31, 563.41, 653.51, 653.61, 653.71, 653.81, 653.91
    
    654.01, 654.11, 654.21, 654.31, 564.41, 654.51, 654.61, 654.71, 654.81, 654.91, 654.02,
654.12, 654.22, 654.32, 564.42, 654.52, 654.62, 654.72, 654.82, 654.92
    
    655.01, 655.11, 655.21, 655.31, 565.41, 655.51, 655.61, 655.71, 655.81, 655.91
    
    656.01, 656.11, 656.21, 656.31, 566.41, 656.51, 656.61, 656.71, 656.81, 656.91
    
    657.01
    
    658.01, 658.11, 658.21, 658.31, 568.41, 658.81, 658.91
    
    659.01, 659.11, 659.21, 659.31, 569.41, 659.51, 659.61, 659.71, 659.81, 659.91
    
    660.01, 660.11, 660.21, 660.31, 660.41, 660.51, 660.61, 660.71, 660.81, 660.91
    
    661.01, 661.11, 661.21, 661.31, 661.41, 661.91
    
    662.01, 662.11, 662.21, 662.31,
    
    663.01, 663.11, 663.21, 663.31, 663.41, 663.51, 663.61, 663.81, 663.91
    
    664 (and any or no trailing characters)
    
    665.01, 665.11, 665.31, 665.41, 665.51, 665.61, 665.71, 665.81, 665.91, 665.22, 665.72,
665.92, 665.92
    
    666.02, 666.12, 666.22, 666.32
    
    667.02, 667.12
    
    668.01, 668.11, 668.21, 66.881, 668.02, 668.12, 668.22, 668.82
    
    669.01, 669.11, 669.21, 669.31, 669.41, 669.51, 669.61, 669.71, 669.81, 669.91, 669.02,
669.12, 669.22, 669.32, 669.42, 669.82, 669.92
    
    670.02
    
    671.01, 671.11, 671.21, 671.31, 671.42, 671.51, 671.81, 671.91, 671.01,671.12, 671.22,
671.52, 671.82, 671.92
    
    672.02
    
    673.01, 673.11, 673.21, 673.31, 673.81, 673.02, 673.12, 673.22, 673.32, 673.82
    
    674.01, 674.02, 674.12, 674.22, 674.32, 674.42, 674.82, 674.92
    
    675.01, 675.11, 675.21, 675.81, 675.91, 675.02, 675.12, 675.22, 675.82, 675.92
    
    676.01, 676.11, 676.21, 676.31, 676.41, 676.51, 676.61, 676.81, 676.91, 676.02, 676.12,
676.22, 676.32, 676.42, 676.52, 676.62, 676.82, 676.92, 677 (no other characters)
    
    V27, V27.0, V27.2, V27.3, V27.4, V27.5, V27.6, V27.7, V27.9
  
    
    59400, 59409, 59410, 59412, 59414, 59430, 59510, 59510, 59514, 59515, 59525, 59610,
59612, 59614, 59618, 59620, 59622, 59821
  HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 




    
    720, 722, 724, 729
 should
 Report # 2 Part S must reconcile to reports #6A and #6B for the Medicaid managed care
at rsik populations. Report # 2 Parts U and V must reconcile to reports #6D and #6E (reports #6D and
#6E on a paid basis) respectively, for the MCSA groups.
 E s child car seat
   should should
 should
  normally
 HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



1
   should should
 should shoule be
     
 1
    
    Because costs for pregnancy outcomes were not included in the capitation rates, a separate maternity premium
payment is paid for pregnancy outcomes (each live birth, still birth, or miscarriage occurring at after or after
the twelfth thirteenth (12
13th) week of gestation). This supplemental payment reimburses HMOs 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, NJKidCare B, C, and D,
DYFS, and Blind/Disabled rate cell groupings. HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Inpatient hospital costs including ancillary services for enrollees while confined to
an acute care hospital, including OOA hospitalization.
 Includes all costs associated with medical services provided in any setting by a
primary care provider, including physicians and other practitioners.
  All costs associated with medical services provided by a physician other than a PCP.
  Includes the facility component of the outpatient visit to a free standing clinic or
to a hospital outpatient department should shall be billed separately and reported in the
appropriate service category line item, e.g. physician specialty services.
  Compensation paid by the HMO to non-physician providers engaged in the delivery of
medical services
  The facility component of the emergency room visit as well as OOA emergency rooms
costs.
  The cost of durable medical Equipment (DME) and supplies
 HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Includes the cost of Prosthetics and Orthotics
  Expenses for all covered dental services.
  Expenses for legend and non-legend drugs provided that include both ingredient costs
and dispensing fees. Exclude expense reported to Human Immunodeficiency Virus (HIV/AIDS
Reimbursable Drugs on line 19.
 Reimbursable HIV/AIDS Drugs
 HIV/AIDS Drugs (protease inhibitors and other anti-retrovirals) and clotting factor
VIII and IX blood products. This expense should shall equal the amount on Revenue Line 2b.
 Care
 Expenses for home health services provided, including nurses, aides and hospice costs
and private duty nursing (PDN
  Expenses for all ambulance, medical intensive care units (MICUs) and invalid coach
services
  The cost of all laboratory and radiology (diagnostic and therapeutic) services for
which the HMO is separately billed
  The cost of routine exams (by non-physicians) and dispensing glasses to correct eye
defects. This category includes the cost of eyeglasses but excludes ophthalmologist costs related
to the treatment of disease or injury to the eye.
  The cost of mental health and substance abuse services including inpatient, physician
services, outpatient hospital, other professional services, and other services associated with
mental health or substance abuse treatment.
  HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Line 26  Incentive Pool Adjustment  A reduction to medical expenses for adjusting
the full medical expenses reported. For example, physician withholds retained by the HMO should
shall be included here.
 The cost of family planning services, including medical history and
physical examinations (including pelvic and breast), diagnostic and laboratory tests, drugs and
biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity
of care genetic counseling.
 7
 Medical expenses not included in lines 9 through 267.
 8 7
  should the should should
 29
 0
 10
 Line 31  Occupancy, Depreciation, and Amortization
 2 and
 HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



3
 Line 33  Marketing Expenses directly related to marketing activities including
advertising, printing, marketing salaries, and fringe benefits, commissions, broker fees, travel,
occupancy, and other expenses allocated to the marketing activity.
   4
 5 8 4
 6 8 5
 37 6
 38
 39 o g
 2
 032 should and
 HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Guidelines
  Example for Quarter Ending
    
    Example Using Dollars06/30/2003xx ReportingPeriodClaims paid in the period
    
    Claims Paid in quarter ending06/30/2003 xx
    
    
    
    
    
    $
    48,000,000+IBNR
at the end of the period
    
    + IBNR as of 06/30/2003xx
    
    
    
    
    
    $
    11,000,000- IBNR at
the end of the prior period
    
    - IBNR as of 03/31/2003xx
    
    
    
    
    
    $
    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 3/31/20xx
    
    
    
    
    
    $
    450,000Claims incurred in the period
    
    Claims incurred in quarter ending 06/30/20xx
    
    
    
    
    
    $
    50,0050,000
 HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Guidelines
  Incurred in Quarter
    
    Incurred in
    
    TotalEnding
    
    03/31/2003xx &06/30/2003xx
    
    PriorClaims paid in QTR
ending
06/30/2003
xx
    
    $
    39,500,000
    
    
    
    
    
    
    $
    8,500,000
    
    
    $
    48,000,000+IBNR as of
06/30/2003
xx
    
    $
    10,900,000
    
    
    
    
    
    
    $
    100,000
    
    
    $
    11,000,000-IBNR as of
03/31/2003
xx
    
    
    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
06/30/2003xx
    
    $
    50,4050,000
    
    
    
    
    
    
    $
    400,000
    
    
    $
    50,0050,000
 03 8 03 44032
 8 032 should Information about a 032 not in Report #1 43 should
  37 38, 39, 434 043
 HMO Financial Guide for Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Guidelines
  2
   -
    
    Cesarean section deliveries-
    
    Vaginal deliveries
   Rate Cell Grouping
    
    Geographic AreaAVDC/NJCPW/NJ KidCare A
    
    NorthernAVDC/NJCPW/NJ KidCare A
    
    CentralAVDC/NJCPW/NJ KidCare A
    
    SouthernAll Other
    
    Statewide
  
 2
    Still or live births at or after the twelfth
thirteenth week of gestation, excluding elective abortions. HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 



Guidelines
               HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 



HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 



HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 



Guidelines
 Report
# 3 (Table 21) :Maternity Outcome Counts
 This
report provides counts of second and third trimester maternity outcomes3 for the
current period and year-to-date.
 The HMO will provide counts for the following:
Live Births
 Cesarean section deliveriesVaginal deliveries
 Non-Live Births
 These counts will be reported for the following rate cell groupings and geographic areas.
 Rate Cell Grouping
    
    Geographic AreaAVDC/NJCPW/NJ KidCare A
    
    NorthernAVDC/NJCPW/NJ KidCare A
    
    CentralAVDC/NJCPW/NJ KidCare A
    
    SouthernAll Other
    
    Statewide
 
 3
    Still or live births at or after the twelfth
thirteenth week of gestation, excluding elective abortions. HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 



Guidelines
    HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 



Guidelines
   
    
    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.
 Multiple births should be counted as one maternity outcome.
  HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 




    
    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 HMO 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 HMO 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 tables will need modification, on a pro forma basis, to reflect corrections
for known errors or skewed payment patterns. The data included in the lag schedules should
shall include all information received to date in order to take advantage of all known
amounts (i.e., RBUCs and paid claims).
 should should should
 should should
 should should should
  HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 



should
        should
  should
 HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 



HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 




    
    Quarterly Certification Statement
    
    Report # 1: Lag Report
 o
    
    Part A: Lag Report for Inpatient Hospital Payments Excluding MCSA Populations.o
    
    Part B: Lag Report for Physician Payments Excluding MCSA Populationso
    
    Part C: Lag Report for Pharmacy Payments Excluding MCSA Populationso
    
    Part D: Lag Report for Other Medical Payments Excluding MCSA Populationso
    
    Part E: Lag Report for MCSA Populations
 
    
    Report # 2: Income Statement by RATE CELL GROUPING
 o
    
    Part A: AFDC/NJCPW/NJ KidCare A  Northern Regiono
    
    Part B: AFDC/NJCPW/NJ KidCare A  Central Regiono
    
    Part C: AFDC/NJCPW/NJ KidCare A  Southern Regiono
    
    Part D: DYFS  Statewideo
    
    Part E: ABD with Medicare  DDD  Statewideo
    
    Part F: ABD with Medicare  non-DDD  Statewideo
    
    Part G: Non-ABD  DDD  Statewideo
    
    Part H: ABD without Medicare  DDD  Statewideo
    
    Part I: ABD without Medicare  Non DDD  Statewideo
    
    Part J: NJ KidCare B&C Statewideo
    
    Park K: NJ KidCare D Statewideo
    
    Part L: Reservedo
    
    Part M: NJ FamilyCare Parents 0-133% FPL  Statewideo
    
    Part N: (Reserved)o
    
    Part O: NJ FamilyCare Parents 134-200 250% FPL  Statewideo
    
    Part P: ABD with Medicare  AIDS- Statewideo
    
    Part Q: Non- ABD   AIDS- Statewideo
    
    Part R1: Maternity- Statewideo
    
    Part R2: Newborn  Statewideo
    
    Part S1: All Rate Cell Groupings Current Quarter  Statewideo
    
    Part S2: All Rate Cell Groupings Year   To -Date  Statewideo
    
    Part S3: Reconciliationso
    
    Part T: Non-State Plan Serviceso
    
    Part U: NJ FamilyCare Adults 0-100% FPL  Statewideo
    
    Part V: Adult Restricted Aliens  Statewide
 
    
    Report # 3: table 21: Maternity Outcome Counts
    
    Report # 4: Claims Processing Lag Report
 o
    
    Part A: Claims Processing Lag Report for Manually Submitted Claimso
    
    Part B: Claims Processing Lag Report for Electronically Submitted Claims
 
    
    Report # 7: Stop Loss Summary
    
    Report # 10 : Third Party Liability Collections
    
    Notes to Financial Reports
  HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 



O Report # 1
    
    O Report # 2
    
    O Report # 3O Report # 4
    
    O Report # 7
    
    O Report # 10
  Date
    
    Chief Financial Officer
    
    Signature
  HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 



HMO Financial Guide for Reporting Specifications
    
    State of New Jersey




---



##### 



Claims Processed During Quarter1
    
    2
    
    
    3
    
    
    4
    
    
    5
    
    
    6
    
    
    7
    
    
    8
    
    
    9
    
    
    10
    
    
    11
    
    
    12
    
    
    13
    
    
    14
    
    
    15
    
    
    16
    
    
    17PercentNon
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Non
    
    
    of NonProcessed
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Processed
    
    
    ProcessedClaims
    
    
    Claims
    
    
    
    
    
    
    Claims
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Claims
    
    
    Claimsfrom
    
    
    Received
    
    
    
    
    
    
    Processed
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    on Hand
    
    
    on HandConsolidated
    
    Prior
    
    
    During
    
    
    Total
    
    
    this
    
    
    01-40
    
    
    Percent
    
    
    41-60
    
    
    Percent
    
    
    61-90
    
    
    Percent
    
    
    91-120
    
    
    Percent
    
    
    >120
    
    
    Percent
    
    
    at end of
    
    
    at End ofCategory of service
    
    quarter
    
    
    Quarter
    
    
    Claims
    
    
    Quarter
    
    
    Days
    
    
    of Total
    
    
    Days
    
    
    of Total
    
    
    Days
    
    
    of Total
    
    
    Days
    
    
    of Total
    
    
    days
    
    
    of Total
    
    
    Quarter
    
    
    QuarterInpatient HospitalPrimary CarePhysician Specialty
ServicesOther
Professional
ServicesEmergency RoomDME/Medical SuppliesProstheticsDentalPharmacyAIDS/HIV
Reimbursable DrugsHome Health CareTransportationLab and X-RayVision Care &
EyeglassesMental
Health/Substance
AbuseOther MedicalGrand Total
  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Claims Processed During Quarter1
    
    2
    
    
    3
    
    
    4
    
    
    5
    
    
    6
    
    
    7
    
    
    8
    
    
    9
    
    
    10
    
    
    11
    
    
    12
    
    
    13
    
    
    14
    
    
    15
    
    
    16
    
    
    17PercentNon
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Non
    
    
    of NonProcessed
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Processed
    
    
    ProcessedClaims
    
    
    Claims
    
    
    
    
    
    
    Claims
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Claims
    
    
    Claimsfrom
    
    
    Received
    
    
    
    
    
    
    Processed
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    on Hand
    
    
    on HandConsolidated
    
    Prior
    
    
    During
    
    
    Total
    
    
    this
    
    
    01-30
    
    
    Percent
    
    
    31-60
    
    
    Percent
    
    
    61-90
    
    
    Percent
    
    
    91-120
    
    
    Percent
    
    
    >120
    
    
    Percent
    
    
    at end of
    
    
    at End ofCategory of service
    
    quarter
    
    
    Quarter
    
    
    Claims
    
    
    Quarter
    
    
    Days
    
    
    of Total
    
    
    Days
    
    
    of Total
    
    
    Days
    
    
    of Total
    
    
    Days
    
    
    of Total
    
    
    days
    
    
    of Total
    
    
    Quarter
    
    
    QuarterInpatient HospitalPrimary CarePhysician Specialty
ServicesOther
Professional
ServicesEmergency RoomDME/Medical SuppliesProstheticsDentalPharmacyAIDS/HIV
Reimbursable DrugsHome Health CareTransportationLab and X-RayVision Care &
EyeglassesMental
Health/Substance
AbuseOther MedicalGrand Total
  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



A. CoverageAggregate Stop Loss
    
    Maximum Per Enrollee Per
    
    
    Maximum Aggregate
    
    
    Includes InsolvencyThreshold
    
    Year
    
    
    Lifetime Per Enrollee
    
    
    Insurance (Y/N)
    
    
    Deductible
    
    
    Cost of Premiums PMPM$
    
    $ Policy Expiration Date
    
    
    
    $
    
    
    
    
    
    
    
    $ 00/00/0000
    
    
    
    $
 BCategory of Eligibility
    
    AFDC
    
    DYFs
    
    ABD
    
    NJ KidCare
    
    FamilyCare
    
    TOTALNumber of Enrollees
Exceeding Stop LossNet Expenditures Above Stop Loss
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 C. List Details for Each Individual (Name or ID Not Required)Net Expenditures Above Stop Loss
    
    
    Primary Diagnosis/Major Procedure
    
    
    Reinsurance Recoveries123456789101112131415Total (lines 1 through 15)Table # 19, Parts S2, Line 6Difference
  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



COA
    
    Employment Related
    
    Motor Vehicle Related
    
    Other
    
    Health InsuranceAFDC**
    
    $
    
    $
    
    $
    
    $DYFS
    
    $
    
    $
    
    $
    
    $Aged with Medicare
    
    $
    
    $
    
    $
    
    $Aged w/o Medicare
    
    $
    
    $
    
    $
    
    $Blind and Disabled
with Medicare +
    
    $
    
    $
    
    $
    
    $Blind and Disabled
w/o Medicare +
    
    $
    
    $
    
    $
    
    $NJ KidCare
    
    $
    
    $
    
    $
    
    $NJ FamilyCare
    
    $
    
    $
    
    $
    
    $Total
    
    $
    
    $
    
    $
    
    $
 
 *
    
    Enter total amount collected for each eligibility category.**
    
    Include New Jersey care children and pregnant women+
    
    Include essential spouses  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 




    
    Part A  Claims Lag report for manually submitted
    
    Part B  Claims Lag report for electronically submitted
 
  
 
 
   HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Current Period
    
    
    Year to DateLive Births
    
    
    Non-live
    
    
    
    Live Births
    
    
    Non-liveC-Section
    
    
    Vaginal
    
    
    births
    
    
    C-Section
    
    
    Vaginal
    
    
    birthsNORTHERN REGIONCENTRAL REGIONSOUTHERN REGIONSTATEWIDE
ALL OTHERTOTAL
   HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



(1)
    
    (2)
    
    (3)
    
    
    (4)
    
    
    (5)
    
    
    (6)
    
    
    (7)
    
    
    (8)
    
    
    (9)
    
    
    (10)
    
    
    (11)
    
    
    (12)
    
    
    (13)
    
    
    (14)
    
    
    (15)
    
    
    (16)
    
    
    (17)
    
    
    (18)
    
    
    (19)
    
    
    (20)
    
    
    (21)
    
    
    (22)
    
    
    (23)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 Prior
    
    
    16 Prior
    
    
    17 Prior
    
    
    18 Prior
    
    
    19 Prior
    
    
    20th PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month1
    
    Current Month2
    
    1st Prior month3
    
    2nd Prior month4
    
    3rd Prior month5
    
    4th Prior month6
    
    5th Prior month7
    
    6th Prior month8
    
    7 Prior month9
    
    8 Prior month10
    
    9 Prior month11
    
    10 Prior month12
    
    11th  Prior month13
    
    12thPrior month14
    
    13 Prior month15
    
    14 Prior month16
    
    15 Prior month17
    
    16 Prior month18
    
    17th prior month19
    
    18th prior month20
    
    19th prior month21
    
    20th prior month22
    
    21st prior month23
    
    22nd prior month24
    
    23rd prior month25
    
    24th prior month26
    
    25th prior month27
    
    26th prior month28
    
    27th prior month29
    
    28th prior month30
    
    29th prior month31
    
    30th prior month32
    
    31st prior month33
    
    32rd prior month34
    
    33 prior month35
    
    34 prior month36
    
    35th prior month37
    
    Months before35th prior month38
    
    Total Claim Payments39
    
    Subcapitation payments40
    
    Pharmacy Rebates41
    
    Settlements
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
    (2)
    
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    (23)Current
    
    
    1st Prior
    
    
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    3 Prior
    
    
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    7 Prior
    
    
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    14 Prior
    
    
    15 Prior
    
    
    16 Prior
    
    
    17 Prior
    
    
    18 Prior
    
    
    19 Prior
    
    
    20th PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month42
    
    Sum of claims,Subcapitation payments, andsettlements43
    
    Current estimate ofremaining liability44
    
    Total Incurred Claims
  (1)
    
    (2)
    
    (24)
    
    
    (25)
    
    
    (26)
    
    
    (27)
    
    
    (28)
    
    
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    (39)
    
    
    (40)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11thPrior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month1
    
    Current Month2
    
    1st Prior month3
    
    2nd Prior month4
    
    3rd Prior month5
    
    4th Prior month6
    
    5th Prior month7
    
    6th Prior month8
    
    7 Prior month9
    
    8 Prior month10
    
    9 Prior month11
    
    10 Prior month12
    
    11th  Prior month13
    
    12thPrior month14
    
    13 Prior month15
    
    14 Prior month16
    
    15 Prior month17
    
    16 Prior month18
    
    17th prior month19
    
    18th prior month20
    
    19th prior month21
    
    20th prior month22
    
    21st prior month23
    
    22nd prior month24
    
    23rd prior month25
    
    24th prior month26
    
    25th prior month27
    
    26th prior month28
    
    27th prior month29
    
    28th prior month30
    
    29th prior month31
    
    30th prior month32
    
    31st prior month33
    
    32rd prior month34
    
    33 prior month35
    
    34 prior month36
    
    35th prior month37
    
    Months before35th prior month38
    
    Total Claim Payments
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
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    (40)Current
    
    
    1st Prior
    
    
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    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11thPrior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month39
    
    Subcapitation payments40
    
    Pharmacy Rebates41
    
    Settlements42
    
    Sum of claims,Subcapitation payments, and settlements43
    
    Current estimate ofremaining liability44
    
    Total Incurred Claims
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
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    (23)Current
    
    
    1st Prior
    
    
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    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
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    10 Prior
    
    
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    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 Prior
    
    
    16 Prior
    
    
    17 Prior
    
    
    18 Prior
    
    
    19 Prior
    
    
    20th PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month1
    
    Current Month2
    
    1st Prior month3
    
    2nd Prior month4
    
    3rd Prior month5
    
    4th Prior month6
    
    5th Prior month7
    
    6th Prior month8
    
    7 Prior month9
    
    8 Prior month10
    
    9 Prior month11
    
    10 Prior month12
    
    11th  Prior month13
    
    12thPrior month14
    
    13 Prior month15
    
    14 Prior month16
    
    15 Prior month17
    
    16 Prior month18
    
    17th prior month19
    
    18th prior month20
    
    19th prior month21
    
    20th prior month22
    
    21st prior month23
    
    22nd prior month24
    
    23rd prior month25
    
    24th prior month26
    
    25th prior month27
    
    26th prior month28
    
    27th prior month29
    
    28th prior month30
    
    29th prior month31
    
    30th prior month32
    
    31st prior month33
    
    32rd prior month34
    
    33 prior month35
    
    34 prior month36
    
    35th prior month37
    
    Months before 35th prior month38
    
    Total Claim Payments39
    
    Subcapitation payments40
    
    Pharmacy Rebates41
    
    Settlements
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
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    (19)
    
    
    (20)
    
    
    (21)
    
    
    (22)
    
    
    (23)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 Prior
    
    
    16 Prior
    
    
    17 Prior
    
    
    18 Prior
    
    
    19 Prior
    
    
    20th PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month42
    
    Sum of claims, Subcapitation
payments, and settlements43
    
    Current estimate of remaining liability44
    
    Total Incurred Claims
  (1)
    
    (2)
    
    (24)
    
    
    (25)
    
    
    (26)
    
    
    (27)
    
    
    (28)
    
    
    (29)
    
    
    (30)
    
    
    (31)
    
    
    (32)
    
    
    (33)
    
    
    (34)
    
    
    (35)
    
    
    (36)
    
    
    (37)
    
    
    (38)
    
    
    (39)
    
    
    (40)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    

    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month1
    
    Current Month2
    
    1st Prior month3
    
    2nd Prior month4
    
    3rd Prior month5
    
    4th Prior month6
    
    5th Prior month7
    
    6th Prior month8
    
    7 Prior month9
    
    8 Prior month10
    
    9 Prior month11
    
    10 Prior month12
    
    11th  Prior month13
    
    12thPrior month14
    
    13 Prior month15
    
    14 Prior month16
    
    15 Prior month17
    
    16 Prior month18
    
    17th prior month19
    
    18th prior month20
    
    19th prior month21
    
    20th prior month22
    
    21st prior month23
    
    22nd prior month24
    
    23rd prior month25
    
    24th prior month26
    
    25th prior month27
    
    26th prior month28
    
    27th prior month29
    
    28th prior month30
    
    29th prior month31
    
    30th prior month32
    
    31st prior month33
    
    32rd prior month34
    
    33 prior month35
    
    34 prior month36
    
    35th prior month37
    
    Months before35th prior month38
    
    Total Claim Payments
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
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    (35)
    
    
    (36)
    
    
    (37)
    
    
    (38)
    
    
    (39)
    
    
    (40)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month39
    
    Subcapitation payments40
    
    Pharmacy Rebates41
    
    Settlements42
    
    Sum of claims,Subcapitation payments, andsettlements43
    
    Current estimate ofremaining liability44
    
    Total Incurred Claims
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
    (2)
    
    (3)
    
    
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    (19)
    
    
    (20)
    
    
    (21)
    
    
    (22)
    
    
    (23)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    

12th Prior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 Prior
    
    
    16 Prior
    
    
    17 Prior
    
    
    18 Prior
    
    
    19 Prior
    
    
    20th PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month1
    
    Current Month2
    
    1st Prior month3
    
    2nd Prior month4
    
    3rd Prior month5
    
    4th Prior month6
    
    5th Prior month7
    
    6th Prior month8
    
    7 Prior month9
    
    8 Prior month10
    
    9 Prior month11
    
    10 Prior month12
    
    11th  Prior month13
    
    12thPrior month14
    
    13 Prior month15
    
    14 Prior month16
    
    15 Prior month17
    
    16 Prior month18
    
    17th prior month19
    
    18th prior month20
    
    19th prior month21
    
    20th prior month22
    
    21st prior month23
    
    22nd prior month24
    
    23rd prior month25
    
    24th prior month26
    
    25th prior month27
    
    26th prior month28
    
    27th prior month29
    
    28th prior month30
    
    29th prior month31
    
    30th prior month32
    
    31st prior month33
    
    32rd prior month34
    
    33 prior month35
    
    34 prior month36
    
    35th prior month37
    
    Months before 35th prior month38
    
    Total Claim Payments39
    
    Subcapitation payments40
    
    Pharmacy Rebates41
    
    Settlements
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
    (2)
    
    (3)
    
    
    (4)
    
    
    (5)
    
    
    (6)
    
    
    (7)
    
    
    (8)
    
    
    (9)
    
    
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    (11)
    
    
    (12)
    
    
    (13)
    
    
    (14)
    
    
    (15)
    
    
    (16)
    
    
    (17)
    
    
    (18)
    
    
    (19)
    
    
    (20)
    
    
    (21)
    
    
    (22)
    
    
    (23)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    

12th Prior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 Prior
    
    
    16 Prior
    
    
    17 Prior
    
    
    18 Prior
    
    
    19 Prior
    
    
    20th PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month42
    
    Sum of claims,Subcapitation payments, and settlements43
    
    Current estimate of remaining liability44
    
    Total Incurred Claims
  (1)
    
    (2)
    
    (24)
    
    
    (25)
    
    
    (26)
    
    
    (27)
    
    
    (28)
    
    
    (29)
    
    
    (30)
    
    
    (31)
    
    
    (32)
    
    
    (33)
    
    
    (34)
    
    
    (35)
    
    
    (36)
    
    
    (37)
    
    
    (38)
    
    
    (39)
    
    
    (40)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month1
    
    Current Month2
    
    1st Prior month3
    
    2nd Prior month4
    
    3rd Prior month5
    
    4th Prior month6
    
    5th Prior month7
    
    6th Prior month8
    
    7 Prior month9
    
    8 Prior month10
    
    9 Prior month11
    
    10 Prior month12
    
    11th  Prior month13
    
    12thPrior month14
    
    13 Prior month15
    
    14 Prior month16
    
    15 Prior month17
    
    16 Prior month18
    
    17th prior month19
    
    18th prior month20
    
    19th prior month21
    
    20th prior month22
    
    21st prior month23
    
    22nd prior month24
    
    23rd prior month25
    
    24th prior month26
    
    25th prior month27
    
    26th prior month28
    
    27th prior month29
    
    28th prior month30
    
    29th prior month31
    
    30th prior month32
    
    31st prior month33
    
    32rd prior month34
    
    33 prior month35
    
    34 prior month36
    
    35th prior month37
    
    Months before 35th prior month38
    
    Total Claim Payments
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
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    (24)
    
    
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    (30)
    
    
    (31)
    
    
    (32)
    
    
    (33)
    
    
    (34)
    
    
    (35)
    
    
    (36)
    
    
    (37)
    
    
    (38)
    
    
    (39)
    
    
    (40)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month39
    
    Subcapitation payments40
    
    Pharmacy Rebates41
    
    Settlements42
    
    Sum of claims, Subcapitation
payments, and settlements43
    
    Current estimate of remaining liability44
    
    Total Incurred Claims
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
    (2)
    
    (3)
    
    
    (4)
    
    
    (5)
    
    
    (6)
    
    
    (7)
    
    
    (8)
    
    
    (9)
    
    
    (10)
    
    
    (11)
    
    
    (12)
    
    
    (13)
    
    
    (14)
    
    
    (15)
    
    
    (16)
    
    
    (17)
    
    
    (18)
    
    
    (19)
    
    
    (20)
    
    
    (21)
    
    
    (22)
    
    
    (23)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 Prior
    
    
    16 Prior
    
    
    17 Prior
    
    
    18 Prior
    
    
    19 Prior
    
    
    20th PriorLine
    
    Month of Payment
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month1
    
    Current Month2
    
    1st Prior month3
    
    2nd Prior month4
    
    3rd Prior month5
    
    4th Prior month6
    
    5th Prior month7
    
    6th Prior month8
    
    7 Prior month9
    
    8 Prior month10
    
    9 Prior month11
    
    10 Prior month12
    
    11th  Prior month13
    
    12thPrior month14
    
    13 Prior month15
    
    14 Prior month16
    
    15 Prior month17
    
    16 Prior month18
    
    17th prior month19
    
    18th prior month20
    
    19th prior month21
    
    20th prior month22
    
    21st prior month23
    
    22nd prior month24
    
    23rd prior month25
    
    24th prior month26
    
    25th prior month27
    
    26th prior month28
    
    27th prior month29
    
    28th prior month30
    
    29th prior month31
    
    30th prior month32
    
    31st prior month33
    
    32rd prior month34
    
    33 prior month35
    
    34 prior month36
    
    35th prior month37
    
    Months before 35th prior month38
    
    Total Claim Payments39
    
    Subcapitation payments40
    
    Pharmacy Rebates41
    
    Settlements
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
    (2)
    
    (3)
    
    
    (4)
    
    
    (5)
    
    
    (6)
    
    
    (7)
    
    
    (8)
    
    
    (9)
    
    
    (10)
    
    
    (11)
    
    
    (12)
    
    
    (13)
    
    
    (14)
    
    
    (15)
    
    
    (16)
    
    
    (17)
    
    
    (18)
    
    
    (19)
    
    
    (20)
    
    
    (21)
    
    
    (22)
    
    
    (23)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 Prior
    
    
    16 Prior
    
    
    17 Prior
    
    
    18 Prior
    
    
    19 Prior
    
    
    20th PriorLine
    
    Month of Payment
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month42
    
    Sum of claims, Subcapitation payments, and settlements43
    
    Current estimate of remaining liability44
    
    Total Incurred Claims
  (1)
    
    (2)
    
    (24)
    
    
    (25)
    
    
    (26)
    
    
    (27)
    
    
    (28)
    
    
    (29)
    
    
    (30)
    
    
    (31)
    
    
    (32)
    
    
    (33)
    
    
    (34)
    
    
    (35)
    
    
    (36)
    
    
    (37)
    
    
    (38)
    
    
    (39)
    
    
    (40)Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 PriorLine
    
    Month of Payment
    
    Month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month1
    
    Current Month2
    
    1st Prior month3
    
    2nd Prior month4
    
    3rd Prior month5
    
    4th Prior month6
    
    5th Prior month7
    
    6th Prior month8
    
    7 Prior month9
    
    8 Prior month10
    
    9 Prior month11
    
    10 Prior month12
    
    11th  Prior month13
    
    12thPrior month14
    
    13 Prior month15
    
    14 Prior month16
    
    15 Prior month17
    
    16 Prior month18
    
    17th prior month19
    
    18th prior month20
    
    19th prior month21
    
    20th prior month22
    
    21st prior month23
    
    22nd prior month24
    
    23rd prior month25
    
    24th prior month26
    
    25th prior month27
    
    26th prior month28
    
    27th prior month29
    
    28th prior month30
    
    29th prior month31
    
    30th prior month32
    
    31st prior month33
    
    32rd prior month34
    
    33 prior month35
    
    34 prior month36
    
    35th prior month37
    
    Months before 35th prior month38
    
    Total Claim Payments
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
    (2)
    
    
    (24)
    
    
    (25)
    
    
    (26)
    
    
    (27)
    
    
    (28)
    
    
    (29)
    
    
    (30)
    
    
    (31)
    
    
    (32)
    
    
    (33)
    
    
    (34)
    
    
    (35)
    
    
    (36)
    
    
    (37)
    
    
    (38)
    
    
    (39)
    
    

(40)Line
    
    Month of Payment
    
    
    Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 PriorMonth
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month39
    
    Subcapitation payments40
    
    Pharmacy Rebates41
    
    Settlements42
    
    Sum of claims,Subcapitation payments, andsettlements43
    
    Current estimate ofremaining liability44
    
    Total Incurred Claims
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
    (2)
    
    (3)
    
    
    (4)
    
    
    (5)
    
    
    (6)
    
    
    (7)
    
    
    (8)
    
    
    (9)
    
    
    (10)
    
    
    (11)
    
    
    (12)
    
    
    (13)
    
    
    (14)
    
    
    (15)
    
    
    (16)
    
    
    (17)
    
    
    (18)
    
    
    (19)
    
    
    (20)
    
    
    (21)
    
    
    (22)
    
    
    (23)Line
    
    Month of Payment
    
    Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 Prior
    
    
    16 Prior
    
    
    17 Prior
    
    
    18 Prior
    
    
    19 Prior
    
    
    20th Priormonth
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month1
    
    Current Month2
    
    1st Prior month3
    
    2nd Prior month4
    
    3rd Prior month5
    
    4th Prior month6
    
    5th Prior month7
    
    6th Prior month8
    
    7 Prior month9
    
    8 Prior month10
    
    9 Prior month11
    
    10 Prior month12
    
    11th  Prior month13
    
    12thPrior month14
    
    13 Prior month15
    
    14 Prior month16
    
    15 Prior month17
    
    16 Prior month18
    
    17th prior month19
    
    18th prior month20
    
    19th prior month21
    
    20th prior month22
    

21st prior month23
    
    22nd prior month24
    
    23rd prior month25
    
    24th prior month26
    
    25th prior month27
    
    26th prior month28
    
    27th prior month29
    
    28th prior month30
    
    29th prior month31
    
    30th prior month32
    

31st prior month33
    
    32rd prior month34
    
    33 prior month35
    
    34 prior month36
    
    35th prior month37
    
    Months before 35th prior month38
    
    Total Claim Payments39
    
    Subcapitation payments40
    
    Pharmacy Rebates41
    
    Settlements
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
    (2)
    
    (3)
    
    
    (4)
    
    
    (5)
    
    
    (6)
    
    
    (7)
    
    
    (8)
    
    
    (9)
    
    
    (10)
    
    
    (11)
    
    
    (12)
    
    
    (13)
    
    
    (14)
    
    
    (15)
    
    
    (16)
    
    
    (17)
    
    
    (18)
    
    
    (19)
    
    
    (20)
    
    
    (21)
    
    
    (22)
    
    
    (23)Line
    
    Month of Payment
    
    Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 Prior
    
    
    16 Prior
    
    
    17 Prior
    
    
    18 Prior
    
    
    19 Prior
    
    
    20th Priormonth
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month42
    
    Sum of claims, Subcapitation
payments, and settlements43
    
    Current estimate of remaining liability44
    
    Total Incurred Claims
  (1)
    
    (2)
    
    (24)
    
    
    (25)
    
    
    (26)
    
    
    (27)
    
    
    (28)
    
    
    (29)
    
    
    (30)
    
    
    (31)
    
    
    (32)
    
    
    (33)
    
    
    (34)
    
    
    (35)
    
    
    (36)
    
    
    (37)
    
    
    (38)
    
    
    (39)
    
    
    (40)Line
    
    Month of Payment
    
    Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 PriorMonth
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month1
    
    Current Month2
    
    1st Prior month3
    
    2nd Prior month4
    
    3rd Prior month5
    
    4th Prior month6
    
    5th Prior month7
    
    6th Prior month8
    
    7 Prior month9
    
    8 Prior month10
    
    9 Prior month11
    
    10 Prior month12
    
    11th  Prior month13
    
    12thPrior month14
    
    13 Prior month15
    
    14 Prior month16
    
    15 Prior month17
    
    16 Prior month18
    
    17th prior month19
    
    18th prior month20
    
    19th prior month21
    
    20th prior month22
    
    21st prior month23
    
    22nd prior month24
    
    23rd prior month25
    
    24th prior month26
    
    25th prior month27
    
    26th prior month28
    
    27th prior month29
    
    28th prior month30
    
    29th prior month31
    
    30th prior month32
    
    31st prior month33
    
    32rd prior month34
    
    33 prior month35
    
    34 prior month36
    
    35th prior month37
    
    Months before 35th prior month38
    
    Total Claim Payments
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(1)
    
    (2)
    
    (24)
    
    
    (25)
    
    
    (26)
    
    
    (27)
    
    
    (28)
    
    
    (29)
    
    
    (30)
    
    
    (31)
    
    
    (32)
    
    
    (33)
    
    
    (34)
    
    
    (35)
    
    
    (36)
    
    
    (37)
    
    
    (38)
    
    
    (39)
    
    
    (40)Line
    
    Month of Payment
    
    Current
    
    
    1st Prior
    
    
    2nd Prior
    
    
    3rd Prior
    
    
    4th Prior
    
    
    5th Prior
    
    
    6th Prior
    
    
    7 Prior
    
    
    8 Prior
    
    
    9 Prior
    
    
    10 Prior
    
    
    11th Prior
    
    
    12thPrior
    
    
    13 Prior
    
    
    14 Prior
    
    
    15 PriorMonth
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month
    
    
    month39
    
    Subcapitation payments40
    
    Pharmacy Rebates41
    
    Settlements42
    
    Sum of claims, Subcapitation
payments, and settlements43
    
    Current estimate of remaining liability44
    
    Total Incurred Claims
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



4
 
  Revenues/Expenses/Administration
    
    
    Three-
    
    
    Three
    
    
    YTD $
    
    
    YTD
    
    
    SFY End
    
    
    SFY End $month
    
    
    month
    
    
    
    
    
    
    PMPM
    
    
    $@9/305
    
    
    @9/30PMPM
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental
 EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 4
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.5
    
    For the twelve months incurred claims expenses
ending State Fiscal Year June 30, total should be reported with an additional
three months of paid claims at quarter ending Sept 30. HMO Financial Reporting Specifications
    
    
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Revenues/Expenses/Administration
    
    
    Three-
    
    
    Three
    
    
    YTD $
    
    
    YTD
    
    
    SFY End
    
    
    SFY End $month
    
    
    month
    
    
    
    
    
    
    PMPM
    
    
    $@9/305
    
    
    @9/30PMPM
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision
for State, Federal and Other Governmental Taxes43
    
    Other than Income taxes644
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 6
    
    Reported items other than State or Federal
income taxes HMO Financial Reporting Specifications
    
    
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



7
 
  Revenues/Expenses/Administration
    
    
    Three-
    
    
    Three
    
    
    YTD $
    
    
    YTD
    
    
    SFY End
    
    
    SFY End $month
    
    
    month
    
    
    
    
    
    
    PMPM
    
    
    $@9/308
    
    
    @9/30PMPM
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable
HIV/AIDS Drugs and Blood Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include ReimbursableHIV/AIDS Drugs and Blood Products)19
    
    Reimbursable
HIV/AIDS Drugs and Blood Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental
 EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 7
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.8
    
    For the twelve months incurred claims expenses
ending State Fiscal Year June 30, total should be reported with an additional
three months of paid claims at quarter ending Sept 30. HMO Financial Reporting Specifications
    
    
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Revenues/Expenses/Administration
    
    
    Three-
    
    
    Three
    
    
    YTD $
    
    
    YTD
    
    
    SFY End
    
    
    SFY End $month
    
    
    month
    
    
    
    
    
    
    PMPM
    
    
    $@9/308
    
    
    @9/30PMPM
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    

Subcontract/Delegated Administrative services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision
for State, Federal and Other Governmental Taxes43
    
    Other than Income taxes944
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 9
    
    Reported items other than State or Federal
income taxes HMO Financial Reporting Specifications
    
    
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



10
 
  Revenues/Expenses/Administration
    
    
    Three-
    
    
    Three
    
    
    YTD $
    
    
    YTD
    
    
    SFY End
    
    
    SFY End $month
    
    
    month
    
    
    
    
    
    
    PMPM
    
    
    $@9/3011
    
    
    @9/30PMPM
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable
HIV/AIDS Drugs and Blood Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include ReimbursableHIV/AIDS Drugs and Blood Products)19
    
    Reimbursable
HIV/AIDS Drugs and Blood Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental
 EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 10
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.11
    
    For the twelve months incurred claims expenses
ending State Fiscal Year June 30, total should be reported with an additional
three months of paid claims at quarter ending Sept 30. HMO Financial Reporting Specifications
    
    
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Revenues/Expenses/Administration
    
    
    Three-
    
    
    Three
    
    
    YTD $
    
    
    YTD
    
    
    SFY End
    
    
    SFY End $month
    
    
    month
    
    
    
    
    
    
    PMPM
    
    
    $@9/3011
    
    
    @9/30PMPM
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision
for State, Federal and Other Governmental Taxes43
    
    Other than Income taxes1244
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 12
    
    Reported items other than State or Federal
income taxes HMO Financial Reporting Specifications
    
    
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



13
 
  Revenues/Expenses/Administration
    
    
    Three-
    
    
    Three
    
    
    YTD $
    
    
    YTD
    
    
    SFY End
    
    
    SFY End $month
    
    
    month
    
    
    
    
    
    
    PMPM
    
    
    $@9/3014
    
    
    @9/30PMPM
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable
HIV/AIDS Drugs and Blood Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy
(not to include Reimbursable HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable
HIV/AIDS Drugs and Blood Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental
 EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 13
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.14
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30. HMO Financial Reporting Specifications
    
    
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Revenues/Expenses/Administration
    
    
    Three-
    
    
    Three
    
    
    YTD $
    
    
    YTD
    
    
    SFY End
    
    
    SFY End $month
    
    
    month
    
    
    
    
    
    
    PMPM
    
    
    $@9/3014
    
    
    @9/30PMPM
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision
for State, Federal and Other Governmental Taxes43
    
    Other than Income taxes1544
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 15
    
    Reported items other than State or Federal
income taxes HMO Financial Reporting Specifications
    
    
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



16
 
  Revenues/Expenses/Administration
    
    
    Three-
    
    
    Three
    
    
    YTD $
    
    
    YTD
    
    
    SFY End
    
    
    SFY End $month
    
    
    month
    
    
    
    
    
    
    PMPM
    
    
    $@9/3016
    
    
    @9/30PMPM
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable
HIV/AIDS Drugs and Blood Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy
(not to include Reimbursable HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable
HIV/AIDS Drugs and Blood Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental
 EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 16
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.17
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30. HMO Financial Reporting Specifications
    
    
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Revenues/Expenses/Administration
    
    
    Three-
    
    
    Three
    
    
    YTD $
    
    
    YTD
    
    
    SFY End
    
    
    SFY End $month
    
    
    month
    
    
    
    
    
    
    PMPM
    
    
    $@9/3016
    
    
    @9/30PMPM
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    

Subcontract/Delegated Administrative services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision
for State, Federal and Other Governmental Taxes43
    
    Other than Income taxes1844
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 18
    
    Reported items other than State or Federal
income taxes HMO Financial Reporting Specifications
    
    
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



19
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3020
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 19
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.20
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3020
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes2144
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 21
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



22
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3023
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 22
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.23
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3023
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes2444
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 24
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



25
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3026
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 25
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.26
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3026
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes2744
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 27
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



28
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3029
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    

    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 28
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.29
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3029
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes3044
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 30
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



31
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3032
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 31
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.32
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3032
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes3344
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 33
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



34
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3035
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 34
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.35
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3035
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes3644
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 36
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Table #19  Part L                Statement Income Statement by Rate Cell Grouping
 Reserved
 FOR THE THREE MONTHS ENDING ___           FOR ___
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month

    

    month
    
    

    
    PMPM

    
    @9/3037

    
    @9/30PMPM

    
    
    
    
    

    
    
    PMPMMember MonthsREVENUES:1
    
    
    
    Capitated Premiums2
    
    
    
    Supplemental Premiums2a
    
    
    
    Maternity2b
    
    
    
    Reimbursable HIV/AIDS Drugs and Blood Product2c
    
    
    
    EPSDT Incentive Payment2d
    
    
    
    Reimbursable Medical and Hospital2e
    
    
    
    Managed Care Service Administrator Premium2f
    
    
    
    Other3
    
    
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    
    
    Interest5
    
    
    
    COB6
    
    
    
    Reinsurance Recoveries7
    
    
    
    Other Revenue8
    
    
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    
    
    Inpatient Hospital10
    
    
    
    Primary Care11
    
    
    
    Physician Specialty Services12
    
    
    
    Outpatient Hospital (excludes ER)13
    
    
    
    Other Professional Services14
    
    
    
    Emergency Room15
    
    
    
    DME/Medical Supplies16
    
    
    
    Prosthetics & Orthotics17
    
    
    
    Covered Dental18
    
    
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    
    
    Reimbursable HIV/AIDS Drugs and Blood Product20
    
    
    
    Home Health, Hospice and PDN21
    
    
    
    Transportation22
    
    
    
    Lab & X-ray23
    
    
    
    Vision Care, including eyeglasses24
    
    
    
    Mental Health/Substance Abuse25
    
    
    
    Reinsurance Expenses26A
    
    
    
    EPSDT Medical & PDN26B
    
    
    
    EPSDT Dental  EPD27
    
    
    
    Family Planning28
    
    
    
    Other Medical29
    
    
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    
    
    Compensation31
    
    
    
    Occupancy/Depreciation/Amortization32
    
    
    
    Interest Expense33
    
    
    
    Education/Outreach34
    
    
    
    Sanctions
 
 37
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month

    

    month
    
    

    
    PMPM

    
    @9/3037

    
    @9/30PMPM

    
    
    
    
    

    
    
    PMPM35
    
    
    
    Corporate Overhead Allocations36
    
    
    
    Subcontract/Delegated Administrative
services37
    
    
    
    Other38
    
    
    
    TOTAL ADMINISTRATION39
    
    
    
    TOTAL EXPENSES40
    
    
    
    OPERATION INCOME (LOSS) (8-39)41
    
    
    
    Extraordinary Item42
    
    
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    
    
    Other than Income taxes3544
    
    
    
    Adjustment for prior period IBNR Estimates45
    
    
    
    Non-claim adjustments46
    
    
    
    NET INCOME (LOSS)
(40-41-42-43-44-45)
 
 38
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



39
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3040
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 39
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.40
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3040
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes4144
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 41
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Table #19  Part N                Income Statement by Rate Cell Grouping
  FOR
THE THREE MONTHS ENDING ___     FOR ___
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-
    
    Three
    
YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3042
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    
    
    Capitated Premiums2
    
    
    
    Supplemental Premiums2a
    
    
    
    Maternity2b
    
    
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    
    
    EPSDT Incentive Payment2d
    
    
    
    Reimbursable Medical and Hospital2e
    
    
    
    Managed Care Service Administrator
Premium2f
    
    
    
    Other3
    
    
    
    Total Premiums (Lines
1+2a+2b+2c+2d+2e+2f)4
    
    
    
    Interest5
    
    
    
    COB6
    
    
    
    Reinsurance Recoveries7
    
    
    
    Other Revenue8
    
    
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    
    
    Inpatient Hospital10
    
    
    
    Primary Care11
    
    
    
    Physician Specialty Services12
    
    
    
    Outpatient Hospital (excludes ER)13
    
    
    
    Other Professional Services14
    
    
    
    Emergency Room15
    
    
    
    DME/Medical Supplies16
    
    
    
    Prosthetics & Orthotics17
    
    
    
    Covered Dental18
    
    
    
    Pharmacy (not to include Reimbursable HIV/AIDS
Drugs and Blood Products)19
    
    
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    
    
    Home Health, Hospice and PDN21
    
    
    
    Transportation22
    
    
    
    Lab & X-ray23
    
    
    
    Vision Care, including eyeglasses24
    
    
    
    Mental Health/Substance Abuse25
    
    
    
    Reinsurance Expenses26A
    
    
    
    EPSDT Medical & PDN26B
    
    
    
    EPSDT Dental  EPD27
    
    
    
    Family Planning28
    
    
    
    Other Medical29
    
    
    
    TOTAL MEDICAL & HOSPITAL (9 THRU
28)ADMINISTRATION:30
    
    
    
    Compensation31
    
    
    
    Occupancy/Depreciation/Amortization32
    
    
    
    Interest Expense33
    
    
    
    Education/Outreach34
    
    
    
    Sanctions35
    
    
    
    Corporate Overhead Allocations
 
 42
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-

    
    Three

    
YTD $
    
    YTD

    
    SFY End

    
    SFY End $month

    
    month

    
    
    
    PMPM

    
    $@9/3042

    
    @9/30PMPM

    
    
    

    
    

    
    
    PMPM36
    
    
    
    Subcontract/Delegated Administrative
services37
    
    
    
    Other38
    
    
    
    TOTAL ADMINISTRATION39
    
    
    
    TOTAL EXPENSES40
    
    
    
    OPERATION INCOME (LOSS) (8-39)41
    
    
    
    Extraordinary Item42
    
    
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    
    
    Other than Income taxes4044
    
    
    
    Adjustment for prior period IBNR Estimates45
    
    
    
    Non-claim adjustments46
    
    
    
    NET INCOME (LOSS)
(40-41-42-43-44-45)
 
 43
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



44
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3045
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 44
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.45
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3045
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes4644
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 46
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



47
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3048
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 47
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.48
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3048
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes4944
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 49
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



50
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3051
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 50
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.51
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3051
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION
 INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes5244
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 52
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



53
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD per
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    delivery
    
    $@9/3054
    
    @9/30per delivery
    
    
    
    
    
    
    
    PMPMDeliveriesREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 53
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.54
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD per
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    delivery
    
    $@9/3054
    
    @9/30per delivery
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes5544
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME
 (LOSS) (40-41-42-43-44-45)
 
 55
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



56
   Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3057
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense
 
 56
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Sevcie Administrator
program.57
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    Three-
    
    Three
    
    YTD $
    
    YTD
    
    SFY End
    
    SFY End $month
    
    month
    
    
    
    PMPM
    
    $@9/3057
    
    @9/30PMPM
    
    
    
    
    
    
    
    PMPM33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION
 INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes5844
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 58
    
    Reported items other than State or Federal
income taxes  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



59
   Revenues/Expenses/Administration
    
    (A)
    
    (B) Three
    
    O=(a)+(b)
    
    Three
    
    SFY End
    
    SFY End $Three-
    
    month
    
    Three-
    
    month
    
    $@9/3060
    
    @9/30month Paid Claims
    
    IBNR & RBUC
    
    month Total $
    
    PMPM
    
    
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood
Product2c
    
    EPSDT Incentive Payment2d
    
    Reimbursable Medical and Hospital2e
    
    Managed Care Service Administrator Premium2f
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    Interest5
    
    COB6
    
    Reinsurance Recoveries7
    
    Other Revenue8
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital10
    
    Primary Care11
    
    Physician Specialty Services12
    
    Outpatient Hospital (excludes ER)13
    
    Other Professional Services14
    
    Emergency Room15
    
    DME/Medical Supplies16
    
    Prosthetics & Orthotics17
    
    Covered Dental18
    
    Pharmacy (not to include Reimbursable
HIV/AIDS Drugs and Blood Products)19
    
    Reimbursable HIV/AIDS Drugs and Blood
Product20
    
    Home Health, Hospice and PDN21
    
    Transportation22
    
    Lab & X-ray23
    
    Vision Care, including eyeglasses24
    
    Mental Health/Substance Abuse25
    
    Reinsurance Expenses26A
    
    EPSDT Medical & PDN26B
    
    EPSDT Dental  EPD27
    
    Family Planning28
    
    Other Medical29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)
 
 59
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Service Administrator
program.60
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30.  HMO Financial Reporting Specifications
    
    State of New Jersey




---



##### 



Revenues/Expenses/Administration
    
    (A)
    
    (B) Three
    
    O=(a)+(b)
    
    Three
    
    SFY End
    
    SFY End $Three-
    
    month
    
    Three-
    
    month
    
    $@9/3060
    
    @9/30month Paid Claims
    
    IBNR & RBUC
    
    month Total $
    
    PMPM
    
    
    
    PMPMADMINISTRATION:30
    
    Compensation31
    
    Occupancy/Depreciation/Amortization32
    
    Interest Expense33
    
    Education/Outreach34
    
    Sanctions35
    
    Corporate Overhead Allocations36
    
    Subcontract/Delegated Administrative
services37
    
    Other38
    
    TOTAL ADMINISTRATION39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other
Governmental Taxes43
    
    Other than Income taxes6144
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 61
    
    Reported items other than State or Federal
income taxes HMO Financial Reporting Specifications
    
    State of New Jersey






---



##### 



Table #19  Part s2
    
    Income Statement by Rate Cell Grouping
 62
 FOR THE THREE MONTHS ENDING
    
    FOR
  (A)YTD
    
    
    (B) YTD
    
    
    O=(a)+(b)
    
    
    
    
    
    
    
    
    
    
    SFY End $Paid
    
    
    IBNR &
    
    
    YTD Total
    
    
    YTD
    
    
    SFY End
    
    
    @9/30Revenues/Expenses/Administration
    
    Claims
    
    
    RBUC
    
    
    $
    
    
    PMPM
    
    
    $@9/3063
    
    
    PMPMMember MonthsREVENUES:1
    
    
    Capitated Premiums2
    
    
    Supplemental Premiums2a
    
    
    Maternity2b
    
    
    Reimbursable HIV/AIDS Drugs and Blood Product2c
    
    
    EPSDT Incentive Payment2d
    
    
    Reimbursable Medical and Hospital2e
    
    
    Managed Care Service Administrator Premium2f
    
    
    Other3
    
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    
    Interest5
    
    
    COB6
    
    
    Reinsurance Recoveries7
    
    
    Other Revenue8
    
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    
    Inpatient Hospital10
    
    
    Primary Care11
    
    
    Physician Specialty Services12
    
    
    Outpatient Hospital (excludes ER)13
    
    
    Other Professional Services14
    
    
    Emergency Room15
    
    
    DME/Medical Supplies16
    
    
    Prosthetics & Orthotics17
    
    
    Covered Dental18
    
    
    Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products)19
    
    
    Reimbursable HIV/AIDS Drugs and Blood Product20
    
    
    Home Health, Hospice and PDN21
    
    
    Transportation22
    
    
    Lab & Xray23
    
    
    Vision Care, including eyeglasses24
    
    
    Mental Health/Substance Abuse25
    
    
    Reinsurance Expenses26A
    
    
    EPSDT Medical & PDN26B
    
    
    EPSDT Dental  EPD27
    
    
    Family Planning28
    
    
    Other Medical29
    
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    
    Compensation31
    
    
    Occupancy/Depreciation/Amortization
 
 62
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Service Administrator
program.63
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



(A)YTD
    
    
    (B) YTD
    
    
    O=(a)+(b)
    
    
    
    
    
    
    
    
    
    
    SFY End $Paid
    
    
    IBNR &
    
    
    YTD Total
    
    
    YTD
    
    
    SFY End
    
    
    @9/30Revenues/Expenses/Administration
    
    Claims
    
    
    RBUC
    
    
    $
    
    
    PMPM
    
    
    $@9/3063
    
    
    PMPM32
    
    
    Interest Expense33
    
    
    Education/Outreach34
    
    
    Sanctions35
    
    
    Corporate Overhead Allocations36
    
    
    Subcontract/Delegated Administrative services37
    
    
    Other38
    
    
    TOTAL ADMINISTRATION39
    
    
    TOTAL EXPENSES40
    
    
    OPERATION INCOME (LOSS) (8-39)41
    
    
    Extraordinary Item42
    
    
    Provision for State, Federal and Other Governmental Taxes43
    
    
    Other than Income taxes6444
    
    
    Adjustment for prior period IBNR Estimates45
    
    
    Non-claim adjustments46
    
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 64
    
    Reported items other than State or Federal
income taxes HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part S3
    
    Income Statement by Rate Cell Grouping
  FOR THE THREE MONTHS ENDING
    
    FOR
  Total PremiumsReceived for At-Only 5 rows provided
    
    
    
    
    
    
    
    
    
    Risk Rate Cell(Insert additional rows if needed)
    
    Date
    
    Check #
    
    Groupings1
    
    
    01/00/00
    
    
    
    0000
    
    
    $2
    
    
    01/00/00
    
    
    
    0000
    
    
    $3
    
    
    01/00/00
    
    
    
    0000
    
    
    $4
    
    
    01/00/00
    
    
    
    0000
    
    
    $5
    
    
    01/00/00
    
    
    
    0000
    
    
    $6 Subtotal Premiums Received (lines 1  5)
    
    
    
    
    
    
    
    
    
    $7 Premiums Reported Quarter in #19S1
    
    
    
    
    
    
    
    
    
    $8 Difference (Lines 6-7)
    
    
    
    
    
    
    
    
    
    $
      HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table # 19  Part S3
    
    Income Statement by Rate Cell Grouping
  FOR THE THREE MONTHS ENDING
    
    FOR
  Three month PaidLag Report
    
    
    Table #19  Parts S1 &S2
    
    
    Claims
    
    
    Three-month IBNR & RBUC
    
    
    Three Month Total $Lag Report #
    
    Medical
    
    
    Line
    
    
    Consolidated Category of Service
    
    
    Lag Report Table #19
    
    
    Lag Report Table #19 Difference
    
    
    Lag Report Table #19 DifferenceCost
    
    
    #
    
    
    
    
    
    
    Difference Part S1
    
    
    Part S1
    
    
    Part S1GroupingTable #20
-Part A
    
    Inpatient Hospital
    
    
    9
    
    
    Inpatient Hospital
    
    $
    
    
    
    $
    
    
    
    $Table #20
    
    Physician
    
    
    10
    
    
    Primary care-Part B
    
    
    
    
    11
    
    
    Physician Specialty Services
    
    $
    
    
    
    $
    
    
    
    $Table 20
    
    Pharmacy
    
    
    18
    
    
    Pharmacy (not to include
    
    $
    
    
    
    $
    
    
    
    $-Part C
    
    
    
    
    
    
    19
    
    
    Reimbursable HIV/AIDSReimbursable HIV/AIDSTable #20
    
    Other
    
    
    12
    
    
    Other Professional Services
    
    $
    
    
    
    $
    
    
    
    $-Part D
    
    
    
    
    
    
    13
    
    
    Emergency Room14
    
    
    DME/Medical Supplies15
    
    
    Prosthetics & Orthotics16
    
    
    Covered Dental17
    
    
    Home Health, Hospice and PDN20
    
    
    Transportation21
    
    
    Lab & X-ray22
    
    
    Vision Care, including eyeglasses23
    
    
    Mental Health/Substance Abuse24
    
    
    Reinsurance Expenses26a
    
    
    EPSDT Medical & PDN26b
    
    
    EPSDT Dental  EPD27
    
    
    Family Planning28
    
    
    Other Medical
  YTD
    
    
    YTD
    
    
    YTDLag Report
    
    Table #19  Parts S1 &S2
    
    Paid Claims
    
    
    IBNR & RBUC
    
    
    Total $Lag Report #
    
    Medical
    
    Line
    
    
    Consolidated Category of Service
    
    
    Lag Report Table #19
    
    
    Lag Report Table #19 Difference
    
    
    Lag Report Table #19 DifferenceCost
    
    #
    
    
    
    
    
    

Difference Part S1
    
    
    Part S1
    
    
    Part S1GroupingTable #20
-Part A
    
    Inpatient Hospital
    
    
    9
    
    
    Inpatient Hospital
    
    $
    
    
    
    $
    
    
    
    
    
    
    
    $
    
    $
    
    
    
    
    
    $
    
    
    
    
    
    
    
    $Table #20
    
    Physician
    
    
    10
    
    
    Primary care
    
    $
    
    
    
    $
    
    
    
    
    
    
    
    $
    
    $
    
    
    
    
    
    $
    
    
    
    
    
    
    
    $-Part B
    
    
    
    
    11
    
    
    Physician Specialty ServicesTable 20
    
    Pharmacy
    
    
    18
    
    
    Pharmacy (not to include
    
    $
    
    
    
    $
    
    
    
    
    
    
    
    $
    
    $
    
    
    
    
    
    $
    
    
    
    
    
    
    
    $-Part C
    
    
    
    
    19
    
    
    Reimbursable HIV/AIDS19
    
    
    Reimbursable HIV/AIDSTable #20
    
    Other
    
    
    12
    
    
    Other Professional Services
    
    $
    
    
    
    $
    
    
    
    
    
    
    
    $
    
    $
    
    
    
    
    
    $
    
    
    
    
    
    
    
    $
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



YTD
    
    
    YTD

    
    YTDLag Report
    
    Table #19  Parts S1 &S2
    
    Paid Claims
    
    
    IBNR & RBUC
    
    Total $Lag Report #
    
    Medical
    
    Line
    
    
    Consolidated Category of Service
    
    
    Lag Report Table #19
    
    
    Lag Report Table #19 Difference
    
    Lag Report Table #19 DifferenceCost
    
    #
    
    
    
    
    
    

Difference Part S1
    
    
    Part S1
    
    Part S1Grouping-Part D
    
    
    
    
    
    
    13
    
    
    Emergency Room14
    
    
    DME/Medical Supplies15
    
    
    Prosthetics & Orthotics16
    
    
    Covered Dental17
    
    
    Home Health, Hospice and PDN20
    
    
    Transportation21
    
    
    Lab & X-ray22
    
    
    Vision Care, including eyeglasses23
    
    
    Mental Health/Substance Abuse24
    
    
    Reinsurance Expenses26
    a
    
    EPSDT Medical & PDN26
    b
    
    EPSDT Dental  EPD27
    
    
    Family Planning28
    
    
    Other Medical
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part S3
    
    Income Statement by Rate Cell Grouping
  FOR THE THREE MONTHS ENDING
    
    FOR
  Incurred inQuarters Prior to1 Claims Paid in Most Recent Order
    
    $2 + IBNR as of Most Recent Quarter (line
43 of #2-A-D lag Triangles)
    
    $3  IBNR as of prior Quarter
    
    $4 + Subcapitation Payments, Pharmacy
Rebates, Settlements as of Most Recent
Quarter
    
    $5 - Subcapitation Payments, Pharmacy
Rebates, Settlements as of Prior Quarter
    
    $6 Prior Period IBNR Adjustment for QTR end
(lines 1+2+3+4-5)
    
    $7 Table #19  Parts S1 Adjustment for
prior period IBNR estimates
(Line 44 of Table #19S1)
    
    $8 Difference (Lines 6-7)
    
    $
  Incurred in Calendar YearsPrior to1 Claims Paid in Most Recent Calendar YTD
    
    $2 + IBNR as of Most Recent Quarter (line 43 of #2-A-D lag Triangles)
    
    $3  IBNR as of prior calendar Year End
    
    $4 + Subcapitation Payments, Pharmacy Rebates, Settlements as of Most
Recent Quarter
    
    $5 - Subcapitation Payments, Pharmacy Rebates, Settlements as of Prior
Calendar Year End
    
    $6 Prior Period IBNR Adjustment for Calendar Year end
(lines 1+2+3+4-5)
    
    $7 Table #19  Parts S1 Adjustment for prior period IBNR estimates
(Line 44 of Table #19S1)
    
    $8 Difference (Lines 6-7)
    
    $
   HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part S3
    
    Income Statement by Rate Cell Grouping
  FOR THE THREE MONTHS ENDING
    
    FOR
  Other Charged DetailedBreakdown Description
    
    Total Incurred $ for the(insert additional rows if needed)
    
    Quarter1234567891011
    
    Total Other Administration Expense (lines 1 through 10)12
    
    Table #19  parts S2 Other Administration Expenses (line 37 of Table #19S1)13
    
    Difference
  Other Charged Detailed
    
    Total Incurred $ YTD1234567891011
    
    Total Other Administration Expense (lines 1 through 10)12
    
    Table #19  parts S2 Other Administration Expenses (line 37 of Table #19S1)13
    
    Difference
   HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FOR THE THREE MONTHS ENDING
    
    FOR(HMO Name)
 AFDC/NJCPW/NJ KidCare A  North
    
    
    AFDC/NJCPW/NJ KidCare A  CentralThree-month
    
    
    Three-month
    
    
    
    
    
    
    
    
    
    
    Three-month
    
    
    Three-monthExpenses
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD Units
    
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11
    
    Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health
Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant
women) populations were transferred into two groups under a managed care Service Administrator
program.1
    
    All medical and administrative expenses must be reported using actual incurred
and paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description12345678910*
    
    If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FOR THE THREE MONTHS ENDING
    
    FOR(HMO Name)
 AFDC/NJCPW/NJ KidCare A  South
    
    
    DYFSThree-month
    
    
    Three-month
    
    
    
    
    
    
    
    
    
    
    Three-month
    
    
    Three-monthExpenses
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD Units
    
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    

    
    $
    
    
    
    $11
    
    Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health
Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant
women) populations were transferred into two groups under a managed care Service Administrator
program.1
    
    All medical and administrative expenses must be reported using actual incurred
and paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description12345678910*
    
    If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FOR THE THREE MONTHS ENDING
    
    FOR(HMO Name)
 ABD with Medicare  DDD
    
    
    ABD With Medicare  Non - DDDThree-month
    
    
    Three-month
    
    
    
    
    
    
    
    
    
    
    Three-month
    
    
    Three-monthExpenses
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD Units
    
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7

    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11
    
    Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health
Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant
women) populations were transferred into two groups under a managed care Service Administrator
program.1
    
    All medical and administrative expenses must be reported using actual incurred
and paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description12345678910*
    
    If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FOR THE THREE MONTHS ENDING
    
    FOR(HMO Name)
 Non-ABD  DDD
    
    
    AVD Without Medicare - DDDThree-month
    
    
    Three-month
    
    
    
    
    
    
    
    
    
    
    Three-month
    
    
    Three-monthExpenses
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD Units
    
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11
    
    Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.1
    
    All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description12345678910*
    
    If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FOR THE THREE MONTHS ENDING
    
    FOR(HMO Name)
 ABD Without Medicare  Non DDD
    
    
    NJ KidCare B&CThree-month
    
    
    Three-month
    
    
    
    
    
    
    
    
    
    
    Three-month
    
    
    Three-monthExpenses
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD Units
    
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    

    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11
    
    Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $

    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.1
    
    All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description12345678910*
    
    If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FOR THE THREE MONTHS ENDING
    
    FOR(HMO Name)
 NJ KidCare D
    
    
    NJ FamilyCare Adults 0-100% FPLThree-month
    
    
    Three-month
    
    
    
    
    
    
    
    
    
    
    Three-month
    
    
    Three-monthExpenses
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD Units
    
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11
    
    Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.1
    
    All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description12345678910*
    
    If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FOR THE THREE MONTHS ENDING
    
    FOR(HMO Name)
 NJ FamilyCare Parents 0-133% FPL
    
    
    NJ FamilyCare Parents 134-250% FPLThree-month
    
    
    Three-month
    
    
    
    
    
    
    
    
    
    
    Three-month
    
    
    Three-monthExpenses
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD Units
    
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11
    
    Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.1
    
    All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description12345678910*
    
    If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FOR THE THREE MONTHS ENDING
    
    FOR(HMO Name)
 ABD with Medicare AIDS
    
    
    NON-ABD - AIDSThree-month
    
    
    Three-month
    
    
    
    
    
    
    
    
    
    
    Three-month
    
    
    Three-monthExpenses
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD Units
    
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11
    
    Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.1
    
    All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description12345678910*
    
    If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FOR THE THREE MONTHS ENDING
    
    FOR(HMO Name)
 Maternity
    
    
    NewbornsThree-month
    
    
    Three-month
    
    
    
    
    
    
    
    
    
    
    Three-month
    
    
    Three-monthExpenses
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD Units
    
    
    $
    
    
    units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    
    
    $
    
    
    

    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11
    
    Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.1
    
    All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description12345678910*
    
    If medial and hospital claims exist for non-state plan services, then must have some amount of
administration for non-State Plan services. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part U
    
    Income Statement by Rate Cell Grouping
 65
 FOR THE THREE MONTHS ENDING
    
    FOR(HMO NAME)
 Three
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    SFY End $Three-
    
    
    month
    
    
    
    
    
    
    YTD
    
    
    SFY End
    
    
    @9/30Revenues/Expenses/Administration
    
    month
    
    
    PMPM
    
    
    YTD $
    
    
    PMPM
    
    
    $@9/3066
    
    
    PMPMMember MonthsREVENUES:1
    
    
    
    Capitated Premiums2
    
    
    
    Supplemental Premiums2a
    
    
    
    Maternity2b
    
    
    
    Reimbursable HIV/AIDS Drugs and Blood Product2c
    
    
    
    EPSDT Incentive Payment2d
    
    
    
    Reimbursable Medical and Hospital2e
    
    
    
    Managed Care Service Administrator Premium2f
    
    
    
    Other3
    
    
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    

    
    
    Interest5
    
    
    
    COB6
    
    
    
    Reinsurance Recoveries7
    
    
    
    Other Revenue8
    
    
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    
    
    Inpatient Hospital10
    
    
    
    Primary Care11
    
    
    
    Physician Specialty Services12
    
    
    
    Outpatient Hospital (excludes ER)13
    
    
    
    Other Professional Services14
    
    
    
    Emergency Room15
    
    
    
    DME/Medical Supplies16
    

    
    
    Prosthetics & Orthotics17
    

    
    
    Covered Dental18
    
    
    
    Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products)19
    
    
    
    Reimbursable HIV/AIDS Drugs and Blood Product20
    
    
    
    Home Health, Hospice and PDN21
    
    
    
    Transportation22
    
    
    
    Lab & X-ray23
    
    
    
    Vision Care, including eyeglasses24
    
    
    
    Mental Health/Substance Abuse25
    
    
    
    Reinsurance Expenses26A
    
    
    
    EPSDT Medical & PDN26B
    
    
    
    EPSDT Dental  EPD27
    
    
    
    Family Planning28
    
    
    
    Other Medical29
    
    
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    
    
    Compensation31
    
    
    
    Occupancy/Depreciation/Amortization32
    
    
    
    Interest Expense33
    

    
    
    Education/Outreach34
    
    
    
    Sanctions35
    

    
    
    Corporate Overhead Allocations36
    
    
    
    Subcontract/Delegated Administrative services37
    
    
    
    Other38
    
    
    
    TOTAL ADMINISTRATION
 
 65
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Service Administrator
program.66
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Three
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    SFY End $Three-
    
    
    month
    
    
    
    
    
    
    YTD
    
    
    SFY End
    
    
    @9/30Revenues/Expenses/Administration
    
    month
    
    
    PMPM
    
    
    YTD $
    
    
    PMPM
    
    
    $@9/3066
    
    
    PMPM39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other Governmental Taxes43
    
    Other than Income taxes6744
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 67
    
    Reported items other than State or Federal
income taxes HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part V
    
    Income Statement by Rate Cell Grouping
 68
 FOR THE THREE MONTHS ENDING
    
    FOR(HMO NAME)
 Three
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    SFY End $Three-
    
    
    month
    
    
    
    
    
    
    YTD
    
    
    SFY End
    
    
    @9/30Revenues/Expenses/Administration
    
    month
    
    
    PMPM
    
    
    YTD $
    
    
    PMPM
    
    
    $@9/3069
    
    
    PMPMMember MonthsREVENUES:1
    

    
    
    Capitated Premiums2
    

    
    
    Supplemental Premiums2a
    
   
    
    Maternity2b
    
    
    
    Reimbursable HIV/AIDS Drugs and Blood ProductEPSDT Incentive Payment2d
    
    
    
    Reimbursable Medical and Hospital2e
    
    
    
    Managed Care Service Administrator Premium2f
    
    
    
    Other3
    
    
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)4
    
    
    
    Interest5
    
    
    
    COB6
    
    
    
    Reinsurance Recoveries7
    
    
    
    Other Revenue8
    
    
    
    TOTAL REVENUE (3+4+5+6+7)EXPENSES:MEDICAL AND HOSPITAL9
    
    
    
    Inpatient Hospital10
    
    
    
    Primary Care11
    
    
    
    Physician Specialty Services12
    

    
    
    Outpatient Hospital (excludes ER)13
    
    
    
    Other Professional Services14
    
    
    
    Emergency Room15
    
    
    
    DME/Medical Supplies16
    
    
    
    Prosthetics & Orthotics17
    
    
    
    Covered Dental18
    
    
    
    Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products)19
    
    
    
    Reimbursable HIV/AIDS Drugs and Blood Product20
    
    
    
    Home Health, Hospice and PDN21
    
    
    
    Transportation22
    
    
    
    Lab & X-ray23
    
    
    
    Vision Care, including eyeglasses24
    
    
    
    Mental Health/Substance Abuse25
    
    
    
    Reinsurance Expenses26A
    
    
    
    EPSDT Medical & PDN26B
    

    
    
    EPSDT Dental  EPD27
    
    
    
    Family Planning28
    
    
    
    Other Medical29
    
    
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    
    
    Compensation31
    
    
    
    Occupancy/Depreciation/Amortization32
    
    
    
    Interest Expense33
    
    
    
    Education/Outreach34
    
    
    
    Sanctions35
    
    
    
    Corporate Overhead Allocations36
    
    
    
    Subcontract/Delegated Administrative services37
    
    
    
    Other38
    
    
    
    TOTAL ADMINISTRATION
 
 68
    
    Notes: Effective November 1, 2003, the
FamilyCare Adults 0-100% FPL, Health Access individuals without dependent
children, and Adult Restricted Aliens (excluding pregnant women) populations
were transferred into two groups under a managed care Service Administrator
program.69
    
    For the twelve months incurred claims
expenses ending State Fiscal Year June 30, total should be reported with an
additional three months of paid claims at quarter ending Sept 30. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Three
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    SFY End $Three-
    
    
    month
    
    
    
    
    
    
    YTD
    
    
    SFY End
    
    
    @9/30Revenues/Expenses/Administration
    
    month
    
    
    PMPM
    
    
    YTD $
    
    
    PMPM
    
    
    $@9/3069
    
    
    PMPM39
    
    TOTAL EXPENSES40
    
    OPERATION INCOME (LOSS) (8-39)41
    
    Extraordinary Item42
    
    Provision for State, Federal and Other Governmental Taxes43
    
    Other than Income taxes7044
    
    Adjustment for prior period IBNR Estimates45
    
    Non-claim adjustments46
    
    NET INCOME (LOSS) (40-41-42-43-44-45)
 
 70
    
    Reported items other than State or Federal
income taxes HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FOR THE THREE MONTHS ENDING

             FOR 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 Part B  Claims Lag report for electronically submittedTable # 7Parts A-C  Stop LossTable # 10  Third Party LiabilityTable # 19Parts A-V  Income Statement by RATE CELL GROUPINGSTable # 20Part A  Lag Report for Inpatient hospital PaymentsPart B  Lag Report for physician PaymentsPart C  Lag Report for pharmacy PaymentsPart
D  Lag Report for Other Medical PaymentsPart E  Lag Report for MCSA PaymentsTable # 21Maternity Outcome Counts
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part A Income Statement by Rate Cell Grouping
 AFDC/NJCPW/NJ KidCare A (Excluding AIDS)  NORTHERN REGION71
 FOR THE THREE MONTHS ENDING                  FOR
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 
 71
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women) populations were transferred into two groups
under a managed care Sevcie Administrator program. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part B Income Statement by Rate Cell Grouping
 AFDC/NJCPW/NJ KidCare A (Excluding AIDS)  CENTRAL REGION72
 FOR THE THREE MONTHS ENDING                  FOR
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17

    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 
 72
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women) populations were transferred into two groups
under a managed care Sevcie Administrator program. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part C Income Statement by Rate Cell Grouping
 AFDC/NJCPW/NJ KidCare A (Excluding AIDS)  SOUTHERN REGION73
 FOR THE THREE MONTHS ENDING                  FOR
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 
 73
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women) populations were transferred into two groups
under a managed care Sevcie Administrator program. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part D Income Statement by Rate Cell Grouping
 DYFS (Excluding AIDS) STATEWIDE
 FOR THE THREE MONTHS ENDING                  FOR
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part E Income Statement by Rate Cell Grouping
 ABD with Medicare  DDD (Excluding AIDS)  STATEWIDE
 FOR THE THREE MONTHS ENDING                  FOR
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part F Income Statement by Rate Cell Grouping
 ABD with Medicare -NON- DDD (Excluding AIDS)  STATEWIDE
 FOR THE THREE MONTHS ENDING                  FOR
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part G Income Statement by Rate Cell Grouping
 N0N-ABD DDD (Excluding AIDS)  STATEWIDE
 FOR THE THREE MONTHS ENDING                  FOR
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part H Income Statement by Rate Cell Grouping
 ABD without Medicare  DDD (Including AIDS)  STATEWIDE
 FOR THE THREE MONTHS ENDING                  FOR
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part E Income Statement by Rate Cell Grouping
 ABD with Medicare  DDD (Excluding AIDS)  STATEWIDE
 FOR THE THREE MONTHS ENDING                  FOR
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part I Income Statement by Rate Cell Grouping
 ABD without Medicare  Non-DDD (Including AIDS)  STATEWIDE
 FOR THE THREE MONTHS ENDING                  FOR
 (HMO NAME)
 Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part J Income Statement by Rate Cell Grouping
 NJKidCare B&C

(Excluding AIDS)  STATEWIDE
 FOR THE THREE MONTHS

ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    

Reimbursable HIV/AIDS Drugs and Blood Product
    

    $
    
    $
    
    $
    
    $2c
    

EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and
Hospital
    
    $
    
    $
    
    $
    
    $2e
    

Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $


    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs
and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part E Income Statement by Rate Cell Grouping
 ABD with Medicare DDD

(Excluding AIDS)  STATEWIDE
 FOR THE THREE MONTHS

ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
        Reimbursable HIV/AIDS Drugs and Blood Product
    

    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part K

Income Statement by Rate Cell Grouping
 NJ KidCare D (Excluding

AIDS)  STATEWIDE
 FOR THE THREE MONTHS

ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    

    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part L

Income Statement by Rate Cell Grouping RESERVED  RESERVED
 FOR THE THREE MONTHS ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part M

Income Statement by Rate Cell Grouping
 NJ FamilyCare Parents

0133% FPL (Excluding AIDS)  STATEWIDE
 FOR THE THREE MONTHS

ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
        Reimbursable HIV/AIDS Drugs and Blood Product
    

    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part N

Income Statement by Rate Cell Grouping )
 Reserved
 FOR THE THREE MONTHS

ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
        Reimbursable HIV/AIDS Drugs and Blood Product
    

    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $

    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part O

Income Statement by Rate Cell Grouping
 FOR THE THREE MONTHS

ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $

    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
        Reimbursable HIV/AIDS Drugs and Blood Product
    

    $
    
    $
    
    $
    
    $2c
    

    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part P

Income Statement by Rate Cell Grouping
 ABD with Medicare

AIDS  STATEWIDE
 FOR THE THREE MONTHS

ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
        Reimbursable HIV/AIDS Drugs and Blood Product
    

    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part Q

Income Statement by Rate Cell Grouping
 Non=ABD 

AIDS STATEWIDE
 FOR THE THREE MONTHS

ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
        Reimbursable HIV/AIDS Drugs and Blood Product
    

    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    

    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part R1

Income Statement by Rate Cell Grouping
 MATERNITY 

STATEWIDE
 FOR THE THREE MONTHS

ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
        Reimbursable HIV/AIDS Drugs and Blood Product
    


    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    

    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part R2

Income Statement by Rate Cell Grouping
 NEWBORN 

STATEWIDE
 FOR THE THREE MONTHS

ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
        Reimbursable HIV/AIDS Drugs and Blood Product
    

    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation

    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    

    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part S

Income Statement by Rate Cell Grouping
 ALL Rate cell groupings STATEWIDE
 FOR THE THREE MONTHS

ENDING ________ FOR _____________
 (HMO NAME)Revenues/Expenses/Administration
    
    Three-month
    
    Three month
    
    YTD $
    
    YTD PMPM$
    
    PMPMMember MonthsREVENUES:1
    
    Capitated Premiums
    
    $
    
    $
    
    $
    
    $2
    
    Supplemental Premiums2a
    
    Maternity2b
    
        Reimbursable HIV/AIDS Drugs and Blood Product
    

    $
    
    $
    
    $
    
    $2c
    
    EPSDT Incentive Payment
    
    $
    
    $
    
    $
    
    $2d
    
    Reimbursable Medical and Hospital
    
    $
    
    $
    
    $
    
    $2e
    
    Managed Care Service Administrator Premium
    
    $
    
    $
    
    $
    
    $2f
    
    Other
    
    $
    
    $
    
    $
    
    $3
    
    Total Premiums (Lines 1+2a+2b+2c+2d+2e+2f)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:MEDICAL AND HOSPITAL9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital (excludes ER)
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy19
    
    Reimbursable HIV/AIDS Drugs and Blood Product
    
    $
    
    $
    
    $
    
    $20
    
    Home Health, Hospice and PDN
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Family Planning
    
    $
    
    $
    
    $
    
    $28
    
    Other Medical
    
    $
    
    $
    
    $
    
    $29
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)ADMINISTRATION:30
    
    Compensation
    
    $
    
    $
    
    $
    
    $31
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $32
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $33
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $34
    
    Sanctions
    
    $
    
    $
    
    $
    
    $37
    
    Other
    
    $
    
    $
    
    $
    
    $38
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $39
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item39
    
    Provision for State, Federal and Other Governmental Taxes40
    
    Adjustment for prior period IBNR Estimates41
    
    NET INCOME (LOSS) (37-38-39-40)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part T  Non-state Plan Service Expenses by Rate Cell Grouping
 Non-State Plan Services
 FOR THE THREE MONTHS ENDING
    
    
    
    FOR(HMO Name)
 AFDC/NJCPW/NJ KidCare A  North
    
    
    AFDC/NJCPW/NJ KidCare A  CentralExpenses
    
    Three-month $
    
    
    Three-month units
    
    
    YTD $
    
    
    YTD Units
    
    
    Three-month $
    
    
    Three-month units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11 Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13 TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1   Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care
Service Administrator program.1   All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves
non-State Plan Services Description) 1
2
3
4
5
6
7
8
9
10
* If medial and hospital claims exist for non-state plan services, then must have some amount of administration for non-State Plan services.
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part T  Non-state Plan Service Expenses by Rate Cell Grouping
 Non-State Plan Services
 FOR THE THREE MONTHS ENDING
    
    
    
    FOR(HMO Name)
 AFDC/NJCPW/NJ KidCare A  South
    
    
    DYFSExpenses
    
    Three-month $
    
    
    Three-month units
    
    
    YTD $
    
    
    YTD Units
    
    
    Three-month $
    
    
    Three-month units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11 Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12 TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13 TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1   Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care
Service Administrator program.1   All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services DescriptioN 1
2
3
4
5
6
7
8
9
10
* If medial and hospital claims exist for non-state plan services, then must have some amount of administration for non-State Plan services.
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part T  Non-state Plan Service Expenses by Rate Cell Grouping
 Non-State Plan Services
 FOR THE THREE MONTHS ENDING
    
    
    
    FOR(HMO Name)
 ABD with Medicare  DDD
    
    
    ABD With Medicare  Non - DDDExpenses
    
    Three-month $
    
    
    Three-month units
    
    
    YTD $
    
    
    YTD Units
    
    
    Three-month $
    
    
    Three-month units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11 Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12 TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13 TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1   Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.1   All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves) non-State Plan Services Description 1
2
3
4
5
6
7
8
9
10
* If medial and hospital claims exist for non-state plan services, then must have some amount of administration for non-State Plan services.
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part T  Non-state Plan Service Expenses by Rate Cell Grouping
 Non-State Plan Services
 FOR THE THREE MONTHS ENDING
    
    
    
    FOR(HMO Name)
 Non-ABD  DDD
    
    
    AVD Without Medicare - DDDExpenses
    
    Three-month $
    
    
    Three-month units
    
    
    YTD $
    
    
    YTD Units
    
    
    Three-month $
    
    
    Three-month units
    
    
    YTD $
    
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $2
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $3
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $4
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $5
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $6
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $7
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $8
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $9
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $10
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $11 Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12 TOTAL ADMINISTRATION
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13 TOTAL EXPENSES (11+12)
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
    
    
    
    $
 
 1   Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care
Service Administrator program.1   All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description 1
2
3
4
5
6
7
8
9
10
* If medial and hospital claims exist for non-state plan services, then must have some amount of administration for non-State Plan services.
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part T  Non-state Plan Service Expenses by Rate Cell Grouping
 Non-State Plan Services
 FOR THE THREE MONTHS ENDING  FOR
 (HMO Name)
 ABD Without Medicare - Non DDD
    
    NJ KidCare B&CThree-month
    
    Three-month
    
    
    
    
    
    Three-month
    
    Three-monthExpenses
    

    $
    
    units
    
    YTD $
    
    YTD Units
    
    $
    
    units
    
    YTD $
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $2
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $3
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $4
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $5
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $6
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $7
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $8
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $9
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $10
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $11
    
    Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.1
    
    All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves) non-State Plan Services Description 1  2  3  4  5  6  7  8  9  10  *If medial and hospital claims exist for non-state plan
services, then must have some amount of administration for non-State Plan services.
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part T  Non-state Plan Service Expenses by Rate Cell Grouping
 Non-State Plan Services
 FOR THE THREE MONTHS ENDING  FOR
 (HMO Name)
 NJ KidCare D
    
    NJ FamilyCare parents 0133% FPLThree-month
    
    Three-month
    
    
    
    
    
    Three-month
    
    Three-monthExpenses
    
    $
    
    units
    
    YTD $
    
    YTD Units
    
    $
    
    units
    
    YTD $
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $2
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $3
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $4
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $5
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $6
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $7
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $8
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $9
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $10
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $11
    
    Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.1
    
    All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves) non-State Plan Services Description 1  2  3  4  5  6  7  8  9  10  *If medial and hospital claims exist for non-state plan
services, then must have some amount of administration for non-State Plan services.
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part T  Non-state Plan Service Expenses by Rate Cell Grouping
 Non-State Plan Services
 FOR THE THREE MONTHS ENDING  FOR
 (HMO Name)
 NJ KidCare D
    
    NJ FamilyCare parents 0133% FPLThree-month
    
    Three-month
    
    
    
    
    
    Three-month
    
    Three-monthExpenses
    
    $
    
    units
    
    YTD $
    
    YTD Units
    
    $
    
    units
    
    YTD $
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $2
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $3
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $4
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $5
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $6
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $7
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $8
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $9
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $10
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $11
    
    Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.1
    
    All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves) non-State Plan Services Description 1  2  3  4  5  6  7  8  9  10  *If medial and hospital claims exist for non-state plan
services, then must have some amount of administration for non-State Plan services.
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part T  Non-state Plan Service Expenses by Rate Cell Grouping
 Non-State Plan Services
 FOR THE THREE MONTHS ENDING  FOR
 (HMO Name)
 ABD With Medicare AIDS
    
    NON ABD AIDSThree-month
    
    Three-month
    
    
    
    
    
    Three-month
    
    Three-monthExpenses
    
    $
    
    units
    
    YTD $
    
    YTD Units
    
    $
    
    units
    
    YTD $
    
    YTD UnitsEXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $2
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $3
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $4
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $5
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $6
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $7
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $8
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $

    
    $
    
    $9
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $10
    
    
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $11
    
    Total MEDICAL AND
HOSPITAL NON-STATE
SERVICES (1 through
10)
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $
    
    $

    
    $
    
    $
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL, Health Access
individuals without dependent children, and Adult Restricted Aliens (excluding pregnant women)
populations were transferred into two groups under a managed care Service Administrator program.1
    
    All medical and administrative expenses must be reported using actual incurred and
paid data for the current period of the calendar year (no reserves) non-State Plan Services Description 1  2  3  4  5  6  7  8  9  10  *If medial and hospital claims exist for non-state plan
services, then must have some amount of administration for non-State Plan services.
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part T  Non-state Plan Service Expenses by Rate Cell Grouping
 Non-State Plan Services
 FOR THE THREE MONTHS ENDING
    
    FOR(HMO Name)
 MaternityExpenses
    
    Three-month
    
    Three-month
    
    YTD
    
    YTD Units$
    
    units
    
    $EXPENSES:MEDICAL AND HOSPITAL NON-STATE SERVICES1
    
    
    
    $
    
    $
    
    $
    
    $2
    
    
    
    $
    
    $
    
    $
    
    $3
    
    
    
    $
    
    $
    
    $
    
    $4
    
    
    
    $
    
    $
    
    $
    
    $5
    
    
    
    $
    
    $
    
    $
    
    $6
    
    
    
    $
    
    $
    
    $
    
    $7
    
    
    
    $
    
    $
    
    $
    
    $8
    
    
    
    $
    
    $
    
    $
    
    $9
    
    
    
    $
    
    $
    
    $
    
    $10
    
    
    
    $
    
    $
    
    $
    
    $11
    
    Total MEDICAL AND HOSPITAL NON-STATE SERVICES (1 through 10)
    
    $
    
    $
    
    $
    
    $ADMINISTRATION FOR NON-STATE PLAN SERVICES12
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $TOTAL EXPENSE FOR NON-STATE PLAN SERVICES13
    
    TOTAL EXPENSES (11+12)
    
    $
    
    $
    
    $
    
    $
 
 1
    
    Notes: Effective November 1, 2003, the FamilyCare Adults 0-100% FPL,
Health Access individuals without dependent children, and Adult Restricted Aliens (excluding
pregnant women) populations were transferred into two groups under a managed care Service
Administrator program.1
    
    All medical and administrative expenses must be reported
using actual incurred and paid data for the current period of the calendar year (no reserves)
non-State Plan Services Description12345678910*
    
    If medial and hospital claims exist for non-state plan services, then must have some amount of administration for non-State Plan services. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part U Income Statement by Rate Cell Grouping
 NJ FamilyCare Adults 0-100% FPL (Excluding AIDS) STATEWIDE 74
 FOR THE THREE MONTHS ENDING
    
    FOR(HMO NAME)
 Revenues/Expenses
    
    Three-month $
    
    Three month
    
    YTD
    
    YTD PMPMPMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product2c
    
    EPSDT Incentive Payment2d
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:
    
    
    
    $
    
    $
    
    $MEDICAL AND HOSPITAL
    
    
    
    $
    
    $
    
    $9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy
    
    $
    
    $
    
    $
    
    $19
    
    Reimbursable HIV/AIDS Drugs20
    
    Home Health Care
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Other Medical
    
    $
    
    $
    
    $
    
    $28
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)
    
    $
    
    $
    
    $
    
    $ADMINISTRATION:
    
    
    
    $
    
    $
    
    $29
    
    Compensation
    
    $
    
    $
    
    $
    
    $30
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $31
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $32
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $33
    
    Marketing
    
    $
    
    $
    
    $
    
    $34
    
    Other
    
    $
    
    $
    
    $
    
    $35
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $36
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS)(8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item
    
    $
    
    $
    
    $
    
    $39
    
    Provision for State, Federal and Other Governmental Taxes
    
    $
    
    $
    
    $
    
    $40
    
    Adjustment for prior period IBNR Estimates
    
    $
    
    $
    
    $
    
    $41
    
    NET INCOME (LOSS) (37-38-39-40)
    
    $
    
    $
    
    $
    
    $
 
 74
    
    Notes: Administrative expenses are to
be allocated to the NJ FamilyCare 0-100% FPL, rate cell groupings HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #19  Part v Income Statement by Rate Cell Grouping
 Adult Restricted Aliens STATEWIDE
 FOR THE THREE MONTHS ENDING
    
    FOR(HMO NAME)
 Revenues/Expenses
    
    Three-month $
    
    Three month

    
    YTD $
    
    YTD PMPMPMPMMember MonthsREVENUES:1
    
    Capitated Premiums2
    
    Supplemental Premiums2a
    
    Maternity2b
    
    Reimbursable HIV/AIDS Drugs and Blood Product2c
    
    EPSDT Incentive Payment2d
    
    Other3
    
    Total Premiums (Lines 1+2a+2b+2c+2d)
    
    $
    
    $
    
    $
    
    $4
    
    Interest
    
    $
    
    $
    
    $
    
    $5
    
    COB
    
    $
    
    $
    
    $
    
    $6
    
    Reinsurance Recoveries
    
    $
    
    $
    
    $
    
    $7
    
    Other Revenue
    
    $
    
    $
    
    $
    
    $8
    
    TOTAL REVENUE (3+4+5+6+7)
    
    $
    
    $
    
    $
    
    $EXPENSES:
    
    
    
    $
    
    $
    
    $MEDICAL AND HOSPITAL
    
    
    
    $
    
    $
    
    $9
    
    Inpatient Hospital
    
    $
    
    $
    
    $
    
    $10
    
    Primary Care
    
    $
    
    $
    
    $
    
    $11
    
    Physician Specialty Services
    
    $
    
    $
    
    $
    
    $12
    
    Outpatient Hospital
    
    $
    
    $
    
    $
    
    $13
    
    Other Professional Services
    
    $
    
    $
    
    $
    
    $14
    
    Emergency Room
    
    $
    
    $
    
    $
    
    $15
    
    DME/Medical Supplies
    
    $
    
    $
    
    $
    
    $16
    
    Prosthetics & Orthotics
    
    $
    
    $
    
    $
    
    $17
    
    Covered Dental
    
    $
    
    $
    
    $
    
    $18
    
    Pharmacy
    
    $
    
    $
    
    $
    
    $19
    
    Reimbursable HIV/AIDS Drugs20
    
    Home Health Care
    
    $
    
    $
    
    $
    
    $21
    
    Transportation
    
    $
    
    $
    
    $
    
    $22
    
    Lab & X-ray
    
    $
    
    $
    
    $
    
    $23
    
    Vision Care, including eyeglasses
    
    $
    
    $
    
    $
    
    $24
    
    Mental Health/Substance Abuse
    
    $
    
    $
    
    $
    
    $25
    
    Reinsurance Expenses
    
    $
    
    $
    
    $
    
    $26
    
    Incentive Pool Adjustment
    
    $
    
    $
    
    $
    
    $27
    
    Other Medical
    
    $
    
    $
    
    $
    
    $28
    
    TOTAL MEDICAL & HOSPITAL (9 THRU 28)
    
    $
    
    $
    
    $
    
    $ADMINISTRATION:
    
    
    
    $
    
    $
    
    $29
    
    Compensation
    
    $
    
    $
    
    $
    
    $30
    
    Occupancy/Depreciation/Amortization
    
    $
    
    $
    
    $
    
    $31
    
    Interest Expense
    
    $
    
    $
    
    $
    
    $32
    
    Education/Outreach
    
    $
    
    $
    
    $
    
    $33
    
    Marketing
    
    $
    
    $
    
    $
    
    $34
    
    Other
    
    $
    
    $
    
    $
    
    $35
    
    TOTAL ADMINISTRATION
    
    $
    
    $
    
    $
    
    $36
    
    TOTAL EXPENSES
    
    $
    
    $
    
    $
    
    $37
    
    OPERATION INCOME (LOSS) (8-39)
    
    $
    
    $
    
    $
    
    $38
    
    Extraordinary Item
    
    $
    
    $
    
    $
    
    $39
    
    Provision for State, Federal and Other Governmental Taxes
    
    $
    
    $
    
    $
    
    $40
    
    Adjustment for prior period IBNR Estimates
    
    $
    
    $
    
    $
    
    $41
    
    NET INCOME (LOSS) (37-38-39-40)
    
    $
    
    $
    
    $
    
    $
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table 20, Parts A through E
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 








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##### 



Table 21
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Table #21  Maternity Outcome Counts
 FOR THE THREE MONTHS ENDING _______________________ FOR __________________
 (HMO NAME)
 Current Period
    
    Year to DateLive Births
    
    Non-live
    
    Live Births

Non-liveC-Section
    
    Vaginal
    
    births
    
    C-Section
    
    Vaginal
    
    birthsNORTHERN REGION
AFDC/NJCPW/NJ
KIDCARE ACENTRAL REGION
AFDC/NJCPW/NJ 
KIDCARE ASOUTHERN REGION
AFDC/NJCPW/NJ
KIDCARE ASTATEWIDE
NJ FamilyCare Parents 134-250%
FPLSTATEWIDE
ALL OTHERTOTAL
 Note: Only outcomes on or after the thirteenth week of gestation should be
included in this report, excluding elective abortions.
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Estate Referral Form
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



HMO Notification of Deceased Members Age 55 and Older
    Quarter EndingHMO
    
    HMO ID
#
  Member Name
    
    DOB
    
    SSN
    
    Date of Death
    
    Medicaid ID #
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Monthly Roster Extract File
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



DATA SET NAME
    
    RECORD SIZE
  Elem
    
    FIELDNAME
    
    CHARS
    
    BYTES
    
    REL TO 1
    
    FMT
    
    COBOL PICTURE
    
    DESCRIPTIONS AND REMARKS1
    
    NX55 CASE NUMBER
    
    10
    
    10
    
    1-10
    
    NU
    
    9(10)2
    
    NX55 RECIPIENT
    
    2
    
    2
    
    11-12
    
    NU
    
    X(02)3
    
    NX55 LAST NAME
    
    12
    
    12
    
    13-24
    
    AN
    
    X(12)4
    
    NX55 FIRST NAME
    
    7
    
    7
    
    25-31
    
    AN
    
    X(07)5
    
    NX55 COUNTY OF RESID
    
    2
    
    2
    
    32-33
    
    AN
    
    X(02)6
    
    NX55 MC CODE
    
    3
    
    3
    
    34-36
    
    AN
    
    X(03)7
    
    NX55 MC EFF DATE
    
    8
    
    8
    
    37-44
    
    NU
    
    9(08)
    
    CCYYMMDD8
    
    NX55 MC TERM DTE
    
    8
    
    8
    
    45-52
    
    NU
    
    9(08)
    
    CCYYMMDD9
    
    NX55 MC PAYMENT CODE
    
    1
    
    1
    
    53-
    
    AN
    
    X(01)10
    
    NX55 MC CAP CODE
    
    5
    
    5
    
    54-58
    
    AN
    
    X(05)11
    
    NX55 PSC
    
    3
    
    3
    
    59-61
    
    AN
    
    X(03)12
    
    NX55 RACE
    
    1
    
    1
    
    62
    
    AN
    
    X(01)13
    
    FILLER
    
    7
    
    7
    
    63-69
    
    AN
    
    X(07)14
    
    NX55 RECORD TYPE
    
    1
    
    1
    
    70
    
    AN
    
    X(01)
 FORMAT B1=BINARY PD=PACKED DECIMAL
    
    ED = EXTENDED DECIMAL
    
    ANALPHANUMERIC NU = NUMBERICLAST UPDATED 3/11/2005 51/30/2002
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Managed Care Register File
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FROM
    
    TO
    
    FREQUENCY
    
    DEFINITIONHIPAA 835 Encounters
    
    UNISYS
    
    HMO
    
    Monthly
    
    This file
represents the
remittance advice
for encounters
received and
processed Unisys.
The HIPAA 835 is a
nationally defined
format and is the
required format for
New Jersey as of
01/01/2005.
Detailed
information
regarding this file
is available in the
HIPPA
Implementation and
New Jersey Medicaid
Companion Guides.
This file is
available via the
NJMMIS website.HIPAA 835 
Capitation and FFS
Claims
    
    UNISYS
    
    HMO
    
    Monthly
    
    This file
represents the
remittance advice
for capitation and
fee-for-service
(FFS) claims
created by Unisys.
The 835 is a
nationally defined
format and is the
required format for
New Jersey.
Detailed
information
regarding this file
is available in the
HIPPA
Implementation and
New Jersey Medicaid
Companion Guides.
This file is
available via the
NJMMIS website.RHMF Extracts
    
    UNISYS
    
    HMO
    
    Monthly
    
    These files
represent
demographic,
eligibility, and
enrollment data for
all HMO enrollees
from the Unisys
Recipient History
Master File (RHMF),
and is produced as
part of the monthly
capitation run by
Unisys. Each of
these file extracts
is detailed below.
These files are
available via the
NJMMIS website.RHMF
Extract  Base
Records
    
    UNISYS
    
    HMO
    
    Monthly
    
    This file extract
will contain
demographic data
for each enrollee.
The data elements
include: Original
ID, Last Name,
First Name, Middle
initial, Date of
Birth, Address Line
1, Address Line 2,
Address Line 3,
Address Line 4,
Address Line 5,
Address Line 6, Zip
Code, Social
Security Number,
Gender code, and
Race Code. This
file is in
comma-delimited
format.RMHF
Extract 
    
    UNISYS
    
    HMO
    
    Monthly
    
    This file extract will contain a
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FROM
    
    TO
    
    FREQUENCY
    
    DEFINITIONEligibility Records
    
    
    
    
    
    
    
    complete
eligibility history
for each enrollee.
The data elements
include: Original
ID, Current ID,
Program Status
Code, Eligibility
Extension code,
Effective Date,
Termination, County
of Residence, and
County of
Supervision. This
file is in
comma-delimited
format.
 Page
1 of 3HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FROM
    
    TO
    
    FREQUENCY
    
    DEFINITIONRHMF Extract 
Enrollment Records
    
    UNISYS
    
    HMO
    
    Monthly
    
    This file extract will contain a
complete managed care enrollment
history for each enrollee. The
data elements include: Original
ID, Current ID, HMO Code,
Payment Code, Effective Date,
Termination Date, Capitation
Code, and Health Benefit
Indicator. This file is in
comma-delimited format.Denied Encounters
Edit File
    
    UNISYS
    
    HMO
    
    Monthly
    
    This data file contains the NJ
Medicaid edit codes posted to
denied encounters. This file
will contain the Internal
Control Number (ICN) assigned to
each encounter, along with a
maximum of ten (10) edit codes.
It serves to alert the HMO
regarding local edit codes,
which are no longer permitted on
the national remittance format
(835) under HIPAA. It is a
comma-delimited file.TPL Extracts
    
    UNISYS
    
    HMO
    
    Monthly
    
    This file represents third party
liability (TPL) data for all HMO
beneficiaries as contained on
the Unisys TPL Resources File.
This file is available via the
NJMMIS website.Pharmacy Claims 
Aged, Blind and
Disabled (ABD)
Enrollees
    
    UNISYS
    
    HMO
    
    Monthly
    
    This file represents pharmacy
claims data for aged, blind or
disabled (ABD) individuals. This
file is available via the NJMMIS
website.Diagnosis Data 
ABDs and DDD
    
    UNISYS
    
    HMO
    
    Monthly
    
    file is in comma-delimited formatHIPAA 837 Encounters
    
    HMO
    
    UNISYS
    
    As Needed
    
    This file represents the
nationally defined format for
submission of non-pharmacy
encounters (institutional,
professional, and dental). It is
the required format for New
Jersey Medicaid. Detailed
information regarding this file
is available in the HIPPA
Implementation and New Jersey
Medicaid Companion Guides.
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FROM
    
    TO
    
    FREQUENCY
    
    DEFINITIONHIPAA NCPDP
Encounters
    
    HMO
    
    UNISYS
    
    As Needed
    
    This file represents the nationally defined format for
submission of pharmacy encounters. It is the required
format for New Jersey Medicaid. Detailed information
regarding this file is available in the HIPPA
Implementation and New Jersey Medicaid Companion
Guides.OIT
    
    HMO
    
    Daily
    
    This file represents the nationally defined format for
the communication of enrollment data to the HMOs. It
has not proprietary equivalent, but is made available
to provide more timely information. Detailed
information regarding this file is available in the
HIPPA Implementation and New Jersey Medicaid Companion
Guides. This file is made available via the OIT
Portal website.OIT
    
    HMO
    
    Weekly
    
    This file represents the nationally defined format for
the communication of enrollment data to the HMOs.
Detailed information regarding this file is available
in the HIPPA Implementation and New Jersey Medicaid
Companion Guides. This file is made available via the
OIT Portal website.OIT
    
    HMO
    
    Monthly
    
    This file represents the nationally defined format for
the communication of enrollment data to the HMOs.
Detailed information regarding this file is available
in the HIPPA Implementation and New Jersey Medicaid
Companion Guides. This file is made available via the
OIT Portal websiteHMO
    
    OIT
    
    As Needed
    
    This file represents certification data and identifies
HMO enrollees as HIV, AIDS, or blood factor 8/9
dependent.HMO
    
    STATE
    
    Monthly
    
    This data represents data for the HMOs provider network.HMO
    
    STATE
    
    Monthly
    
    This data represents data supporting an invoice of
maternity deliveries, for which the State generates a
monthly financial transaction (payment).HMO
    
    STATE
    
    Monthly
    
    This data represents encounter data, which support an
invoice of services provided to ASO beneficiaries, for
which the State generates a monthly financial
transaction (payment).
  
   DATA SET NAME: NX20AMCR
    
    RECORD SIZE 297
  Elem
    
    FIELD NAME
    
    CHARS
    
    BYTES
    
    REL TO 1
    
    FMT
    
    COBOL PICTURE
    
    DESCRIPTIONS AND REMARKS31
    
    NX-TR-MC-RECORD
    
    297
    
    297
    
    1-297
    
    GROUP
    
    X(297)2
    
    NX-TR-MEDICAID ID
    
    12
    
    12
    
    1-12
    
    GROUP
    
    X(12)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Elem
    
    FIELD NAME
    
    CHARS
    
    BYTES
    
    REL TO 1
    
    FMT
    
    COBOL PICTURE
    
    DESCRIPTIONS AND REMARKS1
    
    NX TR CASE NUMBER
    
    10
    
    10
    
    1-10
    
    AN
    
    X(10)2
    
    NXTR RECIPIENT NUMBER
    
    2
    
    2
    
    11-12
    
    AN
    
    X(2)3
    
    NX-TRCHANGE TYPE
    
    1
    
    1
    
    13-13
    
    AN
    
    X(1)4
    
    NX TR CHANGE DATE
    
    8
    
    8
    
    14-21
    
    NU
    
    X(03)5
    
    NX TR SOURCE
    
    4
    
    4
    
    22-25
    
    AN
    
    X(4)6
    
    NX TR CM HMO
    
    8
    
    8
    
    26-28
    
    AN
    
    X(3)7
    
    NX TR LST NAME
    
    1
    
    1
    
    29-40
    
    AN
    
    X(12)8
    
    NX TR FST NAME
    
    5
    
    5
    
    41-47
    
    AN
    
    X(7)9
    
    NX TR DOB
    
    3
    
    3
    
    48-55
    
    NU
    
    9(8)10
    
    NX TR SEX
    
    1
    
    1
    
    56-56
    
    AN
    
    X(1)11
    
    NX TR SSN
    
    7
    
    7
    
    57-65
    
    AN
    
    X(9)12
19
    
    NX TR ADDRESS
    
    141
    
    141
    
    66-206
    
    GROUP
    
    X(141)12
    
    NX TR ADDRESS LINE 1
    
    
    22
    
    
    
    22
    
    
    66-87
    
    AN
    
    X(22)13
    
    NX TR ADDRESS LINE 2
    
    
    22
    
    
    
    22
    
    
    88-109
    
    AN
    
    X(22)14
    
    NX TR ADDRESS LINE 3
    
    
    22
    
    
    
    22
    
    
    110-131
    
    AN
    
    X(22)15
    
    NX TR ADDRESS LINE 4
    
    
    22
    
    
    
    22
    
    
    132-153
    
    AN
    
    X(22)16
    
    NX TR ADDRESS LINE 5
    
    
    22
    
    
    
    22
    
    
    154-175
    
    AN
    
    X(22)17
    
    NX TR ADDRESS LINE 6
    
    
    22
    
    
    
    22
    
    
    176-197
    
    AN
    
    X(22)18
    
    NX TR ZIP CODE
    
    
    5
    
    
    
    5
    
    
    198-202
    
    An
    
    X(5)
 FORMAT B1=BINARY PD=PACKED DECIMAL
    
    ED = EXTENDED DECIMAL
    
    ANALPHANUMERIC NU = NUMBERICLDATE UPDATED 3/11/2005 51/30/2002
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FILE NAME: MANAGED CARE REGISTER FILEEFFECTIVE DATE 4/2002DATA SET NAME: NX20AMCR
    
    RECORD SIZE 297BLOCK SIZE
 Elem
    
    FIELD NAME
    
    CHARS
    
    BYTES
    
    REL TO 1
    
    FMT
    
    COBOL PICTURE
    
    DESCRIPTIONS AND REMARKS19
    

nx-tr-zip
suffix
    
    
    4
    
    
    
    4
    
    
    203-206
    
    AN
    
    
    X
    (4)20
    
    NX-TR-PR
ENROLL DTE
    
    
    12
    
    
    
    12
    
    
    1-12
    
    GROUP
    
    
    X
    (12)
    
    FORMAT YYYYMMDD OR
SPACES21
    
    NX TR PR
DISENROL DTE
    
    
    10
    
    
    
    10
    
    
    1-10
    
    AN
    
    
    X
    (10)
    
    FORMAT YYYYMMDD OR
SPACES22
    
    nxtr PR HMO
CAP CDE
    
    
    2
    
    
    
    2
    
    
    11-12
    
    AN
    
    
    X
    (2)23
    
    NX-TR PR
BENEFIT IND
    
    
    1
    
    
    
    1
    
    
    13-13
    
    AN
    
    
    X

    (1)24
    
    NX TR CURR
ENROLL DTE
    
    
    8
    
    
    
    8
    
    
    14-21
    
    NU
    
    
    X
    (03)
    
    FORMAT YYYYMMDD OR
SPACES25
    
    NXTR CUR
DISENRL DTE
    
    
    4
    
    
    
    4
    
    
    22-25
    
    AN
    
    
    X
    (4)
    
    FORMAT YYYYMMDD OR
SPACES26
    
    NX TR CUR HMO
CAP CDE
    
    
    8
    
    
    
    8
    
    
    26-28
    
    AN
    
    
    X
    (3)27
    
    NX TR BENEFIT
IND
    
    
    1
    
    
    
    1
    
    
    29-40
    
    AN
    
    
    X
    (12)28
    
    NX TR BATCH
NUM
    
    
    5
    
    
    
    5
    
    
    41-47
    
    AN
    
    
    X
    (7)29
    
    NX TR PCM STA
CDE
    
    
    3
    
    
    
    3
    
    
    48-55
    
    NU
    
    
    9
    (8)30
    
    NX TR PR
DISENROL RSN
    
    
    1
    
    
    
    1
    
    
    56-56
    
    AN
    
    
    X
    (1)31
    
    NX TR CURR
DISENROLL RSN
    
    
    7
    
    
    
    7
    
    
    57-65
    
    AN
    
    
    X
    (9)32
    
    NX TR EXT
TYPE CDE
    
    
    141
    
    
    
    141
    
    
    66-206
    
    AN
    
    
    X
    (141)33
    
    NX TR PR
SOURCE CHG
    
    
    22
     
    

    
    22
    
    
    66-87
    
    AN
    
    
    X
    (22)34
    
    NX TR PR PAY
CODE
    
    
    22
    
    
    
    22
    
    
    88-109
    
    AN
    
    
    X
    (22)35
    
    NX TR CURR
PAY CODE
    
    
    22
    
    
    
    22
    
    
    110-131
    
    AN
    
    
    X
    (22)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medical/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Elem
    
    FIELD NAME
    
    CHARS
    
    BYTES
    
    REL TO 1
    
    FMT
    
    COBOL PICTURE
    
    DESCRIPTIONS AND REMARKS36
    
    NX TR TR RACE
    
    
    22
    
    
    
    22
    
    
    132-153
    
    AN
    
    
    X
    (22)37
    
    NX TR FILLER
    
    
    22
    
    
    
    22
    
    
    154-175
    
    AN
    
    
    X
    (22)38
    
    NX TR PHONE
    
    
    22
    
    
    
    22
    
    
    176-197
    
    AN
    
    
    X
    (22)40
    
    nx tr lanc code
    
    
    5
    
    
    
    5
    
    
    198-202
    
    AN
    
    
    X
    (5)
 FORMAT B1=BINARY PD=PACKED DECIMAL
    
    ED = EXTENDED DECIMAL      ANALPHANUMERIC NU = NUMBERICLDATE UPDATED 3/11/2005 51/30/2002
 
 FILE NAME: MANAGED CARE REGISTER FILEEFFECTIVE DATE 4/2002DATA SET NAME: NX20AMCR
    
    RECORD SIZE 297BLOCK SIZE
 DESCRIPTIONS ANDElem
    
    FIELD NAME
    
    CHARS
    
    BYTES
    
    REL TO 1
    
    FMT
    
    COBOL PICTURE
    
    REMARKS1
    
    nx-tr trailer
    
    297
    
    297
    
    GROUP
    
    
    
    
    
    REDEFINES NXOTR MCRECORD2
    
    nx-tr trailer  num
    
    12
    
    12
    
    1-12
    
    GROUP
    
    X(12)
    
    VALUE 99999999999993
    
    nx-tr trailer  ind
    
    1
    
    1
    
    13
    
    AN
    
    X(1)
    
    VALUE Z4
    
    nx-tr tape date
    
    8
    
    8
    
    14-21
    
    AN
    
    X(8)
    
    YYYYMMDD FORMAT5
    
    nx-tr frequency ind
    
    1
    
    1
    
    22
    
    AN
    
    X(1)
    
    VALUE W OR M6
    
    FILLER
    
    3
    
    3
    
    23-25
    
    NU
    
    X(3)7
    
    nx-tr mc hmo
    
    3
    
    3
    
    26-28
    
    AN
    
    X(3)8
    
    nx-tr hmo name
    
    19
    
    19
    
    29-47
    
    AN
    
    X(19)9
    
    FILLER
    
    9
    
    9
    
    48-56
    
    AN
    
    X(9)10
    
    nx-tr total count
    
    9
    
    9
    
    57-65
    
    AN
    
    X(9)11
    
    FILLER
    
    232
    
    232
    
    66-297
    
    NU
    
    X(232)
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medical/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



FORMAT B1=BINARY PD=PACKED DECIMAL
    
    ED = EXTENDED DECIMAL      ANALPHANUMERIC NU = NUMBERICLAST DATE UPDATED 3/11/2005 51/30/2002
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medical/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



School-Based Youth Services Program
  http://www.state.nj.us/humanservices/sp&i/sbys-list.html
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medical/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



PROGRAM DIRECTORS  School-Based Youth Services Program
 ATLANTICDan Carter
    
    Atlantic City Teen Service CenterAltantic City high School(609) 345-8336
    
    1400 Albany AveFAX (609) 345-8373
    
    Altantic City, New Jersey 08401Trish Helms
    
    Pleasantville School Based Program(609) 383-6900x240
    
    701 Mill RoadFAX (609) 383-6952
    
    Pleasantville, NJ 07601BERGENDominic Polifrone
    
    Hackensack High School(201)646-0722
    
    First and Beech StreetsFAX (201)646-1558
    
    Hackensack, NJ 07601BURLINGTONShaun Stern
    
    Pemberton School Based ProgramPO Box 256(609)894-0170
    
    Pemberton High SchoolFAX (609) 894-0153
    
    Pemberton, NJ 08068CAMDENSharon Shields
    
    Camden High Vocational AnnexOffice (856)541-0253
    
    Park and Baird boulevardsFAX (856)541-1989
    
    Camden, NJ 08103Camden HS Site (856)614-7680FAX (856)966-5282Woodrow Wilson Site (856)966-4282East Camden MiddleCAPE MAYCaren Maene
    
    Cape Counseling Service, Inc.ATTN: SBYSP609-884-8641
    
    128 Crest Haven RoadFAX 609-884-4840
    
    Cape May Court House, NJ 08219
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



CUMBERLANDRobert Gondolf
    
    CHCI SBYSP Teen Center856-451-4440
    
    Bridgeton High SchoolBridgeton, NJ 08302Fax 856-451-5815ESSEXMary Ellen Mess
    
    Teen PowerhouseMEMs Office 973-972-635391
    
    west Market StreetSite 973-622-1100 x4080
    
    Newark, NJ 07103Fax 973-372-6545Beverly Canady, site Manager
    
    Irvington School Based Program973-228-3000
    
    Caldwell, NJ 07006GLOUCESTERFrankie Lamborne
    
    Gloucester Co. Institute of Technology856-468-1445
    
    PO Box 800ext. 2151
    
    1360 Tanyard RoadSewell, NJ 08080Wayne Copeland
    
    Clayton Place457 North Delsea DrivePO Box 85Fax 856-863-8329
    
    Clayton, NJ 08312
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



HudsonRichard Quagliariello
    
    Union City Board of EducationProgram Director
    
    3912 Bergen TurnpikeUnion City, NJ 08087(201)392-3646FAX 201-348-1810Nivia Rojas
    
    Emerson High SchoolHuman Services Coordinator
    
    318 18th street201-392-3265
    
    Union City, NJ 07087Agnes Gillespie
    
    Bayonne School Based ProgramBayonne Board of Education201-858-7885
    
    Student Center, Room 124Avenue A and 29th StBayonne, NJ 07002HUNTERDONGary Piscitelli
    
    Hunterdon Medical Center HBH908-788-6401
    
    2100 Wescott Drivefax 908-788-6584
    
    Flemington, NJ 08822David Eichlin, coordinatorMERCERPam Lackey
    
    Trenton School Based ProgramTrenton Central High School609-989-2965
    
    400 Chambers ST. Portable UnitTrenton, NJ 08609MIDDLESEXGail Reynolds
    
    New Brunswick High School732-235-53206
    
    School Based Program1125 Livingston AvenueNew Brunswick, NJ 08901Marylyn Green
    
    Roosevelt School83 Livingston Ave732-235-8438
    
    New Brunswick, NJ 08901
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Leslie Hodes
    
    South Brunswick School Based ProgramSouth Brunswick High SBYSP732-329-4044 x3224
    
    750 Ridge Road, PO Box 183FAX 732-274-1237
    
    Monmouth Junction, NJ 08852MONMOUTHPamela Zern Coviello
    
    Long Branch High School732-728-9533
    
    391 Westwood AveFAX 732-728-9670
    
    Long Branch, NJ 07740MORRISLinda Seeley
    
    Dover High School973-989-0540 (Site)
    
    !00 Grace Street973-989-0045
    
    Dover, NJ 07801OCEANDominick Riggi
    
    Preferred Childrens Services732-363-7272
    
    CN 2036FAX 732-915-5644
    
    Lakewood, NJ 08701Ginny Galaro
    
    Pinelands Regional High SchoolNugentown Road609-296-3106 Ext. 283
    
    PO Box 248FAX 609-294-9519
    
    Tuckerton, NJ 08087-0248PASSAICPaula Howe
    
    School Based Youth Services Program973-881-3333
    
    Kennedy High School973-881-3350/52
    
    62 127 Preakness Ave.FAX 973-881-9532
    
    Paterson, NJ 07522Susan Proietti
    
    Passaic School based Program973-470-5590
    
    185 Paulison Ave973-473-2408
    
    Passaic, NJ 07055FAX 973-473-6883
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



SALEMJoan Hoolahan
    
    Salem County School Based Youth Services ProgramSalem County Vocational Technical Schools856-935-7365
    
    166 Salem-Woodstown RoadSalem, NJ 08079SOMERSETPam Brink
    
    Somerset County Vocational Technical High SchoolPO Box 6350908-526-8900 Ext 7286
    
    North Bridge St & Vogt DriveFAX 908-526-9212
    
    Bridgewater, NJ 08807SUSSEXSharon Hosking
    
    Sussex County Vocational Technical School973-383-6700 x329
    
    105 North Church Road973-579-7725
    
    Sparta, NJ 07871UNIONStacy Greene
    
    Elizabeth SBYSP YES ProgramSocial Service Department908-527-5287
    
    St. Elizabeth HospitalFAX 908-226-2551
    
    225 Williams StElizabeth, NJ 07207Loise Yohalem
    
    Plainfield School Based Youth Services Program908-753-3192
    
    925 Arlington Ave.Fax 908-226-2551
    
    Plainfield, NJ 07060WARRENSue Pappas
    
    Philipsburg SBUSP908-213-2596
    
    Board of Education908-859-2127
    
    575 Elder Ave.FAX 908-213-2062
    
    Philipsburg, NJ 08865
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



Sallie Gorohoff
Coordinator of the Children and Family Initiative in Atlantic City
Shore View Building
101 S Shore Road
Northfield, NJ 08225
609-645 7700x4332
FAX 609-645-5809
 Essex
Rose Smith
SBYSP
Childrens Hospital of NJ
201 Lyons Ave, H1
Newark, NJ 07112
 Monmouth
 Therese T. Henderickson
School Based Health & Social Servcie clinic
Keansburg School District
140 Port Monmouth Rd
Keansburg, NJ 07734
 Hudson
 Marilyn Cintron
Horizon Health Center
Program Administrator for School Based Clinics
714 Bergen Ave
Jersey City, NJ 07360
 Kelly Gleason
District Service Broker
Division of community & Support Services
Jersey City Public Schools
346 Clarement Ave, 6th floor
Jersey City, NJ 07305
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



STAFFINGSITE
    
    SERVICES RENDERED
    
    (with degrees noted)Bridgeton SBYSP
MAJOR HEALTH
PROVIDER
Community Health
Center, INC (FQHC)
    
    Comprehensive adolescent
health care, including
Physicals
HIV/STD, pregnancy screenings
and treatment
Emergency care and referrals
Well and Sick care for infants
and toddlers in child care
centers
Chronic Illness oversight
Immunizations
EPSDTs
Connect children and families
to NJ FamilyCare
    
    2 Registerd Nurses
(full time) who are
shared by high
school, middle
school and
elementary school
2 Nurse
Practitioners, one
full tiem at
Bridgeton High, one
at the middle
school
One MD part time (4
hours/week, plus
phone supervision
and referrals as
needed)Atlantic City High
SPYSP
MAJOR HEALTH
PROVIDER
AtlantiCare
    
    Comprehensive Adolescent Health
Physical Exams
Immunizations
Primary and preventative
Health services
Emergency care and referrals
Health Education
Substance Abuse
Connect children and families
to NJ FamilyCare
    
    1 Registered Nurse
(full time)
1 MD (Pediatrician)
part time for 6
hours/weekElizabeth High SPYSP
MAJOR HEALTH
PROVIDER
St. Elizabeth
Hospital through
SBYSP funding
    
    Comprehensive Adolescent Health
Services focused on
maturational issues;
Pregnancy screens, counseling,
prenatal care, nutrition
education, pregnancy
prevention education with
special attention to immigrant
youth;
Emergency care and referrals
    
    1 Doctor (MD) (at
hospital clinic)
part time for 4
hours/week on site
and referrals as
needed
1 BSN Registered
Nurse full time
1 BSN Registered
Nurse part time
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




---



##### 



STAFFINGSITE
    
    SERVICES RENDERED
    
    (with degrees noted)Referrals & Follow up
for chronic illness, using hospital
services & previous prescriptions
by doctors in other countries;Some sports and school re-admission
physicals
Teen Only clinic at hospital (one
day/week)Note: Hospital is across the street
from the high school
Connect children and families to NJFamilyCareLong Branch High
School
MAJOR HEALTH PROVIDER
SBYSP
Lead Agency (board of Ed) and
SBYSP Director higher
personnel
    
    Primary Health care
(12-13 protocols) asthma, support
group, diabetes support group,
health education, pregnancy testing
and family planning information,
community health referrals,
nutrition counseling, teen
parenting support, and pregnant
teen counseling.
Connect children and families to NJ
FamilyCare
    
    1 NP
MSN (nurse
practitioner with
Masters Degree) full
time
1 Registered Nurse
(full time) part time
16 hours/week
1 MD (Pediatrician)
part time for 6
hours/weekCamden SPYSP
    
    Comprehensive
Adolescent Health Care including:
    
    1 NP
Full time at Camden
High SchoolMAJOR HEALTH PROVIDER
CamCare through $60,000
subcontract SBYSP funds
    
    Physicals (job, sports)
Test (eg. Anemia, sickle cell, HBP,
STD, pregnancy)
Follow up on chronic problems
(e.g., diabetes, anemia, asthma,
allergies, eating disorders)
Substance abuse counseling, family,
therapy referrals
Psychotic symptoms referred to
mental health clinicians
Sexuality: counsel, education, some
treatment (eg., STDs), prenatal
care
Services focused on maturational
issues;
Emergency care and
referrals
    
    1 RN full time
1 Doctor (MD)) part
time for 4 hours/week
at Camden HS and
referrals as needed
1NP part time (20
hours/week) at
Woodrow Wilson High
School
1NP Part time (10
hours/week at east
Camden Middle SchoolImmunization referrals
Well and sick care for infants in
child care centers
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



STAFFINGSITE
    
    SERVICES RENDERED
    
    (with degrees noted)Plainfield SBYSP
    
    Comprehensive
Adolescent Health Care including:
    
    1 Pediatrician (MD)
full timeMAJOR HEALTH PROVIDER
    
    Physicals (job, sports)
HIV, STC, pregnancy screenings and
treatment
    
    1 RNNP (Registered
Nurse Practitioner)
full
timeThe Cardinal Health Center, a
Satellite of Plainfield Health
Center (FQHC)
    
    Emergency care and referrals
Well and sick care for infants and
toddlers in child care centers
Chronic Illness oversight
Immunizations
EPSDTs
Connect children and families to NJ
FamilyCare
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



http://www.state.nj.us/health/lh/lhdeirectory.pdf
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



LOCAL HEALTH DEPARTMENTS IN NEW JERSEY
JANUARY 1999
 ATLANTIC COUNTY
 Atlantic City Health DeptRonald L. Cash, M.P.P., M.P.A.
Dir, Div of Hlth
City Hall
1301 Bacharach Blvd.  4th Floor
Atlantic City, NJ 08401-4603
609-347-5663
 Atlantic County Division of Public Health
Tracye M. Ardle, M.P.H.
Health Officer
201 South Shore Road
Northfield, NJ 08225-2370
609-645 5935
 ABSECON BRIGANTINE BUENA
BUENA VISTA CORBIN EGG HARBOR CITY
EGG HARBOR TWP ESTELLE MANOR FOLSOM
GALLOWAY HAMILTON TWP (ATLANTIC CO.) HAMMONTON
LINWOOD LONGPORT MARGATE
MULLICA NORTHFIELD PLEASANTVILLE
PORT REPUBLIC SOMERS POINT VENTNOR
WEYMOUTH
 BERGEN COUNTY
Bergen County Dept of Health Services
Mark Guarino, MPH
Director
327 E Ridgewood Avenue
Paramus, NJ 07652-4895
201-634-2600
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



ALLENDALE ALPINE CLIFFSIDE PARK
DUMONT EAST RUTHERFORD EDGEWATER
FAIRVIEW FRANKLIN LAKES GLEN ROCK
HASBROUGH HEGHTS HAWORTH HO-HO-KUS
LITTLE FERRY LODI LYNDHURST
MAYWOOD MOONACHIE NORTH ARLINGTON
NORWOOD OAKLAND ORADELL
PARK RIDGE ROCHELLE PARK RUTHERFORD
SADDLE BROOK TETERBORO WOODCLIFF LAKE
WOODRIDGE WYCKOFF TWP
 Bergenfield Health Dept
David Volpe, M.A., B.S.
Health Officer
Borough Hall
198 N. Washington Avenue
Bergenfield, NJ 07621-1395
 201-387-4055 5
E-mail address: health@bergenfieldboro.com
 BERGENFIELD
 Closter Health Dept
Louis S. Apa
Health Officer
Municipal Building
295 Closter Dock Road Closter, NJ 07624-2697
201-784-0752
E-mail address: closter.health@verizon.nethttp://www.bergenhealth.org
 CLOSTER
ROCKLEIGH
 DuRidge Regoinal Health Commission
Guy Stark, BS, MA, PhD
Health Officer
50 Washington Ave
Dumont, NJ 07628-3694
201-387-5028 Fax 201-387-6065
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



DUMONT RIDGEFIELD
GARFIELD RIDGEFIELD PARK TWP
MOONACHIE SADDLE RIVER
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Elmwood Park Dept of Health
Deborah Ricci, M.P.A. Health Officer
Municipal Building 182 Market Street
Elmwood Park, NJ 07407-1497
201-796-1072
E-mail address: elmwoodhealth@aol.com
http://www.bergenhealth.org
 ELMWOOD PARK
HASBROUCK HEIGHTS
 Englewood Health Dept
Violet P. Cherry, A.C.S.W. ,M.P.H., C.H.E.S.
Health Officer
73 South Van Brunt Street
Englewood, NJ 07631-3485
201-568-3450
E-mail address: violetpcherry@cityofenglewood.org
 ENGLEWOOD
 Fair Lawn Health Dept
Denise A. DePalma Farr, MA, CHES
Health Officer
Borough of Fair Lawn 8-01 Fair Lawn Avenue
Fair Lawn, NJ 07410
201-794-5327
E-mail address: health@fairlawn.orghttp://www.bergenhealth.org
 FAIR LAWN
 Fort Lee Health Dept
Stephen S. Wielkocz, M.A
Health Officer
Memorial Health Building 309 Main Street Fort Lee, NJ 07024-4799
201-592-3590
E-mail address: s-wielkocz@fortleenj.org
http://www.bergenhealth.org
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



FORT LEE
Hackensack Health Dept
John G. Christ, M.P.A.

Health Officer
215 State Street
Hackensack, NJ 07601-5582
201-646-3965
FAX # 201-646-3989
 HACKENSACK
 Mid-Bergen Regional Health Commission
Carol Wagner, MS
Director
705 Kinderkamack Road
River Edge, NJ 07661
201-599-6290
 BOGOTA
CARLSTADT
ENGLEWOOD CLIFFS
NEW MILFORD
RAMSEY
RIVER EDGE
SOUTH HACKENSACK TWP
TENAFLY
WALLINGTON
 N.W. Bergen Regional Health Commission
Rod W. Preiss
Health Officer
22 West Prospect Street
Waldwick, NJ 07463
201-445-7217 Fax # 201-445-7219
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



HILLSDALE
MIDLAND PARK
MONTVALE
NORTHVALE OLD
TAPPAN
UPPER SADDLE RIVER
WALDWICK
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Palisades Park Health Dept
Jad Mihalinec, M.A.
Health Officer
Municipal Building
275 Broad Avenue
Palisades Park, NJ 07650-1578
201-585-4106
E-mail address: ppbdhealth@aol.comhttp://www.bergenhealth.org
 PALISADES PARK
 Paramus Board of Health
John Hopper Health Officer
Borough Hall, Jockish Square Paramus, NJ 07652-2771
201-265-2100
E-mail address: jhopper@paramusborough.org
http://www.bergenhealth.org
 MAHWAH
PARAMUS
 Teaneck Dept of Health & Human Services
Wayne A. Fisher, M.A. Health Officer
Municipal Building
818 Teaneck Road
Teaneck, NJ 07666-9998
201-837-4824
E-mail address: wfisher537@aol.com
http://www.bergenhealth.org
 TEANECK
 Township of Washington Local Health Agency
Daniel G. Levy, M.P.A. Health Officer
350 Hudson Avenue
Twp. of Washington, NJ 07675-4798
201-666-8512
E-mail address: dglevy@bellatlantic.net
http://www.bergenhealth.org
 CRESSKILL
DEMAREST
EMERSON
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



HARRINGTON PARK
RIVER VALE
WASHINGTON TWP
 BURLINGTON COUNTY
Burlington County Health Dept
Robert Gogats
Health Officer, Pub Hlth Coord
Raphael Meadow Health Center 15 Pioneer Blvd., PO Box 6000 Westampton, NJ 08060-1384
609-265-5548
E-mail address: rgogats@co.burlington.nj.us
 
 BASS RIVER TWP BEVERLY BORDENTOWN CITY
BORDENTOWN TWPBURLINGTON CITYBURLINGTON TWP
CHESTERFIELD TWP CINNAMINSON TWPDELANCO TWP
DELRAN TWPEASTAMPTON EDGEWATER PK
EVESHAM TWP FIELDSBORO FLORENCE
HAINESPORT LUMBERTON MANSFIELD (BURLINGTON CO.)
MAPLE SHADE MEDFORD LAKES MEDFORD TWP
MOORESTOWN MT HOLLY MT LAUREL
NEW HANOVER NORTH HANOVER PALMYRA
PEMBERTON PEMBERTON TWP RIVERSIDE
RIVERTON SHAMONG SOUTHAMPTON
SPRINGFIELD TWP (BURLINGTON CO.) TABERNACLE WASHINGTON TWP
(BURLINGTON CO.)
WESTAMPTON WILLINGBORO WOODLAND
WRIGHTSTOWN
 CAMDEN COUNTY
Camden County Dept of Health
Jung H. Cho, V.M.D., Dr. P.H. County Health Officer
DiPiero Center, Lakeland Road PO Box 9
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Blackwood, NJ 08012-0009
856-374-6037
E-mail address: ccho@camdencounty.com
http://www.co.camden.nj.us/
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



AUDUBON AUDUBON PARK BARRINGTON
BELLMAWR BERLIN BORO BERLIN TWP
BROOKLAWNCAMDEN CHERRY HILL
CHESILHURST CLEMENTON COLLINGSWOOD
GIBBSBORO GLOUCESTER CITY GLOUCESTER TWP
HADDON HEIGHTS HADDON TWP HADDONFIELD
HI-NELLA LAUREL SPRINGS LAWNSIDE
LINDENWOLD MAGNOLIA MERCHANTVILLE
MT EPHRAIM OAKLYN PENNSAUKEN
PINE HILL PINE VALLEYRUNNEMEDE
SOMERDALE STRATFORD TAVISTOCK
VOORHEES TWP WATERFORD TWP WINSLOW TWP
WOODLYNNE
LHD Code D0400
Fax # 856-374-6034
 CAPE MAY COUNTY
Cape May County Health Dept
Louis Lamanna, M.A., H.O. Pub Hlth Coord
4 Moore Road, DN 601 LHD Code D0500
Cape May Court House, NJ 08210-1601
609-465-1187 Fax #609-465-3933
E-mail address: lamann@co.cape-may.nj.us
http://www.capemaycountygov.net/
 AVALON CAPE MAYCAPE MAY POINT
DENNIS TWP LOWER TWP MIDDLE TWP
NORTH WILDWOOD OCEAN CITY SEA ISLE
STONE HARBOR UPPER TWP WEST CAPE MAY
WEST WILDWOOD WILDWOOD WILDWOOD CREST
WOODBINE
 CUMBERLAND COUNTY
City of Vineland Dept of Health
Louis F. Cresci, Jr., B.A. Health Officer
City Hall
640 E. Wood Street, PO Box 1508
Vineland, NJ 08360-0978
856-794-4131
E-mail address: gsartorio@vinelandcity.org http://www.salem-cumberlandhealth.org/
 VINELAND
 Cumberland/Salem Dept. of Health
Herbert W. Roeschke, Sr. M.S. Health Officer
790 East Commerce Street Bridgeton, NJ 08302
856-453-2150
E-mail address: hroeschke@salemco.orghttp://www.salem-cumberlandhealth.org/
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



BRIDGETON COMMERCIAL TWP DEERFIELD
DOWNE TWP FAIRFIELD TWP (CUMBERLAND CO.) GREENWICH TWP (CUMBERLAND CO.)
HOPEWELL TWP (CUMBERLAND CO.) LAWRENCE TWP (CUMBERLAND CO.)
MAURICE RIVER
MILLVILLE SHILOH STOW CREEK
UPPER DEERFIELD
LHD Code D0680
Fax # 856-794-1159
LHD Code D0600
Fax # 856-453-0338
 ESSEX COUNTY
Bloomfield Dept of Health
Trevor J. Weigle
Health Officer
1 Municipal Plaza
Room 111
Bloomfield, NJ 07003-3487 LHD Code D0708
973-680-4024 Fax # 973-680-4825 E-mail address: health@mail.bloomfieldtwpnj.com
http://www.co.essex.nj.us/
BLOOMFIELD CALDWELL
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



East Orange Health Dept
 Attn: Rochelle Evans, Director Health Department -143 New Street
East Orange, NJ 07017-4918LHD Code D0724
973-266-5465 Fax # 973-266-5402 E-mail address:
http://www.co.essex.nj.us/
 EAST ORANGE
 Essex County Dept of Health
Michael Festa, Ph.D. Health Officer
120 Fairview Avenue
Cedar Grove, NJ 07009 LHD Code D0725
973-228-8152 Fax # 973-403-1754 E-mail address: ecdoh@viconet.comhttp://www.co.essex.nj.us/
 Essex Regional Health Commission
Robert Ferraiuolo, MPA Health Officer
2 Babcock Place
West Orange, NJ 07052
973-325-3212
E-mail address: essexrhc@aol.com
 Irvington Dept of Health & Welfare
Sandra M. Harris, M.S.
Health Officer
Civic Square, Municipal Building
Irvington, NJ 07111-2497 LHD Code D0736
973-399-6647 Fax # 973-371-1489 E-mail address: Plasmodium99@yahoo.com
 IRVINGTON
 Livingston Health Dept
Louis E. Anello, M.E.S.
Director of Health
204 Hillside Avenue
Livingston, NJ 07039-3994
973-535-7961 Fax # 973-535-3234 E-mail address: livingstonhd@aol.com
 LIVINGSTON
 Maplewood Health Dept
Robert D. Roe, M.P.A.
Health Officer
574 Valley Street
Maplewood, NJ 07040-2691
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



973-762-8120 Fax # 973-762-1934
 MAPLEWOOD
 Montclair Health Dept
Thomas A. Restaino Dir, Hlth & Hum Srvcs
205 Claremont Avenue
Montclair, NJ 07042-3401 LHD Code D0752
973-509-4967 Fax # 973-509-1479 E-mail address: tarestaino@aol.com
http://www.co.essex.nj.us/
 BELLEVILLE CEDAR GROVEGLEN RIDGE
MONTCLAIR NUTLEY VERONA WAYNE (PASSAIC CO.)
 Newark Dept of Health
Marsha McGowan, M.P.H., M.A.
Health Officer
110 William Street
Newark, NJ 07102-1316 LHD Code D0756
973-733-7592 Fax # 973-733-5614 E-mail address: mcgowanm@ci.newark.nj.us
 NEWARK
West Caldwell Health Dept
Peter N. Tabbot, M.P.H.
Health Officer
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Boro Hall
30 Clinton Road
West Caldwell, NJ 07006-6774
973-226-2303
E-mail address: PTabbot@aol.com
http://www.co.essex.nj.us/
 FAIRFIELDWEST
CLADWELL
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



West Orange Health Dept
Joseph A. Fonzino, M.S.
Health Officer
Municipal Building
66 Main Street
West Orange, NJ 07052-5404
973-325-4124 Fax # 973-325-4005 E
 ESSEX FELLS
ORANGE
WEST ORANGE
 GLOUCESTER COUNTY
Gloucester County Dept of Health
Donald Benedik
Health Officer
160 Fries Mill Road
Turnersville, NJ 08012
856-262-4101 Fax #856-262-4109
 
 CLAYTON LOGAN SWEDESBORO
DEPTFORD MANTUA EAST GREENWICH
ELK TWP FRANKLIN TWP (GLOUCESTER CO.) GLASSBORO
GREENWICH TWP (GLOUCESTER CO.) HARRISON TWP (GLOUCESTER CO.)
MONROE TWP (GLOUCESTER CO.) NATIONAL PARK
NEWFIELD PAULSBORO PITMAN
SOUTH HARRISON WASHINGTON TWP (GLOUCESTER CO.)
WENONAH WEST DEPTFORD WESTVILLE
WOODBURY WOODBURY HEIGHTS WOOLWICH
 HUDSON COUNTY
Bayonne Dept of Health
Brigid Breivogel, R.N., M.S.
Health Officer
Municipal Building
630 Avenue C
Bayonne, NJ 07002-3878
201-858-6112 Fax # 201-858-6111
 BAYONNE
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Harrison Board of Health
Karen Comer, M.S., C.H.E.S.
Health Officer
318 Harrison Avenue
Harrison, NJ 07029-1752
973-268-2441 Fax # 973-482-2924
 HARRISON
 Hoboken Health Dept
Frank S. Sasso, M.S., M.S.W.
Health Officer
124 Grand Street Hoboken, NJ 07030-4297
201-420-2365 Fax # 201-420-7862
 HOBOKEN
 Jersey City Division of Health
Joseph Castagna, M.S.
Health Officer
586 Newark Avenue
Jersey City, NJ 07306-2302
201-547-5545 Fax # 201-547-4848
 JERSEY CITY
 Kearny Dept of Health
John P. Sarnas, M.A.
Health Officer
645 Kearny Avenue Kearny, NJ 07032-2998
201-997-0600
Fax #201-997-9703
 EAST NEWARK KEARNY
HUDSON CO. DIV. OF ENVIRONMENTAL HEALTH
 North Bergen Health Dept
Richard J. Censullo, M.P.H.
Health Officer
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



1116 43rd Street
North Bergen, NJ 07047
201-392-2084
 NORTH BERGEN
UNION CITY
 Secaucus Health Department
VACANT
Health Officer
20 Centre Avenue
Secaucus, NJ 07094
201-330-2030 FAX 201-330-8352
 SECAUCUS
 West New York Health Dept
Vincent A. Rivelli, M.S.
Health Officer
428  60th Street, Room 31 West New York, NJ 07093
201-295-5070
Fax # 201-869-1715
 GUTTENBERG
WEEHAWKEN
WEST NEW YORK
 HUNTERDON COUNTY
Hunterdon County Dept of Health
John Beckley, M.P.H.
Health Officer
County Complex, Building #7 Route 12  PO Box 2900
Flemington, NJ 08822-1396
908-788-1351
Fax # 908-782-7510
 ALEXANDRIA TWP BETHLEHAM TWP BLOOMSBURY
CALIFON CLINTON TOWN CLINTON TWP
DELAWARE TWP EAST AMWELL TWP FLEMINGTON
FRANKLIN TWP (HUNTERDON CO.) FRENCHTOWN GLEN GARDNER
HAMPTON BORO (HUNTERDON CO.) HIGH BRIDGE HOLLAND
KINGWOOD LAMBERTVILLE LEBANON
LEBANON TWP MILFORD RARITAN TWP
READINGTON TWP STOCKTON TEWKSBURY
UNION TWP WEST AMWELL TWP
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



MERCER COUNTY
 East Windsor Township Health Department
Patricia A. Hart, RS MPH
Health Officer
Municipal Building
16 Lanning Boulevard
East Windsor, NJ 08520-1999
609-443-4000 Fax # 609-443-8030
 EAST WINDSOR TWP
HIGHTSTOWN BORO
 EWING TWP
Hamilton Township Division of Health
Jeffrey J. Plunkett, B.A., M.Ed. Health Officer
2100 Greenwood Avenue
PO Box 00150
Hamilton, NJ 08650-1050
609-890-3820
E-mail address: jplunkett@hamiltonnj.comhttp://www.hamiltonnj.com/index.htm
 HAMILTON TWP
 Hopewell Township Health Dept
Gary A. Guarino
Health Officer
201 Washington Crossing-Pennington Rd Titusville, NJ 08560-1410
609-737-0120
FAX # 609-737-1022
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



HOPEWELL BORO
HOPEWELL TWP
PENNINGTON BORO
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Princeton Regional Health Commission
William J Hinshillwood, MA
Health Officer
Borough Hall
1 Monument Drive, PO Box 390 Princeton, NJ 08542
609-497-7610
E-mail address: dhenry@princetonboro.org
 PRINCETON BORO
PRINCETON TWP
 Lawrence Township Health Department
Carol Chamberlain
Health Officer
PO Box 6006
2207 Lawrenceville Road
Lawrenceville, New Jersey 08648-3198
609-844-7089 Fax # 609-884-5324
 LAWRENCE TWP
 City of Trenton  Dept of Health & Human Services, DOH
Richard D. Salter, M.A.
Health Officer
222 East State Street
Trenton, NJ 08608-1866
609-989-3636
 TRENTON
 West Windsor Township Health Dept
Robert Hary, M.A., M.B.A. Health Officer
PO Box 38
271 Clarksville Road
Princeton Junction, NJ 08550-0038
609-799-2400 FAX # 609-799-2044
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



WASHINGTON TWP
WEST WINDSOR TWP
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



MIDDLESEX COUNTY
Edison Dept of Health & Human Resources
John O. Grun, M.S.
Health Officer
Municipal Complex
100 Municipal Boulevard Edison, NJ 08817-3353
732-248-7290
E-mail address: health@edisonnj.orgwww.edisonnj.org
 EDISON
 Middle-Brook Regional Health Commission
Kevin G. Sumner, M.P.H. Health Officer
Boro Hall
1200 Mountain Avenue Middlesex, NJ 08846-1200
732-356-8090 FAX # 732-356-7954
 BOUND BROOK (SOMERSET CO.)
GREEN BROOK TWP (SOMERSET CO.)
MIDDLESEX BORO
SOUTH BOUND BROOK (SOMERSET CO.)
WARREN TWP (SOMERSET CO.)
WATCHUNG (SOMERSET CO.)
 Middlesex County Public Health Dept
Bernard G Mihalko
Director
35 Oakwood Avenue
Edison, NJ 08837
732-745-3100
 
 CARTERET CRANBURY DUNELLEN
EAST BRUNSWICK HELMETTA HIGHLAND PARK
JAMESBURG METUCHEN MILLTOWN
MONROE TWP (MIDDLESEX CO.) NEW BRUNSWICK NORTH BRUNSWICK
OLD BRIDGE PERTH AMBOY PLAINSBORO
 
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



SAYREVILLE SOUTH AMBOY SOUTH PLAINFIELD
SOUTH RIVER SPOTSWOOD
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Piscataway Township Health Dept
Andrew C. Simpf, Jr., M.A.
Health Officer
455 Hoes Lane
Piscataway, NJ 08854-5097
732-562-2323 Fax # 732-743-2500
 PISCATAWAY
 South Brunswick Health Dept
Stephen J. Papenberg Health Officer
Ridge Road/Route 522 PO Box 190
Monmouth Junction, NJ 08852-0190
732-329-4000 x 237
 ROCKY HILL (SOMERSET CO.)
SOUTH BRUNSWICK
 Woodbridge Twp Dept of Hlth & Hum Srvs
Patrick O Hanson
Health Officer
2 George Frederick Plaza
Woodbridge, NJ 07095 LHD Code D1278
732-855-0600 x 5025 Fax # 732-855-0944
 WOODBRIDGE
 MONMOUTH COUNTY
Colts Neck Township Health Dept
William McBride
Health Officer
124 Cedar Drive
Colts Neck, NJ 07722-0249
732-462-5470
 COLTS NECK
 Freehold Area Health Department
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



R. Chadwick Taylor, MBA
Health Officer
1 Municipal Plaza
Freehold, NJ 07728-3099
732-294-2060 FAX # 732-462-2340
 FREEHOLD BORO
FREEHOLD TWP
MILLSTONE
UPPER FREEHOLD
 Hazlet-Aberdeen Health Dept
Robert N. Scapicio, M.A.
Health Officer
3400 State Highway 35
Suite 9
Hazlet, NJ 07730-0371
732-264-5541 Fax # 732-264-0659
 ABERDEEN
HAZLET
 Long Branch Dept of Health
David Roach, M.P.H. Health Officer
344 Broadway
Long Branch, NJ 07740-6938
732-571-5665
 LONG BRANCH
 Manalapan Township Dept of Health
W. David Richardson, M.P.H. Health Officer
120 Route 522
Manalapan, NJ 07726-3497
732-446-8345
E-mail address: health@twp.manalapan.nj.us
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



MANALAPAN
 Matawan Regional Department of Health
Alan C. Hopper
Health Officer
145 Borad Street
Matawan, New Jersey 07748
732-566-0740 Fax # 732-566-7283
 HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



HOLMDEL
KEANSBURG
KEYPORT
MATAWAN
 Middletown Township Health Dept
Stephen L. McKee
Health Officer
Johnson Gill Annex Building 1 Kings Highway
Middletown, NJ 07748-2594
732-615-2095
E-mail address: smckee@middletownnj.org
 MIDDLETOWN
 Monmouth County Health Dept
Lester W. Jargowsky, M.P.H. Pub Hlth Coord
3435 Highway 9 Freehold, NJ 07728-2850
732-431-7456
E-mail address: ljargows@co.monmouth.nj.us
 ALLENTOWN BORO ASBURY PARK CITY ATL HIGHLANDS BORO
AVON-BY-THE-SEA BORO BELMAR BORO BOROUGH OF LAKE COMO
BRADLEY BEACH BORO ENGLISHTOWN BORO FARMINGDALE BORO
HOWELL TWP MANASQUAN MARLBORO TWP
MATAWAN MILLSTONE TWP NEPTUNE CITY
NEPTUNE TWP OCEANPORT ROOSEVELT BORO
SEA GIRT BORO SPRING LAKE BORO UNION BEACH
WALL TWP
 
 Monmouth Cty Reg Health Commission # 1
Sidney B. Johnson, Jr., M.S., MBA Health Officer
1540 West Park Avenue
Suite 1
Ocean Twp, NJ 07712
732-493-9520
 HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



E-mail address: IPPY2@IX.NETCOM.COM
 
 ALLENHURST BRIELLE DEAL
EATONTOWN FAIR HAVEN HIGHLANDS
HOLMDEL INTERLAKEN KEANSBURG
KEYPORT LITTLE SILVER LOCH ARBOR VILLAGE
MONMOUTH BEACH OCEAN TWP (MONMOUTH CO.) RED BANK
RUMSON SEA BRIGHT SHREWSBURY
SPRING LAKE HEIGHTS SREWSBURY TWP TINTON FALLS
WEST LONG BRANCH
 Red Bank Health Department
Frederick A Riehart
Health officer
90 Monmouth Street, Box 868
Red Bank, New Jersey 07701
732-530-2754
 FAIRHAVEN RED BANK
LITTLE SILVERRUMSON
 MORRIS COUNTY
 Denville Division of Health
Herbert J Yardley, MA
Health Officer
1 Saint Marys Place Denville, NJ 07834-2199
973-625-8305 FAX 973-627-8371
 DENVILLE
 Dover Health Dept
Donald N. Costanzo, M.A., M.P.A.
Health Officer
37 North Sussex Street, Box 798
Dover, NJ 07802-0798
973-366-2200 ext. 120 Fax. 973-328-6604
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



DOVER
 East Hanover Health Dept
Peter Summers, MA
Health Officer
411 Ridgedale Avenue
East Hanover, NJ 07936-1487
973-428-3035 E-mail address:chanover@interactive.net
Fax # 973-428-2986
Website: http://www.easthanovertownship.com
 EAST HANOVER TWP
ROSELAND BORO (ESSEX CO.)
 Township of Hanover Health Dept
George Van Orden, PhD
Health Officer
1000 Route 10, PO Box 250
Whippany,, NJ 07981-0250
973-428-2484 E-mail address:van122w@wonder.em.ede.gov
 HARDING TWP MORRIS TWP
HANOVER TWP
 Jefferson Township Health Dept
Cindee DeGennaro, M.A. Health Officer
1033 Weldon Road
Lake Hopatcong, NJ 07849-0367
973-697-1500 FAX: 973-697-8090
 JEFFERSON TWP
 Borough of Kinnelon Health Department
Calliope C. Alexander, MA, BS
Health Officer
Municipal Building, 130 Kinnelon Road
Kinnelon, New Jersey 07405
973-838-5403 fax 973-838-1862
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



KINNELON
 Lincoln Park Health Dept
Pasquale A. Pignatelli, Jr., M.P.A.
Health Officer
34 Chapel Hill Road
Lincoln Park, NJ 07035-1998
973-694-6306 Fax # 973-628-9512
 BOONTON TWP
LINCOLN PARK
RIVERDALE
 Madison Boro Board of Health
John Theese, M.S.
Health Officer
28 Walnut Street
Madison, NJ 07940-2592
973-593-3079
 CHATHAM BORO CHATHAM TWP FLORHAM PARK BORO
LONG HILL TWP MADISON BORO MINE HILL TWP
MORRIS PLAINS BORO MOUNT ARLINGTON BORO VICTORY GARDEN BORO
 Montville Township Health Dept
John A. Wozniak, Jr., M.E.H. Health Officer
195 Changebridge Road
Montville, NJ 07045-9498
973-331-3316 FAX 973-402-0787
 MONTVILLE
MOUNTAIN LAKES
 Morris County Office of Health Management
Howard Steinberg
Health Officer
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



200 South Street PO Box 914
Morristown, NJ 07963-0914
973-292-6707 FAX# 973-292-6730
 MORRISTOWN
 Mt. Olive Township Health Dept
Frank P. Wilpert
Dir, Hlth, Welf & San
Route 46, PO Box 450 Budd Lake, NJ 07828-3200
973-691-0900 FAX # 973-691-7681
 MT OLIVE
 Parsippany Health Dept
P. Wayne Croughn
Health Officer
Municipal Building
1001 Parsippany Blvd
Parsippany, NJ 07054-1222
973-263-7160 Fax # 973-299-1349
 PARSIPPANY-TROY HILLS
 Pequannock Township Board of Health
Peter Correale
Health Officer
530 Newark-Pompton Turnpike
Pompton Plains, NJ 07444-1799
973-835-5700 x 128 Fax # 973-835-4328
 BLOOMINGDALE (PASSAIC CO.)
BUTLER BORO
PEQUANNOCK
 Randolph Township Board of Health
Clement R. Ferdinando, M.P.H.
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



Health Officer
502 Millbrook Avenue
Randolph, NJ 07869-3799
973-989-7050 Fax # 973-989-7076
http://www.gti.net/randolph/
 RANDOLPH ROCKAWAY BORO
 Rockaway Township Health Dept
Steven C. Levinson, M.S.
Health Officer
65 Mt. Hope Road
Rockaway, NJ 07866-1699
973-983-2848 Fax # 973-983-2497
 BOONTON BORO CHESTER TWP
ROCKAWAY TWP
 Roxbury Township Health Department
Frank A. Grisi
Health Officer
72 Eyland Avenue
Succasunna, NJ 07876-1622
973-448-2028 Fax # 973-252-6079
E-mail address: grisif@roxburynj.us
 ROXBURY WHARTON BORO
 Washington Township Health Dept
Cristianna Cooke-Gibbs, M.P.H. Health Officer
43 Schooleys Mountain Road
Long Valley, NJ 07853
908-876-3650 Fax # 908-876-5138
 WASHINGTON TWP
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



OCEAN COUNTY
Long Beach Island Health Dept
Timothy J. Hilferty
Health Officer
11601 Long Beach Boulevard
Haven Beach, NJ 08008-3661
609-492-1212 Fax # 609-492-9215
 BARNEGAT LIGHT LONG BEACH
BEACH HAVEN SHIP BOTTOM
HARVEY CEDARS SURF CITY
 Ocean County Health Dept
Joseph Przywara, B.A.
Pub Health Coordinator

175 Sunset Avenue PO Box 2191
Toms River, NJ 08754-2191
732-341-9700 FAX 732-341-4467
 E-mail address: OCHD@americom.net
Website: http://www.ochd.org
 BARNEGAT TWP BAY HEAD BEACHWOOD
BERKELEY TWP BRICK TWP DOVER TWP
EAGLESWOOD TWP ISLAND HEIGHTS JACKSON TWP
LAKEHURST LAKEWOOD
LAVALLETTE LITTLE EGG HARBOR TWP MANCHESTER
MANTOLOKING OCEAN GATE OCEAN TWP
PINE BEACH POINT PLEASANT
POINT PLEASANT BEACH S. TOMS RIVER SEASIDE HEIGHTS
SEASIDE PARK STAFFORD TUCKERTON
LACEY TWP PLUMSTEAD
 PASSAIC COUNTY
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



Bloomingdale  See Pequannock (MORRIS CO)
Wanaque  See Pequannock (MORRIS CO)
Wayne  See Montclair (ESSEX CO)
 Clifton Board of Health
Albert Greco, MA
Health Officer
900 Clifton Avenue
Clifton, NJ 07013-2705
973-470-5763 FAX 973-470-5768
E-mail address: agrecol@worldnet.att.net
 CLIFTON
 Township of Little Falls Health Department
John M. Festa, MA
Health Officer
Municipal Annex
35 Stevens Avenue
Little Falls, New Jersey 07424
973-256-0170 FAX 973-890-4501
 LITTLE FALLS
SOUTH ORANGE (ESSEX CO.)
PASSAIC
 Passaic City Health Dept
Henry C McCafferty
Health Officer
City Hall
330 Passaic Street
Passaic, NJ 07055-5814
973-365-5603 FAX 973-365-5582
 PASSAIC
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



Passaic County Dept of Health
John J. Ferraioli
Health Officer
Administrative Bldg, Annex Rm 201
317 Pennsylvania Avenue
Paterson, NJ 07503-1788
973-881-4396 fax 973-225-0222
Email address: jfpedh@intercall.com
 Paterson Division of Health
Joseph J. Surowiec
Health Officer
176 Broadway
Paterson, NJ 07505-1198
973-881-6922 FAX # 973-279-7511
E-mail address: mosses@interactive.net
 HALEDON PROSPECT PARK
HAWTHORNE TOTOWA
NORTH HALEDON WEST PATERSON
PATERSON
 Ringwood Health Dept
Christopher Chapman, M.P.H.
Health Officer
60 Margaret King Avenue
Ringwood, NJ 07456-1703
973-962-7079 Fax # 973-962-6028
 RINGWOOD
WANAQUE
 West Milford Township Health Dept
Kenneth R. Hawkswell, M.P.H.
Health Officer
1480 Union Valley Road
West Milford, NJ 07480-1303
973-728-2720
POMPTON LAKES
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



WEST MILFORD
 SALEM COUNTY
Salem Co. Dept of Health
Lawrence P. Devlin, Jr., M.P.A., R.S., CSW
Health Officer
98 Market Street
Salem, NJ 08079-1995
609-935-7510 Fax # 609-935-8483
 
 ALLOWAY CARNEYS POINT ELMER
ELSINBORO TWP LOWER ALLOWAYS MANNINGTON
OLDMANS PENNS GROVE PENNSVILLE
PILESGROVE PITTSGROVE QUINTON
SALEM UPPER PITTSGROVE WOODSTOWN
 SOMERSET COUNTY
Bround Brook  See Middle Brook (MIDDLESEX CO.)
Green Brook  See Middle Brook (MIDDLESEX CO.)
Rocky Hill  See S. Brunswick (MIDDLESEX CO.)
South Bround Brook  See Middle Brook (MIDDLESEX CO.)
Warren Twp  See Middle Brook (MIDDLESEX CO.)
Watchung  See Middle Brook (MIDDLESEX CO.)
 Bernards Township Health Dept
Lucy A. Forgione, M.S.
Health Officer
262 South Finley Avenue
Basking Ridge, NJ 07920-1418
908-204-3070 FAX 908-204-3075
 CHESTER BORO (MORRIS CO.) FAR HILLS
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



BEDMINSTER BERNARDS BERNARDSVILLE
MENDHAM BORO (MORRIS CO.)
MENDHAM TWP (MORRIS CO.) PEAPACK-GLADSTONE
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



Branchburg Township Health Dept
Leonard H. Williams, MPA, REHS/RS
Health Officer
Branchburg Township Department of Health
34 Kenbury Road
Somersville, NJ 08876
908-526-1300 x 215, FAX # 908-704-1214
E-mail address: bburg@superlink.com
 BRANCHBURG
 Bridgewater Township Health Dept
Richard N Martini, MPH.
Health Officer
700 Garretson Road
PO Box 6300
Bridgewater, NJ 08807-0300
908-725-5750
website: http://www.bcbex.net/bridgewater
 BRIDGEWATER
 Franklin Township Health Dept
Walter P. Galanowsky, M.P.H.
Health Officer
935 Hamilton Street Somerset, NJ 08873-3697
732-873-2500 x 377 FAX # 732-214-0969
 FRANKLIN TWP
 Hillsborough Township Health Dept
Glen Belnay, Ph.D.
Health Officer
379 South Branch Road Hillsborough, NJ 08844
908-369-5652 fax 908-369-8565
 HILLSBOROUGH MILLSTONE BORO
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



Montgomery Township Health Dept
David A. Henry, M.P.H.
Health Officer
Municipal Building
2261 Van Horne Road  Route 206
Belle Mead, NJ 08502-4012
908-359-8211 x245 Fax # 908-359-4308
E-mail address: monthealth@aol.com
 MONTGOMERY
 North Plainfield Health Department
Herbert W. Roesehke, Sr., M.S.
Health Officer
263 Somerset Street
North Plainfield, New Jersey 07060
908-769-2907, Fax # 908-769-6499
 NORTH PLAINFIELD
 Somerset County Health Dept
John A. Horensky, M.S.
Health Officer
County Admin. Bldg.,
20 Grove Street PO Box 3000
Somerville, NJ 08876-1262
908-231-7155 Fax 908-704-8042
 Somerville Health Dept
Steve Krajewski, M.P.H.
Health Officer
25 West End Avenue Municipal Building
Someville, NJ 08876-0399
908-704-6980 Fax # 908-704-8042
E-mail address: skraj@njpha.org
Website: http://www.njpha.org
 MANVILLE RARITAN SOMERVILLE
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



SUSSEX COUNTY
Borough of Hopatcong
Carl Sever, B.A.,
Health Officer
Municipal Building
111 River Styx Road
Hopatcong, NJ 07843-1535
973-770-1200 143 Fax # 973-398-3650
 HOPATCONG
 Sparta Health Dept
Ralph J. DAries, R.S., M.A.
Health Officer
65 Main Street
Sparta, NJ 07871-1986
973-729-6174
 FRANKLIN BORO
HARDYSTOWN
OGDNESBURG
SPARTA
STANHOPE
 Sussex Cty Dept of Health, Public Safety & Senior Srvs
Philip Morlock
Administrator
127 Morris Turnpike
Newton, NJ 07860-7860
973-579-0370 Fax #973-948-2593
 ANDOVER BORO LAFAYETTE
ANDOVER TWP MONTAGUE
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



BRANCHVILLE
BYRAM FRANKFORD FREDON
GREEN TWP HAMBURG
NEWTON
SANDYSTON STILLWATER SUSSEX
WALPACK WANTAGE HAMPTON
 Vernon Township Board of Health
Gene S. Osias, M.S.W.
Health Officer
Municipal Center, 21 Church Street
PO Box 340
Vernon, NJ 07462-0340
973-764-4055 Fax 973-764-4055
 VERNON
 UNION COUNTY
 Clark Health Dept
Nancy A. Ogonowski, M.P.H.
Health Officer
430 Westfield Avenue
Clark, NJ 07066
732-388-3600 x 3045 Fax # 732-388-1268
 CLARK
 Township of Cranford Department of Health
Warren J Hehl, MPA
Health Officer
8 Springfield Avenue
Cranford, NJ 07016-2199
908-709-7238 Fax# 908-276-7664
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



CRANFORD
 Elizabeth Dept. of Health & Human Services
John N. Surmay
Health Officer
City Hall of Elizabeth G-12
50 Winfield Scott Plaza
Elizabeth, NJ 07201-2462
908-820-4060 Fax # 908-820-4290
 ELIZABETH
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



Linden Board of Health
Nancy Koblis
Health Officer
City Hall
301 North Wood Avenue
Linden, NJ 07036-4296 LHD Code D2032
908-474-8409 Fax # 908-474-8418
 LINDEN ROSELLE
 City of Plainfield Health Department
Ruby Hodge, MS, MA
Health Officer
510 Watchung Avenue, PO Box 431
Plainfield, New Jersey 07061- 0431
E-mail Address: jdipane@plainfield.com
Website: http://www.plainfield.com
 PLAINFIELD
 Rahway Health Department
Anthony D. Deige
Health Officer
1 City Hall Avenue
Rahway, NJ 07065-3930
732-827-2081 Fax # 732-381-7668
 HILLSIDE
RAHWAY
WINFIELD TWP
SCOTCH PLAINS
 Summit Health Department
Stuart B. Palfreyman, B.S.E.H., M.S.E.H., R.S.
Health Officer
512 Springfield Avenue
Summit, NJ 07901-3682
908-522-3614 Fax # 908-277-0185
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



BERKELEY HEIGHTS
NEW PROVIDENCE
SUMMIT
 Township of Union Department of Health
Dennis V. SanFilippo, MPA
Health Officer
Municipal Building
1976 Morris Avenue
Union, NJ 07083-1894
908-851-8507 Fax # 908-851-4673
 UNION
KENILWORTH
 Westfield Regional Health Dept
Robert M. Sherr, M.A. Health Officer
Municipal Building
425 East Broad Street
Westfield, NJ 07090-2197
908-789-4070
E-mail address: health@westfieldnj.nethttp://www.westfieldnj.net/health
 FANWOOD
GARWOOD
MOUNTAINSIDE
ROSELLE PARK
SPRINGFIELD
WESTFIELD
 WARREN COUNTY
Warren County Health Dept
John Hawk, MPA
Health Officer
315 W. Washington Avenue
Washington, NJ 07882-2153
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



908-689-6693 Fax # 908-689-3832
E-mail address: hawkjohn@njlincs.net
 ALLAMUCHY ALPHA BELVIDERE
BLAIRSTOWN FRANKLIN TWP (WARREN CO.) FREINGHUYSEN
GREENWICH TWP (WARREN CO.) HACKETTSTOWN HARDWICK
HARMONY HOPE INDEPENDENCE
KNOWLTON LIBERTY LOPATCONG
MANSFIELD (WARREN CO.) OXFORD PHILLPSBURG
POHATCONG WASHINGTON BORO (WARREN CO.) WASHINGTON TWP (WARREN CO.)
WHITE TWP
  HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



Mental Health/Substance Abuse Screening Tools
 HMO Financial Reporting Specifications
    
    State of New Jersey




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##### 



o
    Americhoice
    


    o
    Amerigroup
    
    
    o
    Horizon MercyNJ Health
    
    o
    Health Net
    
    o
    University HealthPlans
 
 Patient Name:
    
    
    
    Date Completed:Member ID#:
    
    
    
    PCP Name:
  
 During the past month generally (questions 1-11):
    
    YES
    
    NO1. Have you been feeling tired or have low energy?2. Have you been having trouble sleeping (Too much or too little)?3. Have you been feeling sad, hopeless, or unusually happy?4. Have you been feeling bad about yourself that you are a failure or have let yourself or
your family down?5. Have you been having trouble concentrating on things, such as watching TV, reading the
newspaper, or reading a book?6. Have you been feeling on edge, nervous?7. Have your eating patterns or appetite changed?8. Have you been trying not to gain weight (making yourself vomit, taking excessive
laxatives, or exercising more than an hour per day)?9. Have you felt sudden fear or panic for no obvious reason?10. Have you been having thoughts that you would be better off dead, or of hurting yourself?11. Are you troubled by being unable to control your anger or by having thoughts about
hurting others?12. Have youa. Ever felt you ought to cut down on your drinking or drug use?b. Ever felt annoyed by people who comment on your drinking or drug use?c. Ever felt bad or guilty about your drinking or drug use?d. Ever had a drink or used drugs first thing in the morning to steady your nerves or get
rid of a hangover (eye opener)?13. Do you have any other concerns about your well-being? Please Explain14. Have you ever sought treatment for any of the above problems for which you checked yes?15. If you checked yes to any of the above questions, how difficult have these problems
made it for you to do your work, go to school, take care of things at home or get along
with other people?Not Difficult At All Somewhat Difficult Very Difficult Extremely Difficult
 HMO Financial Reporting Specifications
    
    State of New JerseyFor
Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



B.4.11 Special Child Health Services Network
 
 http://www.state.nj.us/health/fhs/sccasemg.htm
 The following pages list special child health services network agencies by provider type.
 HMO Financial Reporting Specifications
    
    State of New JerseyFor
Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



NEW JERSEY DEPARTMENT OF HEALTH AND SENIOR SERVICES
SPECIAL CHILD, ADULT AND EARLY INTERVENTION SERVICES
County Case Management Units
 Atlantic County SCHS Case Management Unit
Department. Of Intergenerational Services
101 South Shore Road
Northfield, NJ 08225-2320
609-645-77010 Ext. 4358
Fax # 609-645-5907
 Bergen CountySCHS-Case Management Unit
Bergen County Dept. of Health Services
327 Ridgewood Avenue, Second Floor
Paramus, NJ 07652-4895
(201) 634-2620
Fax # (201) 599-8947
 Burlington CountySCHS-Case Management Unit
Community Nursing Services
Raphael Meadow Health Center
P.O. Box 287 Woodlane Road
Mount Holly, NJ 08060-0287
(609) 267-1950 Ext. 42882
Fax # (609) 702-0541
 Camden CountySCHS-Case Management Unit
Camden County Division of Health
Jefferson House  Lakeland Road, PO Box 9
Blackwood, NJ 08012-0009
(856) 374-6021 or (800) 999-9045
Fax # (856) 374-9734
 Cape May CountySCHS-Case Management Unit
Cape May Dept. of Health
6 Moore Rd. Crest Haven Complex
Cape May Court House, NJ 08210-3067
(609) 465-1203
Fax # (609) 463-3527
 Cumberland CountySCHS-Case Management Unit
Cumberland County Dept. of Health
790 East Commerce Street
Bridgeton, NJ 08302-2293
(856) 453-2154
Fax # (856) 453-0338
 HMO Financial Reporting Specifications
    
    State of New JerseyFor
Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Essex CountySCHS-Case Management Unit
County of Essex Department of Health and Rehabilitation
Division of Community Health Services
Unit of Special Child, Adult and Early Intervention Services
160 Fairview Ave. Rawson Hall, Bldg. #37
Cedar Grove, NJ 07009
(973) 857-4663 or 857-4745
Fax # (973) 857-5163


Gloucester CountySCHS-Case Management Unit
Gloucester County Health Department
160 Fries-Mill Road
Turnersville, NJ 08012-2496
(856) 262-4100 (Ext. 4157)
Fax # (856) 629-0469


Hudson CountySCHS-Case Management Unit
Jersey City Medical Center
50 Baldwin Avenue, Dept. 2124
12 th Floor Clinic Bldg.
Jersey City, NJ 07304-3199
(201) 915-2514
Fax # (201) 915-2565


Hunterdon CountySCHS-Case Management Unit
Hunterdon Medical Center
2100 Wescott Drive
Flemington, NJ 08822-9238
(908) 788-6399
Fax # (908) 788-6581


Mercer CountySCHS-Case Management Unit
Sypek Center
129 Bull Run Road
Pennington, NJ 08534
(609) 730-4152 or (609) 730-4151
Fax # (609) 730-4154


Middlesex CountySCHS-Case Management Unit
Middlesex County Department of Health
75 Bayard Street  5 th Floor
New Brunswick, NJ 08901
(732) 745-3100
Fax # (732) 296-7990


HMO Financial Reporting Specifications
    
    State of New JerseyFor
Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Monmouth CountySCHS-Case Management Unit
Monmouth County  Special Child Health/Early Intervention
141 Bodman Place
Red Bank, NJ 07701
(732) 224-6950
Fax # (732) 747-4404
 Morris CountySCHS-Case Management Unit
Morristown Memorial Hospital
100 Madison Avenue, Box 99
Morristown, NJ 07960-6095
(973) 971-4155
Fax # (973) 290-7358
 Ocean CountySCHS-Case Management Unit
Ocean County Department of Health
PO Box 2191
Sunset Avenue
Toms River, NJ 08754-2191
(732) 341-9700 Ext. 7602
Fax # (732) 341-5461
 Passaic CountySCHS-Case Management Unit
Catholic Family and Community Services
279 Carroll Street
Paterson, NJ 07505
(973) 523-6778
Fax # (973) 523-7715E-mail address: schspassaic@aol.com
 Salem CountySCHS-Case Management Unit
Salem County Department of Health
98 Market Street
Salem, NJ 08079-1911
(856) 935-7510 Ext. 8479
Fax # (856) 935-8483
 Somerset CountySCHS-Case Management Unit
Somerset Handicapped Childrens Treatment Center
377 Union Avenue
P.O. Box 6824
Bridgewater, NJ 08807-0824
(908) 725-2366
Fax # (908) 725-3945
 HMO Financial Reporting Specifications
    
    State of New JerseyFor
Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Sussex CountySCHS-Case Management Unit
Sussex County Health Department
Division of Public Health Nursing
129 Morris Turnpike
Newton, NJ 07860
(973) 948-5400 Ext. 49
Fax # (973) 948-2270
 Union CountySCHS-Case Management Unit
328 South Avenue
Fanwood, NJ 07023
(908) 889-0950
Fax # (908) 889-7535
 Warren CountySCHS-Case Management Unit
Warren County Health Department
Special Child, Adult and Early Intervention Services
162 East Washington Avenue
Washington, NJ 07882-2196
(908) 689-6000 Ext. 258
Fax # (908) 835-1172E-mail address: wcschs@netscape.net
 HMO Financial Reporting Specifications
    
    State of New JerseyFor
Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



Ryan White CARE Act Grantees
 
 http://www.state.nj.us/health/fhs/sregional.htm
 HMO Financial Reporting Specifications
    
    State of New JerseyFor
Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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##### 



RYAN WHITE HIV CARE
CONSORTIA/RESOURCE CENTERS
 The Consortia/Resource Centers provide regional planning and coordination of comprehensive
HIVrelated services: information and referral, prevention education, and a network of care and
treatment based on community-based case management.
 AIDS Coalition of Southern New Jersey
Resource Center
100 Essex Road, Suite 300
Bellmawr, NJ 08031
609-933-9500 FAX (609)933-9515
 Good Shepherd Community Services, Inc.
1576 Palisade Avenue
Ft. Lee, NJ 07024
201-461-7241 Fax: 201-461-2307
 Mercer County HIV Consortium
447 Bellevue Avenue
Trenton, NJ 08618
609-278-9555 or 1-800-550-6755 Fax: 609-278-0553
 Middlesex County HIV Resource Center
Visiting Nurse Association of Central Jersey
275 Hobart Street
Perth Amboy, NJ 08861
732-442-6225 Fax: 732-442-4285
 Monmouth-Ocean HIV Care Consortium
VNA of Central Jersey Foundation, Inc.
625 Bangs Avenue
Asbury Park, NJ 07712
732-502-5122 or 1-800-947-0020 Fax: 732-774-6006
Resource Center: 732-502-5128
 Passaic County AIDS Resource Center
Coalition on AIDS in Passaic County, Inc.
100 Hamilton Plaza, Room 707
Paterson, NJ 07505
973-742-6742 Fax: 973-742-6750
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Somerset-Hunterdon HIV Care Consortium
Womens Health and Counseling Center
95 Veterans Memorial Drive
Somerville, NJ 08876
1-800-313-2335 Fax: 908-526-7023
Resource Center 908-704-9641
 South Jersey AIDS Alliance
Resource Center Atlantic/Cape May HIV Case Consortium
19 Gordons Alley
Atlantic City, NJ 08101
609-347-1085 FAX 609-348-8775
 South Jersey Council on AIDS
(serving Burlington, Camden, Salem and Gloucester)
120 White Horse Pike, Suite 110
Haddon Heights, NJ 08035
609-547-6600 Fax: 609-547-6656
 The HIV Care Consortium/Resource Center
Atlantic City Medical Center
16 South Ohio Avenue
Atlantic City, NJ 08401
609-441-8181 or 1-800-281-2437 Fax: 609-441-8938
 Union County HIV Consortium
Union County HIV Resource Center
80 West Grand Street  Lower Level
Elizabeth, NJ 07202
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B.5.2 Cost-Sharing Requirements for NJ FamilyCare Plan C, Plan D and Plan H
Beneficiaries
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SERVICE
    
    AMOUNT OF COPAYMENT1. Outpatient Hospital Clinic Visits, including
Diagnostic Testing
    
    $5 copayment for each outpatient clinic visit
that is not for preventive services2. Independent Clinic Visits
    
    $5 copayment for each visit except
for preventive services3. Hospital Outpatient Mental Health Visits
    
    $25 copayment for each visit4. Outpatient Substance Abuse Services
for Detoxification
    
    $5 copayment for each
visit5. 4. Hospital
Outpatient Emergency Services
Covered for Emergency Services only, including
services provided in an outpatient hospital
department or an urgent care facility. [Note:
Triage and medical screenings must be covered
in all situations.]
    
    $35 copayment; no copayment is required if the
member was referred to the Emergency Room by
his/her primary care provider for services
that should have been rendered in the primary
care providers office or if the member is
admitted into the hospital.6. 5. Primary Care
Provider Services provided during normal office
hours
    
    $5 copayment for each visit (except for
preventive services.)7.6. Primary Care
Provider Services during nonoffice hours and for
home visits
    
    $10 copayment for each visit8. 7. Prescription Drugs
    
    $5 copayment. If greater than a 34-day supply
of a prescription drug is dispensed, a $10
copayment applies.9. 8. Nurse Midwives,
non-maternity services; certified nurse
practitioner, clinical nurse specialist
    
    $5 copayment except for preventive services;
$10 for services rendered during non-office
hours and for home visits10. 9. Physician
specialist office visits during normal office hours
    
    $5 copayment per visit11. 10. Physician
specialist office visits during nonoffice hours or
home visits
    
    $10 copayment per visit12. 11. Psychologist
Services
    
    $5 copayment for each visit13. 12. Laboratory and
X-ray Services
    
    $5 copayment for each visit that is not part
of an office visit
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    State of New JerseyFor
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Financial Guide for Reporting Medicaid/NJ FamilyCare Rate Cell Grouping
Costs Reserved
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    State of New JerseyFor
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HMO Financial
Reporting Manual
For Medicaid/NJ FamilyCare
Rate Cell Grouping Costs
 State of New Jersey
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    State of New JerseyFor
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1. Introduction
    
    
    22. General Instructions
    
    
    73. Report Specifications
    
    
    9 Report #1: Lag Report (Table 20, Parts A-E)
    
    
    9 Report #2: Income Statements by Rate Cell Grouping (Table 19, Parts A-V)
    
    
    13Table 19, Parts A  S3: Medicaid/NJ FamilyCare Managed Care at Risk GroupingsTable 19, Part T: Non State Plan ServicesTable 19, Parts U and V: Managed Care Service Administrator Groupings Report #3: Maternity Outcome Counts (Table 21)
    
    
    24 Report #4: Claims Processing Lag Report (Parts A  B)
    
    
    25 Report #7: Stop Loss Summary (Parts A- C)
    
    
    29 Report #10: Third Party Liability Collections
    
    
    304. Incurred But Not Reported (IBNR) Methodology
    
    Appendix A5. Report Forms
    
    Appendix B
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Purpose
 The objective of this Financial Reporting Specifications is to ensure uniformity, accuracy and
completeness in reporting Medicaid/NJ FamilyCare rate cell groupings. In addition, the provision
of this Financial Reporting Specifications to the HMOs will help to eliminate inconsistencies, as
reports can vary in the presentation of items such as allocation of expenses, accrual of incurred
but not reported (IBNR) claims, handling of maternity claims, and other items. All reports shall
be submitted as outlined in the general instructions. The financial reports submitted from this
Financial Reporting Specifications will be used in future rate setting and to better assess the
financial performance of HMOs.
 The reports in this Financial Reporting Specifications are to supplement, not replace, the
reporting requirements currently required in the Division of Medical Assistance and Health Services
(DMAHS) Managed Care Contract (please refer to Section A of the contract). Key differences between
this Financial Reporting Specifications and the reports currently submitted to the State are as
follows:
 *Rate cell grouping detail;
*Regional detail;
*IBNR calculation detail; and
*Timing of submissions.
 Rate Cell Groupings
 This Financial Reporting Specifications requires key cost reporting by rate cell grouping.
Rate cells have been combined into nineteen rate cell groupings for these reporting purposes
(seventeen rate call groupings for Medicaid/NJ FamilyCare Managed care at risk populations and two
rate cell groupings for Managed Care Service Administrator (MCSA) populations). Please note where
Acquired Immunodeficiency Syndrome (AIDS) individuals are included or excluded in the rate cell
groupings. Also note that maternity and newborn costs are reported as separate rate cell groupings
and shall be excluded from other rate cell groupings. The rate cell groupings are as follows:
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Rate CellReference
    
    Rate Cell Grouping
    
    Capitation 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 includingi 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 (DYFA),
including Foster Care
children and children
with Adoption
Assistance, excluding
individuals with AIDS.Table
#19 
Part E
    
    ABD with Medicare 
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 
DDD
(Excluding AIDS)
    
    
    711R1  711R3
813R1  813R3
823R1  823R3
    
    
    ABD individuals who
receive Medicare and
are not eligible for
services through the
DDD, excluding
individuals with AIDS.Table
#19 
Part G
    
    Non ABD  DDD
(Excluding AIDS)
    
    
    47399
    
    
    Non ABD individuals
eligible for services
through the DDD,
excluding individuals
with AIDS.Table
#19 
Part H
    
    ABD without
Medicare  DDD
(Including AIDS)
    
    
    49339
    
    
    ABD individuals not
receiving Medicare and
eligible for services
through the DDD,
including individuals
with AIDS.
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Rate CellReference
    
    Rate Cell Grouping
    
    Capitation Code
    
    DescriptionAFDC/SSI/DDDTable
#19 
Part I
    
    ABD without
Medicare  DDD
(Including AIDS)
    
    
    71099,
    
    
    ABD individuals not
receiving Medicare and
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 FamilyCare
Parents 0-133% FPL
(Excluding AIDS)
    
    
    57199, 57899, 58499
    
    
    Parents with dependent
children with family
income between 0% and
133% FPL, excluding
individuals with AIDS.Table
#19 
Part O
    
    NJ FamilyCare
Parents 134-250% FPL
(Excluding AIDS)
    
    
    95499, 97499, 98499
    
    
    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
    
    ABD with Medicare
P- AIDS
    
    
    28499, 45499
    
    
    ABD individuals with
AIDS who receive
Medicare, including
those eligible for
DDD, excluding the
risk adjusted
populations.
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Rate CellReference
    
    Rate Cell Grouping
    
    Capitation Code
    
    DescriptionAFDC/SSI/DDDTable
#19 
Part Q
    
    Non ABD  AIDS
    
    27499, 47499, 27699
    
    Non ABD individuals
with AIDS including
AFDC, NJCPW, NJ
KidCare DYFS, 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
Report #2R1 in the
Report Specifications
section.Table
#19 
PartR2
    
    Newborn
    
    Include 6 newborn
claims costs
associated within:
103R1, 103R3.
30399, 60399,
80399, 90399
    
    Pleae refer to
criteria outlined in
the instructions for
Report #2R2, in the
Report Specifications
section.MCSATable
#19 
Part U
    
    NJ FamilyCare
Adults 0-100% FPL
(Excluding AIDS)
    
    65499, 97499, 68499
    
    Single adults and
couples without
dependent children
with family income
between 0% and 100%
FPL, adults and
couples without
dependent children
under the age of 23,
with family incomes up
to and including 250%
of FPL, excluding
individuals with AIDS.
Includes health
Access Individuals
without dependent
children.Table
#19 
Part V
    
    Adult Restricted
Aliens
    
    40199, 40299, 40399
    
    Classification based
on restricted alien
status in PSCs 310-
330, 410- 430, 470 and
380 over the age of
20, or FamilyCare PSCs
763, and 497 & 498,
and corresponding cap
codes.
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Geographic Regions
 Some of the reports in this HMO Reporting Specifications request information from the three
geographic regions corresponding to those used in rate setting. Listed below are the counties
included in each geographic region:
 Northern (Region 1)
    
    Central (Region 2)
    
    Southern (Region 3)Bergen
    
    Essex
    
    AtlanticHudson
    
    Mercer
    
    BurlingtonHunterdon
    
    Middlesex
    
    CamdenMorris
    
    Union
    
    Cape MayPassaic
    
    
    
    CumberlandSomset
    
    
    
    GloucesterSussex
    
    
    
    MonmouthWarren
    
    
    
    OceanSalem
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The following are general instructions for completing the various reports required to be submitted
by the HMOs to the State. These instructions are designed to promote uniformity in reporting.
 Due Dates
 All Medicaid/NJ FamilyCare revenues and expenses must be reported using the accrual basis of
accounting except for Report #2 Parts T-V (Non-State Plan Services by rate cell grouping and MCSA
groupings). Report #2 Parts T-V shall be reported on a paid basis. Reports shall be submitted
quarterly and are due 45 days following each quarter end:
 Quarterly Reports
 Quarter Ending:
    
    Due Date:March 31
    
    May 15June 30
    
    August 15September 30
    
    November 15December 31
    
    February 15
 If a due date falls on a weekend or state holiday, reports will be due the next business day.
Please submit the completed reports to:
 State of New Jersey
Director, HMO Financial ReportingDavid.Moran@dhs.state.nj.us
 and
 Mercer Government Human Services Consulting
Actuarial ServicesMike.Nordstrom@mercer.com
 Format
 The HMO will submit these reports electronically, including notes to the financial statements, in
the formats specified, to the e-mail addresses listed above. Copies of the reports are included in
Appendix B of this manual.
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Annual Audit Requirement
 Please refer to Section 7.27 for the audit requirements in the managed care contract.
 Other Instructions
 Line titles and columnar headings of the various reports are, in general, self explanatory.
Specific instructions are provided for items that may have some question as to content. Any entry
for which no specific instructions are included shall be made in accordance with sound accounting
principles and in a manner consistent with related items covered by specific instructions.
 Incorporate adjustments to prior data in current reporting period. Adjustments for prior period
IBNR estimates shall be included on Report #2, Table 19, Parts S1 and S2, in Line 42, and a
detailed reconciliation shall be included on Report #2, Table 19, Part S3. Information about any
adjustments that pertain to prior periods shall be explained in a note to the reports. However, if
there was material error in preparation of the prior period report, a revised report shall be
submitted.
 Unanswered questions or blank lines on any report or schedule will render the report or schedule
incomplete and may result in a resubmission request. Any resubmission must be clearly identified
as such. If no answers or entries are to be made, write None, Not Applicable (N/A), or 0 in
the space provided. Always use predefined categories or classifications before reporting an amount
as Other.
 Dollar amounts shall be reported to the nearest dollar. Per member month (PMPM) amounts, however,
shall be shown with two digits to the right of the decimal point.
 Additional sheets referencing the applicable reports must be attached for further explanation. The
contractor shall use Notes to Financial Reports in Appendix B for write ins and explanations.
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Report #1: Lag Reports (Table 20, Parts A-E)
 Analyzing the accuracy of historical medical claims liability estimates is necessary in assessing
the adequacy of current liabilities. In addition, valid IBNR liability estimates are crucial when
utilizing financial statements in the managed care rate setting process. This schedule provides
the necessary information to make this analysis.
 Information is provided on Inpatient Hospital, Physician, Pharmacy, and Other Medical Payments on
Parts A through D, respectively, with all rate cell groupings combined, excluding the managed Care
Service Administrator (MCSA) rate cell groupings. Lag report information shall be provided for
each Medical Cost Grouping as defined below and map to the corresponding consolidated category of
service for the corresponding incurral period within Report #2, Table 19, Parts S1 and S2. A
detailed reconciliation of the lag report information and Income Statements by Rate Cell Group
shall be included on Report #2, Table 19, Part S3. Information about any adjustments that pertain
shall be explained in a note to the reports.
 Managed CareConsolidated
    
    Income Statement
    
    Category of
    
    Medical Cost
    
    Lag ReportCategory of Service
    
    Reference
    
    Service Codes
    
    Grouping
    
    ReferenceInpatient Hospital
    
    Table #19  Parts
S1 & S2, Line 9
    
    
    01
    
    
    Inpatient Hospital
    
    Table #20  Part APrimary Care
    
    Table #19  Parts
S1 & S2, Line 10
    
    
    10P
    
    
    Physician
    
    Table #20  Part BPhysician
Specialty Services
    
    Table #19  Parts
S1 & S2, Line 11
    
    
    10S
    
    
    Physician
    
    Table #20  Part BPharmacy (not to
include
Reimbursable
HIV/AIDS Drugs and
Blood Products)
    
    Table #19  Parts
S1 & S2, Line 18
    
    
    20N
    
    
    Pharmacy
    
    Table #20  Part CReimbursable
HIV/AIDS Drugs and
Blood Products
    
    Table #19  Parts
S1 & S2, Line 19
    
    
    20H
    
    
    Pharmacy
    
    Table #20  Part COutpatient
Hospital (excludes
ER)
    
    Table #19  Parts
S1 & S2, Line 12
    
    
    04N
    
    
    Other
    
    Table #20  Part DOther Professional
Services
    
    Table #19  Parts
S1 & S2, Line 13
    
    14, 15S, 17, PAS
    
    Other
    
    Table #20  Part DEmergency Room
    
    Table #19  Parts
S1 & S2, Line 14
    
    
    04e
    
    
    Other
    
    Table #20  Part D
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Managed CareConsolidated
    
    Income Statement
    
    Category of
    
    Medical Cost
    
    Lag ReportCategory of Service
    
    Reference
    
    Service Codes
    
    Grouping
    
    ReferenceDME/Medical
Supplies
    
    Table #19  Parts
S1 & S2, Line 15
    
    
    30, 31, 32
    
    
    Other
    
    Table #20  Part DProsthetics and
Orthotics
    
    Table #19  Parts
S1 & S2, Line 16
    
    
    18
    
    
    Other
    
    Table #20  Part DDental
    
    Table #19  Parts
S1 & S2, Line 17
    
    
    11
    
    
    Other
    
    Table #20  Part DHome health,
Hospice, & PDN
    
    Table #19  Parts
S1 & S2, Line 20
    
    40, 50, PDN
    
    Other
    
    Table #20  Part DTransportation
    
    Table #19  Parts
S1 & S2, Line 21
    
    
    70
    
    
    Other
    
    Table #20  Part DLab & X-ray
    
    Table #19  Parts
S1 & S2, Line 22
    
    
    60, 65
    
    
    Other
    
    Table #20  Part DVision Care
including
Eyeglasses
    
    Table #19  Parts
S1 & S2, Line 23
    
    
    09, 13
    
    
    Other
    
    Table #20  Part DMental Health/Substance
Abuse
    
    Table #19  Parts
S1 & S2, Line 24
    
    MH, SA
    
    Other
    
    Table #20  Part DEPSDT Medical & PDN
    
    Table #19  Parts
S1 & S2, Line 26a
    
    08D, EPM
    
    Other
    
    Table #20  Part DEPSDT Dental
    
    Table #19  Parts
S1 & S2, Line 26b
    
    EPD
    
    Other
    
    Table #20  Part DFamily Planning
    
    Table #19  Parts
S1 & S2, Line 27
    
    FP
    
    Other
    
    Table #20  Part DOther Medical
    
    Table #19  Parts
S1 & S2, Line 28
    
    XM
    
    Other
    
    Table #20  Part D
 The schedules are arranged with the month of service horizontally and the month of payment
vertically. Therefore, payments made during the current month for services rendered during the
current month would be reported in Line 1, Column 3, while payments made during the current month
for services rendered in prior months would be reported on Line 1, Columns 4 through 39. Please
note that columns 13 through 38 and rows 11 through 36 are hidden in the sample worksheet. Lines 1
though 3 contain data for payments made in the current period. Earlier data on Lines 4 through 37
shall match data on appropriate lines on the prior periods submission. If Lines 4 through 37
change from the prior periods submission, include an explanation. The current month is the last
month of the period that is being reported. For example, in the report for the
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period ended June 30, 2003, the current month would be June 2003, and the first prior month would
be May 2003. Do not include risk pool distributions as payments in this schedule.
 Report #1 must provide data for the period beginning with the first month the HMO is responsible
for providing medical benefits to Medicaid/NJ FamilyCare recipients, and ending with the current
month.
 Line 39  Subcapitation payments shall be reported here, by month of payment. They are not to be
included above Line 39. For the current period, Line 39 shall contain new data in Columns 3
through 5. Data in columns 6 through 38 shall match data in appropriate columns on the prior
periods submission. If columns 6 through 38 change from the prior periods submission, include an
explanation.
 Line 40  Report pharmacy rebates anticipated for drugs dispensed this period. Adjust as
appropriate any adjustment applicable to a prior period. Only complete for the Pharmacy Payment
report, Part C.
 Line 41  The HMO shall report payments on Lines 1-36. If the HMO makes a settlement or other
payment that cannot be reported on Lines 1-36 due to lack of data, the amount shall be reported on
Line 41. If the service month(s) can be determined, the settlement dollars can be allocated to the
service month. Otherwise, the payment month can be used as a substitute for the service month. If
an amount is shown on Line 41 in columns 3 through 5, include an explanation. If columns 6 and
greater change from the prior submission, also include an explanation.
 Line 42  This line is the total amount paid to date for services rendered. Line 42 shall equal
the sum of Lines 38, 39 and 41. For the Pharmacy Payment report, Part C, also include Line 40.
 Line 43  This line provides the current estimate of remaining liability for unpaid claims for each
month of service. The amount in each column on this line must be updated each period.
The amount in Column 40 is the sum of amounts in Columns 3 through 39. The sum of the amounts in
Column 40, in parts A through D, is the unpaid claim liability (IBNR and reported but unpaid claims
(RBUC)). Please refer to attachment A for a methodology for calculating IBNR.
 Line 44  The total incurred claims is the sum of Lines 42 (the amounts paid to date) and Line 43
(estimate of unpaid claims liability). Amounts on Line 44 are shown for each month.
 The State recognizes that claims liabilities may include the administrative portion of claim
settlement expenses. Any liability for future claim settlement expense must be disclosed in the
notes in the reports.
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The Family Care 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 the State 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.
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Report #2: Income Statement by Rate Cell Grouping (Table 19, Parts A  V)
 This report is meant to provide detailed summary information on revenues and expenses. A separate
report is to be completed for each of the fifteen rate cell groupings and for Maternity and
Newborn, with Report #2 Part S1 and S2 being the summations fo Parts A-R2 respectively for quarter
end and calendar year to date end. For reporting purposes, AIDS revenues and expenses are
included or excluded from the rate cell groupings as indicated on the report forms and in the
chart defining the rate cell groupings provided on page 2.
 Additionally, State fiscal year end information will be provided on the first fiscal quarter
ending reports (September 30). This information shall include all data with incurred dates
through the most recent completed state fiscal year, with paid data through September 30 (incurred
in 12 months, paid in 15 months). Reports are to be completed for each of the fifteen rate cell
groupings and for Maternity and Newborn categories. Besides quarter ending September 30, this
information is not required for any other quarter ending time periods.
 The Family Care 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 the State 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 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 COAs, shall now only be included in Part V. Revenue and expenses
for non-risk FamilyCare Adults 0  100 percent of FPL will be reported within Part U.
 Do not include maternity or newborn revenues or expenses in Parts A  Q. Only include Maternity
and newborn revenues and maternity expenses on the Income Statement for Maternity, part R1,and for
All Rate Cell Groupings, parts S1 and S2. Include newborn expenses on the Income Statement for
Newborn, part R2, and for All Rate Cell Groupings, Parts S1 and S2. Include Maternity costs
associated with the following codes for still births or live births after the twelfth week of
gestation, excluding elective abortions:
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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##### 



ICD 9 Diagnosis Codes:
 *640.01, 640.81, 640.91*641.01, 641.11, 641.21, 641.31, 641.81, 641.91,*642.01, 642.11, 642.21, 642.31, 642.41, 642.51, 642.61, 642.71, 642.91, 642.02, 642.12, 642.22,
642.32, 642.42, 642.52, 642.62, 642.72, 642.92*643.01, 643.11, 643.21, 643.81, 643.81*645.01*646.01, 646.11, 646.12, 646.21, 646.22, 646.31, 646.41, 646.42, 646.51, 646.52, 646.61, 646.62,
646.71, 646.81, 646.82, 646.91*647.01,647.11, 647.21, 647.31, 647.41, 647.51, 647.61, 647.81, 647.91, 647.02, 647.12, 647.22,
647.32, 647.42, 647.52, 647.62, 647.82, 647.92*648.01,648.11, 648.21, 648.31, 648.41, 648.51, 648.61, 648.71, 648.81, 648.91, 648.02, 648.12,
648.22, 648.32, 647.42, 648.52, 648.62, 648.72, 648.82, 648.92*650 (and any or no trailing characters)*651.01,651.11, 651.21, 651.31, 651.41, 651.51, 651.61, 651.81, 651.91*652.01,652.11, 652.21, 652.31, 652.41, 652.51, 652.61, 652.71, 652.81, 652.91*653.01,653.11, 653.21, 653.31, 653.41, 653.51, 653.61, 653.71, 653.81, 653.91*654.01,654.11, 654.21, 654.31, 654.41, 654.51, 654.61, 654.71, 654.81, 654.91, 654.02, 654.12,
654.22, 654.32, 647.42, 654.52, 654.62, 654.72, 654.82, 654.92*655.01,655.11, 655.21, 655.31, 655.41, 655.51, 655.61, 655.71, 655.81, 655.91*656.01,656.11, 656.21, 656.31, 656.41, 656.51, 656.61, 656.71, 656.81, 656.91*657.01*658.01,658.11, 658.21, 658.31, 658.41, 658.81, 658.91*659.01,659.11, 659.21, 659.31, 659.41, 659.51, 659.61, 659.71, 659.81, 659.91*660.01,660.11, 660.21, 660.31, 660.41, 660.51, 660.61, 660.71, 660.81, 660.91*661.01,661.11, 661.21, 661.31, 661.41, 661.91*662.01,662.11, 662.21, 662.31*663.01,663.11, 663.21, 663.31, 663.41, 663.51, 663.61, 663.81, 663.91*664 (and any or no trailing characters)*665.01,665.11, 665.31, 665.41, 665.51, 665.61, 665.71, 665.81, 665.91, 665.22, 665.72, 665.82,
665.92*666.02, 666.12, 666.22, 666.32*667.02, 667.12*668.01, 668.11, 668.21, 668.81, 668.02, 668.12, 668.22, 668.82*669.01, 669.11, 669.21, 669.31, 669.41, 669.51, 669.61, 669.71, 669.81, 669.91, 669.02, 669.12,
669.22, 669.32, 669.42, 669.82, 669.92*670.02*671.01, 671.11, 671.21, 671.31, 671.42, 671.51, 671.81, 671.91, 671.02, 671.12, 671.22, 671.52,
671.82, 671.92*672.02*673.01, 673.11, 673.21, 673.31, 673.81, 673.02, 673.12, 673.22, 673.32, 673.82*674.01, 674.02, 674.12, 674.22, 674.32, 674.42, 674.82, 674.92*675.01, 675.11, 675.21, 675.81, 675.91, 675302, 675.12, 675.22, 675.22, 675.82, 675.92
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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*676.01, 676.11, 676.21, 676.31, 676.41, 676.51, 676.61, 676.81, 676.91, 676.02, 676.12,
676.22, 676.32, 676.42, 676.52, 676.62, 676.82, 676.92, 677 (no other characters)*V27, V27.0, V27.1, V27.2, V27.3, V27.4, V27.5, V27.6, V27.7, V27.9CPT-4 Codes*59400, 59409, 59410, 54912, 59414, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618,
596250, 59622, 59821Revenue Codes*720, 722, 724, 729
 Additionally, Report R2 (Income Statement for Newborn) includes newborn claims for the partial
month of birth and the first two (2) months thereafter, previously reported in the
AFDC/NJCPW/KidCare B, C, and D, DYFS, and Blind/Disabled rate cell groupings. Age shall be
determined by counting the childs age as of their last birthday, on the first of the month in
which the claim is incurred.
 Except for non-State Plan Services (Part T) and MCSA reports (Parts U  V), all revenues and
expenses must be reported on Report #2 using the accrual basis of accounting for the requested
period of the calendar year. Cumulative YTD revenues and expenses are also required in this
report. Each report is based on statewide reporting except for the rate cell grouping
AFDC/NJCPW/NJ KidCare A, which is to be reported for each of the Norther, Central and southern
regions (Report #2 Parts A-C). Each report must provide total dollar amounts and PMPM amounts.
Cells shaded are not to be filled out.
 The non-State Plan services (see: Supplemental Benefits, Article 4.1.8 of the contract) report
(Part T) has been created to provide information on benefits/services reported within Report #2,
Parts A-S2 in excess of the State Plan. All medical and administrative expenses must be reported
using actual incurred and paid data for the current period of the calendar year. Unit cost
expenses for the non-State Plan services must also be provided. An example of non-State Plan
approved medical expenses would be enhanced eyeglass allowance and over the counter drugs for
adults.
 All medical and administrative expenses within the MCSA reports (Parts U  V) must be reported
using paid data for he current period of the calendar year.
 Member Months
 A member month is equivalent to the one member for whom th HMO has recognized capitation based
revenue for the entire month. Where the revenue is recognized for only part of a month for a given
individual, a partial, pro-rated member month shall be counted. A partial member month is
pro-rated based on the actual number of days in a particular month. The member
months shall be reported on a cumulative basis by the rate cell grouping as shown on the report.
Enter the number of member months for the
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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current period in the second column of the Member Months line and the member months for the year to
date in the fourth column.
 The Maternity Income Statement, Part R1, shall list number of deliveries, rather than member
months. Newborn member months, as defined in the previous section, will be reported within Part R2
and are not to be included with Parts S1  S2.
 Revenue
 Line 1  Capitated Premiums  Revenue recognized on a prepaid basis for enrollees for provision of
a specified range of health services over a defined period of time, generally one month. If
advance payments are made to the HMO, for more than one reporting period, the portion of he payment
that has not been earned must be treated as a liability (Unearned Premiums). Refer to Part S3 for
reconciliations.
 Line 2  Supplemental Premiums  Revenue paid to the HMO in addition to capitated premiums for
certain services provided. See Lines 2a through 2f below.
 Line
2a 
Maternity75  Supplemental payment per pregnancy outcome. This line item shall
only be included in Part R1 (Maternity) and Parts S1 and S2 (All Rate Cell Groupings).
 Line 2b  Reimbursable HIV/AIDS Drugs and Blood Products  Supplemental payment for HIV/AIDS Drugs
(protease inhibitors and, effective 7/1/01 other anti-retrovirals) and clotting factor VIII and IX
blood products.
 Line 2c  Early and periodic Screening, Diagnosis and Treatment (EPSDT) Incentive Payment 
Supplemental payment for EPSDT services.
 Line 2d  Reimbursible 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 be included in Part U (FamilyCare Adults 0  100 percent of FPL)
and Part V (Adult Restricted Aliens), and is not be included in Parts S1 and S2 (All Rate Cell
Groupings).
 
 75
    
    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) wee of gestation). This supplemental
payment reimburses HMOs 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.  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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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 included in Part U
(FamilyCare Adults 0  100 percent of FPL), and Part V (Adult Restricted Aliens), and is not be
included in Parts S1 and S2 (All Rate Cell Groupings).
 Line 2f  Other  Any other revenue paid by DMAHS to the HMO in addition to capitation for covered
services that is not included in Lines 2a, 2b, 2c, 2d or 2e above.

Line 3  Total Premiums  All Medicaid/NJ FamilyCare premiums pad to the HMO reported on lines 1,
2a, 2b, 2c, 2 d, 2e and 2f. A detailed reconciliation of total premiums received and reported on
the Income Statement in Part S1 shall be included on Report #2, Table 19, Part S3. Information
about any differences shall be explained in a note to the reports.

Line 4  Interest   Interest earned from all sources including escrow and reserve accounts.

Line 5  C.O.B.  Income from Coordination of Benefits (COB) and Subrogration. Alternatively, COB
for a particular claim may be recognized as a negative claim expense.

Line 6  Reinsurance Recoveries  Income from the settlement of claims resulting from a plicy with
a private reinsurance carrier.

Line 7  Other Revenue  Revenue from sources not covered in the previous revenue accounts.

Line 8  Total Revenue  Total revenue (the sume of lines 3 through 7).


Expenses


Medical and Hospital

Line 9  Inpatient Hospital  Code 01  For description, see the Medicare/NJ FamilyCare Managed
Care Contract.

Line 10  Primary Care  Code 10P  For description, see the Medicare/NJ FamilyCare Managed Care
Contract.

Line 11  Physician Specialty Services  Code 10S  For description, see the Medicare/NJ FamilyCare
Managed Care Contract. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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Line 12  Outpatient Hospital (excludes ER)  Code 04N  For description, see the Medicare/NJ FamilyCare Managed Care Contract.
  Line 13  Other Professional Services  Codes 14, 15S, 17, PAS  For descriptions see the Medicare/NJ FamilyCare Managed Care Contract.
 Line 14  Emergency Room  Code 04E  For description, see the Medicare/NJ FamilyCare Managed Care Contract.

Line 15  DME/Medical Supplies  Codes 30, 31, 32  For descriptions see the Medicare/NJ FamilyCare
Managed Care Contract.

Line 16  Prosthetics and Orthotics  Code 18  For description, see the Medicare/NJ FamilyCare
Managed Care Contract.

Line 17  Covered Dental  Code 11  For description, see the Medicare/NJ FamilyCare Managed Care
Contract.

Line 18  Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products)  Code 20N  For
description, see the Medicare/NJ FamilyCare Managed Care Contract.

Line 19  Reimbursable HIV/AIDS Drugs and Blood Products  Code 20H  For description, see the
Medicare/NJ FamilyCare Managed Care Contract.

Line 20  Home Health, Hospice, PDN  Codes 40, 50, PDN  For descriptions, see the Medicare/NJ
FamilyCare Managed Care Contract.

Line 21  Transportation  Code 70 For description, see the Medicare/NJ FamilyCare Managed Care
Contract.

Line 22  Lab & X-ray  Codes 60, 65  For descriptions, see the Medicare/NJ FamilyCare Managed
Care Contract.

Line 23  vision Care including Eyeglasses  Codes 09, 13  For descriptions, see the Medicare/NJ
FamilyCare Managed Care Contract.

Line 24  Mental health/Substance Abuse  Codes MH, SA  For descriptions, see the Medicare/NJ
FamilyCare Managed Care Contract.

Line 25  Reinsurance Expenses  Expenses for reinsurance or stop loss insurance made to a
contracted reinsurer. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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Line 26a  EPSDT Medical & PDN  Codes 08D, EPM  For descriptions, see the Medicare/NJ FamilyCare
Managed Care Contract.
 Line 26b  EPSDT Dental  Code EPD  For description, see the Medicare/NJ FamilyCare Managed Care
Contract.
  Line 27  Family Planning  Code FP  For description, see the Medicare/NJ FamilyCare Managed Care
Contract.

Line 28  Other Medical  Code XM  For description, see the Medicare/NJ FamilyCare Managed Care
Contract

Line 29  Total Medical and Hospital  The total of all medical and hospital expenses. (sum of
lines 9 through 28)


Administration

Administrative expenses shall be reported on designated forms for the MCSA populations (Parts U and
V) and the forms for all rate cell groupings (Parts S1  s2). Except for the MCSA rate cell
groupings, this eliminates the need to allocate these costs across the remaining rate cell
groupings. As the State has the responsibility for financial risk for medical costs of the 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 Parts S1  S2. The administration expenses for these
populations shall be reported separately in Parts U  V. Administration must also be reported on
Part T if the HMO provides any non-State Plan services. Costs associated with the overall
management and operation of the HMO including the following components:

Line 30  Compensation  All expenses for administrative services including compensation and fringe
benefits for personnel time devoted to or in direct support of administration. Include expenses
for management contracts. Do not include marketing expenses her.

Line 31  Occupancy, Depreciation, and Amortization.

Line 32  Interest expense  Interest paid during the period on loans.

Line 33  Education/Outreach and Marketing  Expenses incurred for education and outreach
activities for enrollees. Expenses directly related to marketing activities including advertising,
printing, marketing salaries and fringe benefits, commissions, broker fees, travel, occupancy, and
other expenses allocated to the marketing activity. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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Line 34  Sanctions  Expenses related to events where DMAHS finds the contractor to be out of
compliance with the program standards, performance standards, or the terms and conditions of the
Medicaid managed care contract.

Line 35  Corporate Overhead Allocations  All expenses for management fees, and other allocations
of corporate expenses. Methodologies for allocated expenses may include PMPM, percent of revenue,
percent of head counts and/or full time equivalents  (FTE), etc. Include an explanation of the expenses included and the basis of methodology in
the notes to the financial reports.

Line 36  Subcontracted/Delegated Administrative Services  Administrative portion of delegated
administrative expenses such as Pharmacy Benefits Manager (PBM) or Third Party Administrators (TPA)
payments that cover costs such as claims processing and medical management of the PBM/TPA. An
example of TPA expenses includes dental subcontractors and delegated case management administrative
expenses.

Line 37  Other C  Costs which are not appropriately assigned to the health plan administration
categories defined in lines 30 to 36 above. An explanation for this expense must be detailed on
Table 19, Part S3 for categories where the expense is greater than $250,000.

Line 38  Total Administration  the total of costs of administration (the sum of lines 30 through
37).

Line 39  Total Expenses  The sum of Total Medical and Hospital Expenses (line 29) and Total
Administration (line 38).

Line 40  Operation Income (Loss)  Excess or deficiency of Total Revenue (line 8) minus Total
Expenses (line 39).

Line 41  Extraordinary Item  A non-recurring gain or loss.

Line 42  Provision for State, and Federal, and other governmentalIncome Taxes  All income taxes
for the period.

Line 43  Other than Income Taxes  Expenses other than state or federal income taxes (i.e. State
assessments irrespective of profit position).

Line 44  Adjustment for prior period IBNR estimates  Shall include a reconciliation within Part
S3, an explanation of prior period IBNR estimates, and a detailed calculation within Report HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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#2,
Table 20, Parts A through D. A contra expense would be reported if IBNR estimates exceeded actual
expenses. HMO Financial Reporting Specifications
    
    State of New JerseyFor Medicaid/NJ FamilyCare Rate Cell Grouping Costs




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In the explanation below, the term IBNR (Incurred But Not Reported) is used to represent all
claims incurred but unpaid. In statutory accounting for HMOs the incurred claims for a period are
calculated as follows:
 Example forQuarter Ending 06/30/20xx
    
    Example usingReporting Period
    
    Dollars- Claims paid in the period
    
    - Claims paid in quarter 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 theperiod
    
    + Subcapitaiton
Payments, Pharmacy Rebates, Settlements as of 06/30/20xx
    
    
    +$500,000- Subcapitation Payments, Pharmacy Rebates, Settlements at the end of theperiod
    
    - Subcapitation Payments, Pharmacy Rebates, Settlements as of 03/31/20xx
    
    
    -$450,000- Claims incurred in the period
    
    - Claims incurred in quarter ending 06/30/20xx
    
    
    $50,050,000
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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The above calculation can be split into two components  the first for services rendered in the
period and the second for services rendered prior to the period, as follows:
 Incurred in
    
    
    Incurred inQuarter Ending
    
    
    03/31/20xx &06/30/20xx
    
    
    Prior
    
    
    TotalClaims Paid in Qtr Ending 06/30/20xx
    
    
    $35,500,000
    
    
    
    $8,500,000
    
    
    
    $48,000,000+ IBNR as of 06/30/20xx
    
    
    $10,900,000
    
    
    
    $100,000
    
    
    
    $11,000,000- IBNR as of 3/31/20xx
    
    None
    
    
    
    $9,000,000
    
    
    
    $9,000,000+ Subcapitaiton Payments, Pharmacy Rebates, Settlements as of 06/30/20xx
    
    
    $50,000
    
    
    
    $450,000
    
    
    
    $500,000+ Subcapitaiton 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
 In the example, claims incurred in the quarter ending 06/30/20xx are $50.45 million. This is the
amount that would be shown on Report #2S line 29; the Statewide Total Hospital and Medical Expense
for the 3 months ended 06/30/20xx. The negative $0.4 million would be reported on line 44
Adjustment for prior period IBNR estimates. This is the effect of the estimation error for the
prior year end IBNR. Such estimation errors are to be expected, since the actual amount of unpaid
claims will never exactly match the estimate made earlier.
 The sum of the amounts on lines 29 and 44 shall be consistent with the statutory accounting amount
of claims recognized as incurred in the period, $50 million in the
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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example above. Any non-claim adjustments for prior periods which are not to be grouped into Line
44, but in line 45, and shall be explained in a note to the reports. A detailed reconciliation of
prior period IBNR shall be included on Report #2, Table 19, Part S3.
 Line 45  Non claim adjustments for prior periods.
 Line 46  Net Income (Loss)  Operation Income (Loss) (line 40) minus Lines 41, 42, 43, 44, and 45.
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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Report #3 (Table 21): Maternity Outcome Counts
 This
report provides counts of second and third trimester maternity
outcomes76 for the
current period and year to date.
 The HMO will provide counts for the following:
 *Live births
 Cesarean Section deliveries
 Vaginal deliveries
 *Non live births
 These counts will be reported for the following rate cell groupings and geographic areas:
 Rate Cell Grouping
    
    Geographic AreaAFDC/NJCPW/NJ KidCare A
    
    NorthernAFDC/NJCPW/NJ KidCare A
    
    CentralAFDC/NJCPW/NJ KidCare A
    
    SouthernAll Other
    
    Statewide
 Multiple births should be counted as one maternity outcome.
 
 76
    
    Still or live births at or after the thirteenth week of gestation, excluding elective abortions.  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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Report #4: Claims Processing Lag Report (Tables 4A & 4B)
 This report is meant to provide a detailed summary of manual and electronic submitted claims that
were processed during the quarter.
 Table 4A
 Use Table 4A, to report manually submitted claims that were processed during the quarterly period.
Claims submitted and processed electronically must be reported separately on Table 4B. Manual
claims submission shall be processed within 40 days of receipt. Report amounts for each
consolidated category of service and total listed in Column 1 in the following columns:
 Column 2 Non-Processed Claims from Prior Quarters  Enter the number of manually submitted claims
on hand that were unprocessed as of the closing date of the last quarterly period. The number shall
be the same that was reported in Column 16 of the last prior quarterly report.
 Column 3  Claims Received During Quarter  Enter the amount of all manually submitted claims that
were received curing the quarterly period being reported.
 Column 4  Total Claims  Enter the sum of Columns 2 and 3.
 Column 5- Claims Processed This Quarter Enter the amount of all manually submitted claims
processed (both paid and denied) during the quarterly period being reported. Do not count pended
claims.
 Column 6  01-40 Days   Enter the number of manually submitted claims that were processed (either
paid or denied) within 40 days of their receipt. Note: The number of days required to process a
claim is calculated by comparing the date the claim was received by the contractor to the date the
claim was paid or denied by the contractor (See Article 7.16.5 of this contract for further
details.).
 Column 7  Percent of Total- Enter the percentage of manually submitted claims processed within 40
days (Compared to the total claims processed. Divide Column 6 by Column 5 to arrive at percent).
 Column 8  41-60 Days  Enter the number of manually submitted claims that were processed (either
paid or denied) between 41-60 days of their receipt.
 Column 9 Percent of Total  Enter the percentage of manually submitted claims processed within
between 41-60 days (Compared to the total claims processed. Divide Column 8 by Column 5 to arrive
at percent).
 Column 10  61-90 Days- Enter the number of manually submitted claims that were processed (either
paid or denied) between 61-90 days of their receipt
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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##### 



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




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Column 5- Claims Processed This Quarter Enter the amount of all electronically submitted claims
processed (both paid and denied) during the quarterly period being reported. Do not count pended
claims.
 Column 6  01-30 Days   Enter the number of electronically submitted claims that were processed
(either paid or denied) within 30 days of their receipt. Note: The number of days required to
process a claim is calculated by comparing the date the claim was received by the contractor to the
date the claim was paid or denied by the contractor (See Article 7.16.5 of this contract for
further details.).
 Column 7  Percent of Total- Enter the percentage of electronically submitted claims processed
within 40 days (Compared to the total claims processed. Divide Column 6 by Column 5 to arrive at
percent).
 Column 8  31-60 Days  Enter the number of electronically submitted claims that were processed
(either paid or denied) between 31-60 days of their receipt.
 Column 9 Percent of Total  Enter the percentage of electronically submitted claims processed
within between 31-60 days (Compared to the total claims processed. Divide Column 8 by Column 5 to
arrive at percent).
 Column 10  61-90 Days- Enter the number of electronically submitted claims that were processed
(either paid or denied) between 61-90 days of their receipt
 Column 11  Percent of Total  Enter the percentage of electronically submitted claims processed
within between 61-90 days (Compared to the total claims processed. Divide Column 12 by Column 5 to
arrive at percent).
 Column 12  91-120 Days -Enter the number of electronically submitted claims that were processed
(either paid or denied) between 90-120 days of their receipt
 Column 13  Percent of Total  Enter the percentage of electronically submitted claims processed
within between 90-120 days (Compared to the total claims processed. Divide Column 12 by Column 5 to
arrive at percent).
 Column 14   >120 Days Enter the number of electronically submitted claims that were processed
(either paid or denied) after 120 days of their receipt.
 Column 15  Percent of Total  Enter the percentage of electronically submitted claims processed
after 120 days (Compared to the total claims processed. Divide Column 14 by Column 5 to arrive at
percent).
 Column 16  Non Processed Claims on Hand at End of Quarter -Enter the number of electronically
submitted claims on hand that were not processed as of closing date of the last report period.
(Should be the difference of Column 4 minus Column 5). Same number should match number of claims
entered in column 2 of next quarter reports.
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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Column 17  Percent of Claims Not Processed at End of Quarter (Column 17). Divide Column 16 by
Column 4 to arrive at percent.
 HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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Report
# 7:   Stop Loss Summary (Table 7, Parts A-C)
 The contractor shall identify reinsurance coverage in effect during the calendar year for the
reporting period ending Dec 31 of each year. For each of the designated eligibility categories, the
contractor shall report the total number of enrollees that exceeded the stop loss threshold and the
total net expenditures exceeding the stop loss threshold during the period.
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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Report
# 10: Third Party Liability Collections (Table 10)
 The contractor shall report quarterly the categories of all third party
liability collections and shall include the amounts and nature of all third party payments
recovered for Medicaid/NJ FamilyCare enrollees including but not limited to payments for services
ad condition which are:
       Covered through coordination of benefits;      Employment related injuries or illnesses;      Related to motor vehicle accidents, whether injured as pedestrians, drivers, passengers or bicyclists; and      Contained in diagnosis Codes 800 through 999 (ICD9CM) with the exception of Code 994.6.
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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Appendix A  IBNR Methodology
 IBNR Methodology
 IBNRs are difficult to estimate because of the quantity of service and exact service cost are not
always known until claims are actually received. Since medical claims are the major expenses
incurred by the HMOs, it is extremely important to accurately identify costs for outstanding
unbilled services. To accomplish this, a reliable claims system and a logical IBNR methodology are
required.
 Selection of the most appropriate system for estimating IBNR claims expense requires judgment based
on an HMOs own circumstances, characteristics, and the availability and reliability of various
data sources. A primary estimation methodology along with supplementary analysis usually produces
the most accurate IBNR estimates. Other common elements needed for successful IBNR systems are:
 
    
    An IBNR system must function as part of the overall financial management and claims
system. These systems combine to collect, analyze, and share claims data. They require
effective referral, prior authorization, utilization review, and discharge planning
functions. Also, the HMO 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 HMO 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 tables will need modification, on a pro forma basis, to reflect corrections
for known errors or skewed payment patterns. The data included in the lag schedules shall
include all information received to date in order to take advantage of all known amounts
(i.e., RBUCs and paid claims).
    
    Accurate, complete, and timely claims data should shall be monitored, collected,
compiled, and evaluated as early as possible. Whenever practical, claims data collection
and analysis shall begin before the service is provided (i.e. prior authorization records).
This prospective claims data, together with claims data collected as the services are
provided, shall be used to identify claims liabilities. Claims data shall also be
segregated to permit analysis by major rate code, region/county, and consolidated category
of service.
 Subcontractor agreements shall clearly state each partys responsibility for
claims/encounter submission, prior notification, authorization, and reimbursement rates. These
agreements shall be in writing, clearly understood and followed consistently by each party.
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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The individual IBNR amounts, once established, shall be monitored for adequacy and
adjusted as needed. If IBNR estimates are subsequently found to be significantly inaccurate,
analysis shall be performed to determine the reasons for the inaccuracy. Such an analysis shall be
used to refine an HMOs IBNR methodology if applicable.
 There are several different methods that can be used to determine the amount of IBNRs. The HMO
shall employ the one that best meets its needs and accurately estimates its IBNRs. If an HMO is
utilizing a method different from the methods included herein, a detailed description of the
process must be submitted to the State for approval. This process may be described in the notes to
Financial Reports section. The IBNR methodology used by the HMO must be evaluated by the HMOs
independent accountant or actuary for reasonableness.
 Case Basis Method
 Accruals are based on estimates of individual claims and/or episodes. This method is generally used
for those types of claims where the amount of the cost will be large, requiring prior
authorization. The final estimated cost could be made after the services have been authorized by
the HMO. For example, if an HMO knows how many hospitals days were authorized for a certain time
period, and can incorporate the contracted reimbursement arrangement(s) with the hospital (s), a
reasonable estimate should be attainable. This is also the most common and can be the most accurate
method for small and medium sized organizations.
 Average Cost Method
 As the name suggests, average costs of services are used to estimate total expense. The expenses
estimated using average costs. Two primary average costs methods are discussed below. It is
important to note that each method may be used by and HMO to estimate different categories of IBNRs
(i.e. hospitalization vs. other medical). Also, either method may be utilized in conjunction with
other IBNR methodologies discussed in this document.
 PMPM Averages
 Under this method the average costs are based on the population of each rate code (or group of
homogenous rate codes) over a given time period, in this case one month. The average cost may cover
one or more service categories and it multiplied by the number of members in the specific
population to estimate the total expense of the service category. Any claims paid are subtracted
from the expense estimate that results in the IBNR liability estimate for that service category.
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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Per Diem or Per Service Averages
 Averages for this method are of specific occurrences known by the HMO at the time of the
estimation. Therefore, it is first necessary to know how many hospital days, procedure or visits
were authorized as of the date for which the IBNR is being estimated. Again, once the total expense
has been estimated, the amount of related paid claims shall be subtracted to get the IBNR
liability. This method is primarily used for hospitalization IBNRs as HMOs know the amount of
hospital days authorized at any given time.
 Lag Tables
 Lag tables are used to track historical payment patterns. When a sufficient history exists and a
regular claims submission pattern has been established, this methodology can be employed. All HMOs
shall use lag information as a validation test for accruals calculated using other methods, if it
is not the primary methodology employed. Typically, the information on the schedules I organized
according to the month claims are incurred on the horizontal axis and the month claims are paid by
the HMO on the vertical axis.
 Once a number of months becomes fully developed (i.e. claims submissions are thought to be
complete for the month of service), the information can be utilized to effectively estimate IBNRs.
Computing the average period over which claims are submitted historically and applying this
information to months that are not yet fully developed does this.
 HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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Appendix B  Report Forms
 Quarterly Report Forms
 This section includes copies of the forms to be completed electronically by the HMO for each quarter.
 
    
    Quarterly Certification Statement
    
    Report #1: 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
 
    
    Report #2: Income Statement by RATE CELL GROUPING
 
    
    Part A: AFDC/NJCPW/NJ KidCare A  Northern Region
    
    Part B: AFDC/NJCPW/NJ KidCare A  Central Region
    
    Part C: AFDC/NJCPW/NJ KidCare A  Southern Region
    
    Part D: DYFS  Statewide
    
    Part E: ABD with Medicare  DDD  Statewide
    
    Part F: ABD with Medicare  non-DDD  Statewide
    
    Part G: Non-ABD  DDD  Statewide
    
    Part H: ABD without Medicare  DDD  Statewide
    
    Part I: ABD without Medicare  Non DDD  Statewide
    
    Part J: NJ KidCare B&C Statewide
    
    Park K: NJ KidCare D Statewide
    
    Part L: Reserved
    
    Part M: NJ FamilyCare Parents 0-133% FPL  Statewide
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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
    
    Part N: (Reserved)
    
    Part O: NJ FamilyCare Parents 134-200 250% FPL  Statewide
    
    Part P: ABD with Medicare  AIDS- Statewide
    
    Part Q: Non- ABD   AIDS- Statewide
    
    Part R1: Maternity- Statewide
    
    Part R2: Newborn  Statewide
    
    Part S1: All Rate Cell Groupings Current Quarter  Statewide
    
    Part S2: All Rate Cell Groupings Year   To -Date  Statewide
    
    Part S3: Reconciliations
    
    Part T: Non-State Plan Services
    
    Part U: NJ FamilyCare Adults 0-100% FPL  Statewide
    
    Part V: Adult Restricted Aliens  Statewide
 
    
    Report #3: table 21: Maternity Outcome Counts
    
    Report #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
 
    
    Report #7: Stop Loss Summary
    
    Report #10 : Third Party Liability Collections
    
    Notes to Financial Reports
  HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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QUARTERLY CERTIFICATION STATEMENT
OF
 HMO NAME
 TO THE
NEW JERSEY DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
 FOR THE PERIOD ENDED
 
 (Month/day/year)
 Name of Preparer ___
Title ___
Phone Number ___
 Please check which reports are included with this packet:
 O
Report
#1                O Report #2                O Report #3
O Report #4                O Report #7                O Report #10
 I hereby attest that the information submitted in the reports herein is current, complete
and accurate to the best of my knowledge. I understand that whoever knowingly and willfully
makes or causes to be made a false statement or representation on the reports may be
prosecuted under applicable state laws. In addition, knowingly and willfully failing to
fully and accurately disclose the information requested may result in denial of a request to
participate, or where the entity already participates, a termination of an HMOs agreement
or contract with the State.
 Date                Chief Financial Officer               
                Signature
 HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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Appendix B  Report Forms
 NOTE TO
FINANCIAL REPORTS
 Any notes or further explanation 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.
 HMO Financial Reporting Specifications
For Medicaid/NJ FamilyCare Rate Cell Grouping Costs
    
    State of New Jersey




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Agreed Upon Procedures  For Rate Cell Cost Report Reserved




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AGREED UPON PROCEDURES
 For Rate Cell Cost Reports
 The following agreed upon procedures between the plan and its independent public accountant
are required to meet audit requirements of Rate Cell Grouping Cost Reports as further explained in
Article 7.27.1B of the contract.
 Procedures contained herein are established as minimum requirements. Additional procedures may be
added and performed as agreed to by the contractor and the accountant performing them without DMAHS
approval. However, changes, deletions or variations to the procedures specified herein will
require prior approval of DMAHS.




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Report
#1 Claim Lag Triangles
 Step
1: Validate the mathematical accuracy of Report #1.
 Step 2: Validate the accuracy of the amounts paid for each month.
 a.
    
    Trace and agree monthly amount to the supporting documentation used by the
contractor to complete the report.b.
    
    Trace and agree each monthly amount to the monthly check register or claims
system monthly summary.
 Step 3: Validate the accuracy of the amounts paid in the individual cells.
 a.
    
    For the claims paid and incurred on Report #1, trace and agree 4 cells to the
supporting documentation used by the contractor to complete the report.
 Step 4: Validate the accuracy of the amounts that comprise the individual cells.
 b.
    
    Select 8 claims from each lag triangle.c.
    
    Verify the claim is reported in the correct month of service by tracing and
agreeing to the date of service on the claim.d.
    
    Verify the claim is reported in the correct month of payment by tracing and
agreeing to bank statements.e.
    
    Verify the claim is reported in the correct month of payment by tracing and
agreeing type of service to the hard/electronic copy of the claim.f.
    
    Verify the claim is related to a New Jersey Medicaid or NJ Family Care
beneficiary by tracing and agreeing to the member eligibility system.
 Step 5: Validate the accuracy of the subcapitation payments reported
 a.
    
    Select 2 cells from each of applicable lag trianglesb.
    
    Trace and agree selected cells to the supporting documentation used by the
contractor to complete the report.
 Step 6: Validate the accuracy of the amounts that comprise subcapitation payments
 a.
    
    Verify that the transaction is recorded in the correct month of service by
tracing and agreeing to the invoice or check request that substantiates the check.
 b.
    
    Verify that the check has cleared the bank by tracing and agreeing to the bank
statement.
 c.
    
    Verify the transaction is accurately reported in Report #1 by tracing and
agreeing to the contract provider type and covered services.
 Step 7: Validate the accuracy of amounts reported as Pharmacy Rebates.
 a.
    
    Select 2 cells from each of the applicable lag triangles.




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b.
    
    Trace and agree selected cells the supporting documentation used by the
contractor to complete the report.c.
    
    Trace and agree each monthly amount to the monthly check register or claims
system monthly summary.
 Report
#2 Income Statement by Rate Cell Groupings
 Step 1: Verify that amounts reported as Medicaid/NJ Family Care expense are consistent with
amounts reported in statutory filings.
 a.
    
    Trace and agree total amounts reported as Medicaid/NJ Family Care expense to
statutory filings as of December 31.
 Step 2: Verify member months reported is accurate
 a.
    
    Confirm member months with the State of New Jersey
 Step 3: Verify the accuracy of dollar amounts reported as capitated premiums
 a.
    
    Select 5 income statement categories by Rate Cell Grouping (IS).b.
    
    Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.c.
    
    Select 4 months of capitated premiums and trace and agree amounts to remittance
advices received from the DMAHS.
 Step 4: Verify the accuracy of dollar amounts reported as HIV/AIDS Reimbursable Drugs Revenue.
 a.
    
    Select 5 income statement categories by Rate Cell Grouping (IS).b.
    
    Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.c.
    
    Select 4 months of capitated premiums and trace and agree amounts to remittance
advices received from the DMAHS.
 Step 5: Verify the accuracy of dollar amounts reported as EPSDT Incentive Payment Revenue.
 a.
    
    Select 5 income statement categories by Rate Cell Grouping (IS).b.
    
    Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.d.
    
    Select 4 months of capitated premiums and trace and agree amounts to remittance
advices received from the DMAHS.
 Step 6: Verify the accuracy of dollar amounts reported as Interest Revenue.
 a.
    
    Select 5 income statement categories by Rate Cell Grouping (IS).




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b.
    
    Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.
 Step 7: Verify the accuracy of dollar amounts reported as COB.
 a.
    
    Select 5 income statement categories by Rate Cell Grouping (IS).b.
    
    Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.
 Step 8: Verify the accuracy of dollar amounts reported as Reinsurance Recoveries.
 a.
    
    Select 5 income statement categories by Rate Cell Grouping (IS).b.
    
    Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.
 Step 9: Verify the accuracy of amounts reported as Medical and Hospital Expenses.
 a.
    
    Select at least one type of Medical and Hospital Expense from each of the
income statement categories by Rate Cell Groupings.b.
    
    Trace and agree selected cells to the supporting documentation used by the
contractor to complete the IS.c.
    
    Select one claim from each of the rate cell groupings selected in step 9a.d.
    
    Trace and agree amount reported in each cell to actual claims paid and an
allocation of expenses incurred but not paid.e.
    
    For the claim selected in step 9c, recalculate the allocation of incurred but
not reported to each income statement to determine if they are in same proportional
amounts as claims paid.f.
    
    For the claim selected in step c, trace and agree the classification of the
medical expense to the classification prescribed by DMAHS in the HMO Guide for
Reporting Medicaid/NJ Family Care Rate Cell Grouping Costs. Determine the claims
selected from step 9a and are included in the appropriate IS by Rate Cell Grouping and
that all Medical and Hospital Expenses are classified appropriately in lines 9-27.
 Step 10: Verify the accuracy of the amounts reported in Part S  Income.
 a.
    
    Trace and agree total amounts reported in Part S to amounts reported in the
individual income statements by Rate Cell Groupings.




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Report
#3 Maternity Outcomes
 Step 1: Verify the accuracy of amounts reported in Report 3.
 a.
    
    Trace and agree amounts reported as maternity outcomes to the supporting
documentation used by the contractor to complete the report.b.
    
    Select 5 outcomes from step a.c.
    
    Verify the outcome is reported in the correct region by tracing and agreeing
back to supporting documentation.d.
    
    Verify the outcome is reported in the correct eligibility category by tracing
and agreeing back to supporting documentation.e.
    
    Verify the outcome is reported in the correct category (c-section, vaginal, or
non live birth) by tracing and agreeing back to supporting documentation.f.
    
    Verify the outcome is not an elected abortion by tracing and agreeing back to
supporting documentation.g.
    
    Verify the outcome was reported for outcomes after 12 weeks of gestation by
tracing and agreeing back to supporting documentation.