exv10w25w3



 




Exhibit 10.25.3




	 	 	 	 	 
	



Jon S. Corzine

Governor

	 	

State of New Jersey

Department of Human Services

Division of Medical Assistance and Health Services

P.O. Box 712 

Trenton, NJ 08625-0712

Telephone 1-800-356-1561

June 8, 2007
	 	


 Jennifer Velez

Acting Commissioner


John  R. Guhl

Director






Peter D. Haytaian

President and Chief Executive Officer

AMERIGROUP New Jersey, Inc.

399 Thornall Street, 9th Floor

Edison, NJ 08837




Dear Mr. Haytaian:



Enclosed is your copy of a recently processed contract amendment. This amendment will extend the
managed care contract through June 30, 2008. The amendment has been approved by the Centers for
Medicare and Medicaid Services.




Thank your for your continued interest in Medicaid managed care.




Sincerely,




)




Rita Hemingway

Director, Contract Relations

Office of Managed Health Care




RH;dg




Enclosure





			
	c:	 	Jill Simone, MD

John Koehn

Jennifer Langer





New Jersey Is An Equal Opportunity Employer




 









 








STATE OF NEW JERSEY




DEPARTMENT OF HUMAN SERVICES




DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES


AND





AMERIGROUP NEW JERSEY, INC.




AGREEMENT TO PROVIDE HMO SERVICES



In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract between AMERIGROUP New
Jersey, Inc. and the State of New Jersey, Department of Human Services, Division of Medical
Assistance and Health Services (DMAHS), effective date October 1, 2000, all parties agree that the
contract shall be amended, effective July 1, 2007, as follows:




 









 









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






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






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




 









 






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






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






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






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






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




 









 










All other terms and conditions of the October 1, 2000 contract and subsequent amendments remain
unchanged except as noted above.



The contracting parties indicate their agreement by their signatures.




	 	 	 	 	 	 	 	 	 	 	 
	AMERIGROUP
	 	State of New Jersey

	New Jersey, Inc.
	 	Department of Human Services

	 
	 	 	 	 	 	 	 	 	 	 
	BY:

	 	/s/ Peter D. Haytaian
 

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

John R. Guhl
	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	TITLE: President & CEO	 	TITLE: Director, DMAHS
	 
	 	 	 	 	 	 	 	 	 	 
	DATE: 4/13/07	 	date: 4/20/07
	 
	 	 	 	 	 	 	 	 	 	 
	APPROVED AS TO FORM ONLY	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Attorney General	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	State of New Jersey	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	BY:

	 	[ILLEGIBLE]
 

Deputy Attorney General
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	DATE: 4/17/07	 	 	 	 	 	 






 









 







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






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






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





			
	 	 	 
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	PSC	 	PSC	 	Race Code
	Cost Sharing	 	No Cost Sharing	 	No Cost Sharing
	301
	 	300
	 	3
	493
	 	380	 	 
	494
	 	497	 	 
	495
	 	700	 	 
	498
	 	763	 	 
	498

(w/corresponding 

cap code) 

701
	 	380, 310, 320, 330,

410, 420, 430, 470,

497 (with

corresponding cap

codes)	 	 







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






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






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





	 	 	 
	PSC	 	PSC
	Cost Sharing	 	No Cost Sharing
	498 (w/corresponding 

cap code) 

701
	 	380, 310, 320, 330, 410, 420,

430, 470, 497 (with

corresponding cap codes)
	 
	 	700
	 
	 	763






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





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






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






	3.3.2	 	PROVIDER CREDENTIALING






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





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






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






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






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






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






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






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






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





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






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






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






	3.9.1	 	REQUIRED ENCOUNTER DATA ELEMENTS






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






	3.9.2	 	SUBMISSION OF TEST ENCOUNTER DATA






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





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






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





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






	4.1.2	 	BENEFIT PACKAGE






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





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






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





	 	 	 	 	 	 	 
	1.

	 	 	290.0	 	 	Senile dementia, simple type
	2.

	 	 	290.1	 	 	Presenile dementia
	3.

	 	 	290.10	 	 	Presenile dementia, uncomplicated
	4.

	 	 	290.11	 	 	Presenile dementia with delerium
	5.

	 	 	290.12	 	 	Presenile dementia with delusional features
	6.

	 	 	290.13	 	 	Presenile dementia with depressive features
	7.

	 	 	290.2	 	 	Senile dementia with delusional or depressive features
	8.

	 	 	290.20	 	 	Senile dementia with delusional features
	9.

	 	 	290.21	 	 	Senile dementia with depressive features
	10.

	 	 	290.3	 	 	Senile dementia with delerium
	11.

	 	 	290.4	 	 	Arteriosclerotic dementia
	12.

	 	 	290.40	 	 	Arteriosclerotic dementia, uncomplicated
	13.

	 	 	290.41	 	 	Arteriosclerotic dementia with delirium
	14.

	 	 	290.42	 	 	Arteriosclerotic dementia with delusional features
	15.

	 	 	290.43	 	 	Arteriosclerotic dementia with depressive features
	16.

	 	 	290.8	 	 	Other specific senile psychotic conditions
	17.

	 	 	290.9	 	 	Unspecified senile psychotic condition
	18.

	 	 	291.1	 	 	Alcohol amnestic syndrome
	19.

	 	 	291.2	 	 	Other alcoholic dementia
	20.

	 	 	292.82	 	 	Drug induced dementia
	21.

	 	 	292.83	 	 	Drug-induced amnestic syndrome
	22.

	 	 	292.9	 	 	Unspecified drug induced mental disorders
	23.

	 	 	293.0	 	 	Acute delirium
	24.

	 	 	293.1	 	 	Subacute delirium
	25.

	 	 	293.8	 	 	Other specific transient organic mental disorders
	26.

	 	 	293.81	 	 	Organic delusional syndrome
	27.

	 	 	293.82	 	 	Organic hallucinosis syndrome
	28.

	 	 	293.83	 	 	Organic affective syndrome
	29.

	 	 	293.84	 	 	Organic anxiety syndrome
	30.

	 	 	294.0	 	 	Amnestic syndrome
	31.

	 	 	294.1	 	 	Dementia in conditions classified elsewhere
	32.

	 	 	294.8	 	 	Other specified organic brain syndromes (chronic)
	33.

	 	 	294.9	 	 	Unspecified organic brain syndrome (chronic)
	34.

	 	 	305.1	 	 	Non-dependent abuse of drugs — tobacco
	35.

	 	 	310.0	 	 	Frontal lobe syndrome
	36.

	 	 	310.2	 	 	Postconcussion syndrome
	37.

	 	 	310.8	 	 	Other specified nonpsychotic mental disorder following

organic brain damage






			
	 	 	 
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	 	 	 	07110
	 
	 	 	 	07130
	 
	 	 	 	07210






	4.1.4	 	MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR






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






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






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






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






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






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






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





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






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


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






	 	6.	 	Submission and Publication of the Formulary.






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






	 	7.	 	If the formulary includes generic equivalents, the contractor shall provide for a brand name
exception process for prescribers to use when medically necessary. For MCSA enrollees, the
contractor should implement a mandatory generic drug substitution program consistent with
Medicaid program requirements. (Not applicable to non-MCSA contractor).
	 
	 	8.	 	The contractor shall establish and maintain a procedure, approved by DMAHS, for internal
review and resolution of complaints, such as timely access and coverage issues, drug
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	 	E.	 	The contractor shall permit its pharmacy providers to dispense a 72-hour supply of any drug, on
or off the formulary, that is subject to a prior authorization process. (e.g., Article 4.2.4.B.5.f)






	4.2.5	 	LABORATORY SERVICES






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






	4.2.6	 	EPSDT SCREENING SERVICES






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






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





			
	 	 	 
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	4.5	 	ENROLLEES WITH SPECIAL NEEDS
	 
	4.5.1	 	INTRODUCTION
	 
	 	 	For purposes of this contract, adults with special needs includes complex/chronic medical
conditions requiring specialized health care services, including persons with physical, mental,
substance abuse, and/or developmental disabilities, including such persons who are homeless.
Children with special health care needs are those who have or are at increased risk for a chronic
physical, developmental, behavioral, or emotional condition and who also require health and related
services of a type or amount beyond that required by children generally.

	 
	 	 	In addition to the standards set forth in this Article, contractor shall make all reasonable
efforts and accommodations to ensure that services provided to enrollees with special needs are
equal in quality and accessibility to those provided to all other enrollees.
 
	 
	4.5.2	 	GENERAL REQUIREMENTS






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






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





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






	4.5.3	 	PROVIDER NETWORK REQUIREMENTS






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






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





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






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






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






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





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






	4.5.5	 	CHILDREN WITH SPECIAL HEALTH CARE NEEDS






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






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






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






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





			
	 	 	 
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	4.6.5	 	CARE MANAGEMENT






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






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






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






	 	5.	 	Protocols for the following care management activities:






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






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





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






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






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






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





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






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






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






	 	A.	 	Primary care providers who will serve enrollees listed by






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






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






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





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






	 	a.	 	Medical Toxicology

	 	b.	 	
Developmental & Behavioral Pediatrics

	 	c.	 	Medical Genetics

	 	d.	 	Specialty Centers (Centers of Excellence)

	 	e.	 	Other Specialty Centers/Providers

	 	f.	 	DME providers

	 	g.	 	Medical suppliers

	 	h.	 	Prosthetists, orthotists, pedorthists
	 	i.	 	Hearing aid suppliers
	 	j.	 	Transportation providers






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






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





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





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





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






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






	5.8.3	 	ANNUAL INFORMATION TO ENROLLEES






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






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





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






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





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






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






	 	C.	 	Enrollment Inducements






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






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






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






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






	 	1.	 	Cessation or reduction of enrollment including auto assignment.

	 
	 	2.	 	Reduction or elimination of marketing and/or community event participation.





			
	 	 	 
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Liquidated Damages:




If the contractor does not provide or perform the requirement within fifteen (15) business
days of the written notice, or longer if allowed by the Department, or through an approved
corrective action plan, the Department may impose liquidated damages of $250 per
requirement per day for each day the requirement continues not to be provided or performed.
If after fifteen (15) additional days from the date the Department imposes liquidated
damages, the requirement still has not been provided or performed, the Department, after
written notice to the contractor, may increase the liquidated damages to $500 per
requirement per day for each day the requirement continues to be unprovided or unperformed.




Note: If the failure to provide required services or the contractor’s operations are
interrupted or compromised due to a natural disaster and/or Act of God and after diligent
efforts, the contractor cannot make other provisions for the delivery of services or
conduct of operations, the Department may determine, at its sole discretion, not to impose
liquidated damages. The contractor shall present a plan of correction to the Department for
approval within two (2) business days of the event or where possible, prior to the event
when known, such as advance warnings of an oncoming hurricane.



7.16.3 TIMELY REPORTING REQUIREMENTS





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






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





			
	 	 	 
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7.16.4 ACCURATE REPORTING REQUIREMENTS





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






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





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





7.16.5 TIMELY PAYMENTS TO MEDICAL PROVIDERS





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




Liquidated Damages:




Liquidated damages may be assessed if the contractor does not meet the above requirements
on a quarterly basis. Based on the contractor-reported information on the claims lag
reports, the Department shall determine for each time period (thirty (30)/forty (40),
sixty (60), and ninety (90) days) the actual percentage of claims processed (electronic
and manual claims shall be added together). This number shall be subtracted



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





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





7.27 FINANCIAL STATEMENTS




7.27.1 AUDITED FINANCIAL STATEMENTS (SAP BASIS)





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





			
	 	 	 
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The contractor shall require its independent public accountant to prepare a
letter and report of findings which shall be submitted to DMAHS by June 1 of each
year. Only the fourth quarter report (period October 1 through
December 31) of each calendar year will be subject to this Audit of Income
Statements by Rate Cell Grouping.




The contractor shall require its independent public accountant to explain any
differences between the Statewide Income Statement by Rate Cell Grouping Cost
Reports (Report 2 — Parts SI through S3) and the annual audit statements in the
letter.




When findings indicate significantly reduced Medical/Hospital Expenses from those
originally reported, a corresponding rate reduction may take effect in future
periods.




The Department at its sole discretion shall have the right to conduct targeted
audits, request additional information or reporting, and/or investigate or verify
submitted reports for any period of the contract term at the contractor’s expense.



7.27.2 UNAUDITED FINANCIAL STATEMENTS (SAP)





Contractor shall submit to DMAHS all quarterly and annual financial statements and annual
supplements in accordance with Statutory Accounting Principles (SAP) required in N.J.A.C.
8:38-11.6. Submissions to DMAHS shall be on the same time frame described in N.J.A.C.
8:38-14, i.e., quarterly reports are due the fifteenth (15th) day of the second
month following the quarter end and statutory unaudited statement and the annual
supplemental are due March 1 covering the preceding calendar year. Such information shall
be subject to the confidentiality provisions in Article 7.40.



7.28 FEDERAL APPROVAL AND FUNDING





This managed care contract shall not be implemented until and unless all necessary
federal approval and funding have been obtained.



7.29 CONFLICT OF INTEREST





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





			
	 	 	 
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8.4 MEDICAL COST RATIO




8.4.1 MEDICAL COST RATIO STANDARD





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




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






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





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






Calculation of MCR. The calculation of MCR will
be made using information submitted by each
the contractor on the quarterly reports — Income Statement by Rate Cell Grouping (Section
A.7.21 of the Appendices, Table 19, ). The costs related to 8.4. 1.A 1-3 are to be reported
on Table 6 and the allowable amount will be added to the calculation of Medical and
Hospital Expenses. The sum of all applicable quarters in the SFY for which the MCR is
calculated for Total Medical and Hospital Expenses less Coordination of Benefits (COB) and
less reinsurance recoveries will be divided by the sum of all applicable quarters of
Medicaid/NJ FamilyCare premiums to arrive at the ratio. In addition, the DMAHS will allow
for any applicable premium adjustments in the MCR calculation. At its sole discretion, the
State reserves the right to recompute the MCR to determine direct medical expenditures of
eighty (80) percent for a period of up to three (3) years prior to the close of the state
fiscal year under review for MCR determination and recover the underexpenditure as
delineated in Article 8.4.3.



8.4.2 RESERVED




8.4.3 DAMAGESRECOVERY OF UNDEREXPENDITURE



The Department shall have the right to impose damages on a contractor that has
failed to maintain an appropriate MCR.recover the amount of payments from the
State not spent on medical costs as defined above. The damages shall be assessed
when MCR is below 80% and an underexpenditure occurs. The formula for- imposing damages
follows:




     ACTUAL MCR




     80% or above          NONE          NONE




          .15 times          .15 times

                    underexpenditure     underexpenditure




     75.00 77.99%     .50 times     .50 times

                    underexpenditure     underexpenditure




     74.99 or below     .90 times     1.00 times

                    underexpenditure     underexpenditure



If at 180 days after the SFY end the MCR is below 80.0%, the State shall recover 100% of the
underexpenditure. If the contractor fails to meet the MCR requirement and a penalty
is appliedrecovery is made, a plan of corrective action shall be required.




8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS




			
	 	 	 
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8.5.1 REGIONS





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




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






Contractors may contract for one or more regions but, except as provided in Article 2,
may not contract for part of a region.



8.5.2 MAJOR PREMIUM GROUPS





The following is a list of the major premium groups. The individual rate groups (e.g.
children under 2 years, etc.) with their respective rates are presented in the rate
tables in the appendix.



8.5.2.1 AFDC/TANF, DYFS AND AGING OUT FOSTER CARE CHILDREN, NJC PREGNANT WOMEN, AND NJ FAMILYCARE
PLAN A CHILDREN





This grouping includes capitation rates for Aid to Families with Dependent Children
(AFDC)/Temporary Assistance for Needy Families (TANF), DYFS and Aging Out Children in
Foster Care, New Jersey Care Pregnant Women and Children, and NJ FamilyCare Plan A
children (includes individuals under 21 in PSC 380), but excludes individuals who have
AIDS or are clients of DDD, as well as AFDC/TANF restricted alien individuals over the age
of 20.99 years old.



8.5.2.2 NJ FAMILYCARE PLANS B & C





This grouping includes capitation rates for NJ FamilyCare Plans B and C enrollees,
excluding individuals with AIDS and/or DDD clients.



8.5.2.3 NJ FAMILYCARE PLAN D CHILDREN





This grouping includes capitation rates for NJ FamilyCare Plan D children, excluding
individuals with AIDS.



8.5.2.4 NJ FAMILYCARE PLAN D PARENTS/CARETAKERS




			
	 	 	 
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This grouping includes capitation rates for NJ FamilyCare Plan D parents/caretakers,
excluding individuals with AIDS, and restricted alien individuals, and include only
enrollees 19 years of age or older.



8.5.2.5 RESERVED DYFS AND AGING OUT FOSTER CHILDREN





This grouping includes capitation rates for Division of Youth and
Family Services, excluding individuals with AIDS and clients of DDD.



8.5.2.6 ABD WITHOUT MEDICARE





Compensation to the contractor for the ABD individuals without Medicare will be
risk-adjusted using the Health Based Payments System (HBPS), which is described in Article
8.6. HBPS adjusts for the diagnosis of AIDS; therefore, separate AIDS rates are not
necessary for this population. Finally, the HBPS adjusts for age and sex so separate rates
for age and sex within this population are not necessary.



8.5.2.7 ABD WITH MEDICARE AND OTHER DUAL ELIGIBLES





This grouping includes capitation rates for all enrollees with Medicare, excluding dual
eligibles (Medicaid and Medicare) individuals with AIDS and clients of DDD.



8.5.2.8 CLIENTS OF DDD





This grouping includes all enrollees except ABD individuals without Medicare. The
contractor shall be paid separate, statewide rates for subgroups of the DDD population,
excluding individuals with AIDS. These rates include covered MH/SA services.



8.5.2.9 ENROLLEES WITH AIDS





This grouping includes all enrollees except ABD individuals without Medicare.




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





8.5.2.10 RESERVED




8.5.3 NEWBORN INFANTS





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



			
	 	 	 
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SECTION A

REPORTS



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




1/20077/2007 Changes




 









 








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



State of New Jersey




 









 





			
	 	 	 
	Contractor Financial Reporting Manual
	 	State of New Jersey






Contents




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






			
	 	 	 
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11




Introduction



Purpose



The objective of this Financial Reporting Specifications is to ensure uniformity, accuracy
and completeness in reporting Medicaid/NJ FamilyCare rate cell groupings. In addition, the
provision of this Financial Reporting Specifications to the Contractors will help to eliminate
inconsistencies, as reports can vary in the presentation of items such as allocation of expenses,
accrual of incurred-but-not-reported (IBNR) claims, handling of maternity claims, and other items.
All reports shall be submitted as outlined in the general instructions. The financial reports
submitted from this Financial Reporting Specifications will be used in future rate setting and to
better assess the financial performance of Contractors.



The reports in this Financial Reporting Specifications are to supplement, not replace, the
reporting requirements currently required in the Division of Medical Assistance and Health
Services (DMAHS) Managed Care Contract (please refer to Section A of the contract). Key
differences between this Financial Reporting Specifications and the reports currently submitted to
DMAHS are as follows:





	§	 	Rate cell grouping detail;






	§	 	Regional detail;






	§	 	IBNR calculation detail; and






	§	 	Timing of submissions.





			
	 	 	 
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Rate Cell Groupings



—This Financial Reporting Specifications requires key cost reporting by rate cell
grouping. Rate cells have been combined into 15 rate cell groupings for
these reporting purposes (seventeen rate cell groupings for Medicaid/NJ FamilyCare
Managed Care



at riskreporting purposes populations and two rate
cell groupings for Managed Care Service Administrator (MCSA) populations). Please
note where Acquired Immunodeficiency Syndrome (AIDS) individuals are included or excluded in the
rate cell groupings. Also note that maternity and newborn costs are reported as separate rate
cell groupings and shall be excluded from other rate cell groupings. The rate cell groupings are
as follows:




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

	 
	 	 	 	 	 	 
	Table #19—

Parts A, B, C

	 	AFDC/NJCPW/NJ KidCare A


(Excluding AIDS)
	 	125R1-125R3

143R1-143R3

171R1-171R3

172R1-172R3

183R1-183R3

	 	Individuals
eligible for Aid to
Families with
Dependent Children
(AFDC), New Jersey
Care Pregnant Women
(NJCPW), or NJ
KidCare A (children
below the age of 19
with family incomes
up to and including
133% of the federal
poverty level
(FPL)), excluding
individuals with
AIDS.
	 
	 	 	 	 	 	 
	Table #19

Part D

	 	DYFS Clients

(Excluding AIDS)
	 	32599. 34399

	 	Individuals eligible
through the
Division of Youth
and Family Services
(DYFS), including
Foster Care
children and
children with
Adoption
Assistance, excluding individuals with
AIDS.
	 
	 	 	 	 	 	 
	Table #19—

Part E

	 	ABD with Medicare and Other
Dual Eligibles — DDD


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

Part F

	 	ABD with Medicare and Other
Dual Eligibles — Non-DDD


(Excluding AIDS)
	 	711R1-711R3

813R1-813R3

823R1-823R3

863R1-863R3
	 	ABD individuals who
receive Medicare
and are not
eligible for
services through
the DDD, excluding
individuals with
AIDS.
	 
	 	 	 	 	 	 
	Table #19—

Part G

	 	Non-ABD — ODD 


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






			
	 	 	 
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	Rate Cell	 	 	 	Capitation	 	 
	Reference	 	Rate Cell Grouping	 	Code	 	Description
	Table #19—

Part H

	 	ABD without Medicare —DDD


(Including AIDS)
	 	49399, 49499 
	 	ABD
individuals not
receiving Medicare
and eligible for
services through
the DDD, including
individuals with
AIDS.
	 
	 	 	 	 	 	 
	Table #19—

Part l

	 	ABD without Medicare —Non-DDD


(Including AIDS)
	 	71099, 81099,

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

	 
	 	 	 	 	 	 
	Table #19—

Part J

	 	NJ KidCare B&C


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

Part K

	 	NJ KidCare D


(Excluding AIDS)
	 	92599, 93399 
	 	Eligible
children under age
19 with family
income between 201%
and up to and
including 350% FPL,
excluding
individuals with
AIDS.
	 
	 	 	 	 	 	 
	Table #19—

Part M

	 	NJ
Family Care Parents /Adults
NJ

FamilyCare

Parents 0 133% FPL


(Excluding AIDS)
	 	56199, 56299,

57399
57199

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


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


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






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

Part O



	 	NJ
FamilyCare
 Parents
13/1-250%
FPL


(Excluding
AIDS)
	 	95499,

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

	 
	 	 	 	 	 	 
	Table #19—

Part P

	 	ABD with Medicare and
Other Dual Eligibles —
AIDS
	 	28499, 48499
	 	ABD
individuals with
AIDS who receive
Medicare, including
those eligible for
DDD, excluding the
risk-adjusted
populations.
	 
	 	 	 	 	 	 
	Table #19—

Part Q

	 	Non-ABD — AIDS
	 	27499, 47499,

27699
	 	Non-ABD
individuals with
AIDS including
AFDC, NJCPW, NJ
KidCare, and
NJ FamilyCare
Parents, excluding
the risk-adjusted
populations.
	 
	 	 	 	 	 	 
	Table #19—

Part R1

	 	Maternity
	 	N/A
	 	Please refer
to criteria
outlined in the
instructions for
Table 19 Part R1 in
the Report
Specifications
section.
	 
	 	 	 	 	 	 
	Table #19—

Part R2

	 	Newborn
	 	Includes

newborn claims

costs

associated

within: 103R1 -

103R3, 30399,

60399, 80399,

90399
	 	Please refer
to criteria
outlined in the
instructions for
Table 19 Part R2,
in the Report
Specifications
section.
	 
	 	 	 	 	 	 
	MCSA

	 
	 	 	 	 	 	 
	
Table #19

Part U



	 	NJ
FamilyCare
Adults 0 100%
FPL


(Excluding
AIDS)
	 	65499,

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






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

Part V



	 	Adult
Restricted
Aliens
	 	40199,

40299, 40399
	 	Classification based on
restricted alien
status in PSCs 310
-330,

410 —
430,
-470 and 380 over
the age of 20, or
NJ FamilyCare PSCs
763, and -497 & 498
with corresponding
cap
codes.






			
	 	 	 
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	Contractor Financial Reporting Manual
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Geographic Regions



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




	 	 	 	 	 
	Northern (Region 1)	 	Central (Region 2)	 	Southern (Region 3)
	Bergen

	 	Essex
	 	Atlantic
	Hudson

	 	Mercer
	 	Burlington
	Hunterdon

	 	Middlesex
	 	Camden
	Morris

	 	Union
	 	Cape May
	Passaic

	 	 	 	Cumberland
	Somerset

	 	 	 	Gloucester
	Sussex

	 	 	 	Monmouth
	Warren

	 	 	 	Ocean
	 

	 	 	 	Salem






			
	 	 	 
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2 2




General Instructions



The following are general instructions for completing the various tables required to be
submitted by the Contractors to DMAHS. These instructions are designed to promote uniformity in
reporting.




Due Dates



All Medicaid/NJ FamilyCare revenues and expenses must be reported using the accrual basis of
accounting except for Table 19, Parts T V (Non-State Plan Services by rate cell
grouping and MCSA groupings). Table 19, Parts T V shall be reported on a paid basis.
Reports shall be submitted quarterly and are due 45 days following each quarter end:



12-Month Period End Reports Due Each Quarter




	 	 	 
	Quarter Ending:	 	Due Date:
	March 31

	 	May 15
	June 30

	 	August 15
	September 30

	 	November 15
	December 31

	 	February 15






Annual Supplemental Reports Due




	 	 	 
	Quarter Ending:	 	Due Date:
	September 30

	 	November 105





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




			
	 	 	 
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	Contractor Financial Reporting Manual
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-sound development of capitation rates will be requested in writing and be due within 15
days of the request. Please submit the completed reports to:



State of New Jersey

Director, HMO Financial Reporting

David.Moran@dhs.state.nj.us



and



Mercer Government Human Services Consulting

Actuarial Services

Mike.Nordstrom@mercer.com



In the event that Medicaid financial statements are submitted with errors that require restatement,
DMAHS, in its sole discretion, shall require the Contractor to engage independent auditors to do a
more thorough review or audit of the financial statements. DMAHS shall not reimburse the Contractor
for any additional costs related to an additional review or audit.




Format



The Contractor will submit these reports electronically, using Excel spreadsheets in the
formats and on the forms specified in this manual without alteration, to the e-mail addresses
listed above or to an alternate DMAHS secure website it may establish during the period of this
contract. Copies of the reports are included in Appendix D of this manual.




Web-Based Financial Reporting



The contractor will log into a secure web-based portal to submit the Excel spreadsheets
that comprise the Medicaid Financial Reports (MFR). Upon submission, the MFR data will pass
through a series of edits to measure completeness and the basic accuracy of the mandatory reports.
The contractor will then be notified via the system if the reports were rejected along with a
description of the error








			
	 	 	 
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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 the current reporting period. Adjustments for prior
period IBNR estimates shall be included on Table 19, Part S2, in Line 45, and a detailed
reconciliation shall be included on Table 19, Part S3. Information about any adjustments that
pertain to prior periods shall be explained in a note to the reports. However, if there was
material error in preparation of the prior period report, a revised report shall be submitted.



Unanswered questions or blank lines on any report or schedule will render the report or schedule
incomplete and may result in a resubmission request. Any resubmission must be clearly identified
as such. If no answers or entries are to be made, write “None”, “Not Applicable (N/A)”, or “-0-”
in the space provided. Always use predefined categories or classifications before reporting an
amount as “Other”.



Dollar amounts shall be reported to the nearest dollar. Per member per month (PMPM) amounts,
however, shall be shown with two digits to the right of the decimal point.



Additional sheets referencing the applicable reports must be attached for further explanation. The
Contractor shall use “Notes to Financial Reports” in Appendix B for write-ins and explanations.




			
	 	 	 
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33




Report Specifications




Table 20:
Lag Reports (Parts A-ED)

Submission Due at Each Quarter End



Analyzing the accuracy of historical medical claims liability estimates is necessary in
assessing the adequacy of current liabilities. In addition, valid IBNR liability estimates are
crucial when utilizing financial statements in the managed care rate setting process. This
schedule provides, the necessary information to make this analysis.



Information
is provided on Inpatient Hospital, Physician, Pharmacy, and Other Medical Payments on
Parts A through D, respectively, with all rate cell groupings
combined,excluding the Managed Care Service Administrator
(MCSA) rate cell
groupings. Lag report information shall be provided for each Medical Cost Grouping
as defined below and map to the corresponding consolidated category of service for the
corresponding incurral period within Table 19, Part S2. A detailed reconciliation of the lag
report information and Income Statements by Rate Cell Group shall be included on Table 19, Part
S3. Information about any adjustments that pertain shall be explained in a note to the reports.




	 	 	 	 	 	 	 
	 	 	 	 	Medical	 	 
	Consolidated	 	Income Statement	 	Cost	 	Lag Report
	Category of Service	 	Reference	 	Grouping	 	Reference
	Inpatient Hospital

	 	Table #19 — Part S2,
Line 9
	 	Inpatient

Hospital
	 	Table #20 — Part A
	 
	 	 	 	 	 	 
	Primary Care

	 	Table #19 — Part S2,

Line 10
	 	Physician
	 	Table #20 — Part B
	 
	 	 	 	 	 	 
	Physician Specialty 

Services

	 	Table #19 — Part S2,
Line 11
	 	Physician
	 	Table #20 — Part B






			
	 	 	 
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	 	 	 	 	Medical	 	 
	Consolidated	 	Income Statement	 	Cost	 	Lag Report
	Category of Service	 	Reference	 	Grouping	 	Reference
	Pharmacy (not to
include Reimbursable
HIV/AIDS Drugs and Blood
Products)

	 	Table #19 — Part S2, Line 18
	 	Pharmacy
	 	Table #20 — Part C
	 
	 	 	 	 	 	 
	Reimbursable HIV/AIDS Drugs
and Blood Products

	 	Table #19 — Part S2, Line 19
	 	Pharmacy
	 	Table #20 — Part C
	 
	 	 	 	 	 	 
	Outpatient Hospital

(excludes ER)

	 	Table #19 — Part S2, Line 12
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	Other Professional Services

	 	Table #19 — Part S2, Line 13
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	Emergency Room

	 	Table #19 — Part S2, Line 14
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	DME/Medical Supplies

	 	Table #19 — Part S2, Line 15
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	Prosthetics and Orthotics

	 	Table #19 — Part S2, Line 16
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	Dental

	 	Table #19 — Part S2, Line 17
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	Home Health, Hospice,. &PDN

	 	Table #19 — Part S2, Line 20
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	Transportation

	 	Table #19 — Part S2, Line 21
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	Lab & X-ray

	 	Table #19 — Part S2, Line 22
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	Vision Care including 

Eyeglasses

	 	Table #19 — Part S2, Line 23
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	Mental Health/ Substance Abuse

	 	Table #19 — Part S2, Line 24
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	EPSDT Medical & PDN

	 	Table #19 — Part S2, Line 26
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	EPSDT Dental

	 	Table #19 — Part S2, Line 27
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	Family Planning

	 	Table #19 — Part S2, Line 28
	 	Other
	 	Table #20 — Part D
	 
	 	 	 	 	 	 
	Other Medical

	 	Table #19 — Part S2, Line 29
	 	Other
	 	Table #20 — Part D








 




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





			
	 	 	 
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The schedules are arranged with the month of service horizontally and the month of payment
vertically. Therefore, payments made during the current month for services rendered during the
current month would be reported in Line 1, Column 3, while payments made during the current month
for services rendered in prior months would be reported on Line 1, Columns 4 through 39. Please
note that columns 13 through 38 and rows 11 through 36 are hidden in the sample worksheet. Lines 1
through 3 contain data for payments made in the current period. Earlier data on Lines 4 through 37
shall match data on appropriate lines on the prior period’s submission. If Lines 4 through 37
changes from the prior period’s submission, include an explanation. The current month is the last
month of the period that is being reported. For example, in the report for the period ended June
30, 2003, the current month would be June 2003, and the first prior month would be May 2003. Do
not include risk pool distributions as payments in this schedule.



Table 20 must provide data for the period beginning with the first month the Contractor is
responsible for providing medical benefits to Medicaid/NJ FamilyCare recipients, and ending with
the current month.



Line 39 — Subcapitation payments shall be reported here, by month of payment. They are not to be
included above Line 39. For the current period, Line 39 shall contain new data in Columns 3
through 5. Data in columns 6 through 38 shall match data in appropriate columns on the prior
period’s submission. If columns 6 through 38 change from the prior period’s submission, include an
explanation.



Line 40 — Report pharmacy rebates anticipated for drugs dispensed this period. Adjust as
appropriate any adjustment applicable to a prior period. Only complete for the Pharmacy Payment
report, Part C.



Line 41 — The Contractor shall report payments on Lines 1 — 36. If the Contractor makes a
settlement or other payment that cannot be reported on Lines 1-36 due to lack of data, the amount
shall be reported on Line 41. If the service month(s) can be determined, the settlement dollars
can be allocated to the service month. Otherwise, the payment month can be used as a substitute
for the service month. If an amount is shown on Line 41 in columns 3 through 5, include an
explanation. If columns 6 and greater change from the prior submission, also include an
explanation.



Line 42 — This line is the total amount paid to date for services rendered. Line 42 shall equal
the sum of Lines 38, 39, and 41. For the Pharmacy Payment report, Part C, also include Line 40.



Line 43 — This line provides the current estimate of remaining liability for unpaid claims for each
month of service. The amount in each column on this line must be updated each period. The
amount in Column 40 is the sum of amounts in Columns 3 through 39. The sum of the amounts in Column
40, in parts A through D, is the unpaid claim liability (IBNR and reported-but-unpaid-claims
(RBUC)). Please refer to Attachment A for a methodology for calculating IBNR.




			
	 	 	 
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Line 44 — The total incurred claims is the sum of Lines 42 (the amounts paid to date) and
Line 43 (estimate of unpaid claims liability). Amounts on Line 44 are shown for each month.



DMAHS recognizes that claims liabilities may include the administrative portion of claim
settlement expenses. Any liability for future claim settlement expense must be disclosed in the
notes in the reports.



The NJ FamilyCare Adults 0 — 100 percent of FPL, Health
Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant
women) populations are classified into two groups under the MCSA program. As DMAHS has assumed the
responsibility for financial risk for medical costs of these populations, the medical expenses for
these populations shall be excluded from Parts A — D of the Lag Report.
All medical expenses for these populations must be reported within Part E of the Lag
Report.




			
	 	 	 
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Table 19:
Income Statement by Rate Cell Grouping (Parts A – R2, U,
V)


Submission Due at Each Quarter End



This report is meant to provide detailed summary information on revenues and expenses. A
consolidated report is to be completed for each of the fifteen rate cell groupings and for
Maternity and Newborn, with Table 19 Part S2 being the summation of Parts A-R2 respectively for
the 12-months ending. For reporting purposes, AIDS revenues and expenses are included or excluded
from the rate cell groupings as indicated on the report forms and in the chart defining the rate
cell groupings provided on page 2.



Additionally, State fiscal year-end information will be provided on the first fiscal quarter
ending reports (September 30). This information shall include all data with incurred dates through
the most recent completed state fiscal year, with paid data through September 30 (incurred in 12
months, paid in 15 months). Reports are to be completed for each of the 15 rate cell groupings and
for Maternity and Newborn categories. Besides quarter ending
September 30, this information is not
required for any other quarter ending time periods.



The NJ
FamilyCare Adults 0 – 100 percent of FPL, Health
Access individuals without dependent children, and Adult Restricted Aliens (excluding pregnant
women) populations are classified into two groups under the MCSA program. As DMAHS has assumed the
responsibility for financial risk for medical costs of these
populations, the medical and
administrative expenses and premiums for these populations shall be excluded from all rate cell
groupings in Parts A – T and reported separately in Parts U and V. Part
V has been created to provide information on services for the non-risk Adult Restricted Aliens
(excluding pregnant women). The Adult Restricted Aliens (excluding pregnant women) expenses and
revenues, which have been scattered across several categories of aid, shall now only be included
in Part V. Revenue and expenses for non-risk NJ FamilyCare Adults
0 – 100 percent of FPL will be reported within
Part U.



Do not
include maternity or newborn revenues or expenses in Parts A – Q. Only include Maternity
and newborn revenues and maternity expenses on the Income Statement for Maternity, Part R1, and
for All Rate Cell Groupings, Part S2. Include newborn expenses on the Income Statement for
Newborn, Part R2, and for All Rate Cell Groupings, Part S2. Include Maternity costs associated
with the following codes for still births or live births after the twelfth week of gestation,
excluding elective/induced abortions:




DRG Codes:



§
370–375 or 650–652;or




DRG Codes only with specific ICD-9 Diagnosis Codes:



§  DRG codes 380 or 381 plus one of the following ICD-9 codes: 632, 634.0-634.99
and 637.0-637.99; or




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




Additionally, Table 19, Part R2 (Income Statement for Newborn) includes newborn claims for the
partial month of birth and the first two (2) months thereafter, previously reported in the
AFDC/NJCPW/KidCare A, NJ KidCare B, C, and D, DYFS. and Blind/Disabled rate cell groupings. Age
shall be determined by counting the child’s age as of their last birthday, on the first of the
month in which the claim is incurred.



Except for non-State Plan services (Part T) and MCSA reports (Parts
U – V), all revenues and expenses must be reported on Table 19 (A-R2) using the
accrual basis of accounting for the requested period. Each report is based on statewide
reporting except for the rate cell grouping AFDC/NJCPW/NJ KidCare A, which is to be reported
for each of the Northern, Central and Southern regions (Table 19
Parts A-C). Each report must
provide total dollar amounts and PMPM amounts. Cells shaded are not to be filled out.



The non-State Plan services (see: Supplemental Benefits, Article 4.1.8 of the contract) report
(Part T) has been created to provide information on benefits/services reported within Table 19,
Parts A-S2 in excess of the State Plan. All medical and administrative expenses must be reported
using actual incurred and paid data for the requested period. Unit cost expenses for the non-State
Plan services must also be provided. An example of non-State Plan approved medical expenses would
be enhanced eyeglass allowance and over-the-counter drugs for adults.



All medical and administrative expenses within the MCSA reports (Parts
U – V) must be reported using paid - data for-the current period of the
calendar year.




Member Months



A member month is equivalent to the one member for whom the Contractor has recognized
capitation-based revenue for the entire month. Where the revenue is recognized for only part of a
month for a given individual, a partial, pro-rated member month shall be counted. A partial member
month is pro-rated based on the actual number of days in a particular month. The member months
shall be reported on a cumulative basis by the rate cell grouping as shown on the report. Enter
the number of member months for the current period in the second column of the Member Months line
and the member months for the year-to-date in the fourth column.



The Maternity Income Statement, Part R1, shall list number of deliveries, rather than member
months.



Newborn member months will be reported within Part R2 and are not to be included with Part S2. It
is expected that there shall be approximately 2.5 member months reported for each delivery as the
newborn time period is on average 75 days. Any variation from 2.5 member months may suggest a
reporting inconsistency. For counting newborn member months, it is appropriate to group by age (in
months) and then sum the first 2 months. As defined in the previous section, age should be
determined by counting the




			
	 	 	 
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child’s age as of their last birthday, on the first of the month in which the claim was
incurred. The following example illustrates the formula for determining a child’s age in months:



Example: Date of birth = January 15



Age
on January 1st - 0 months (count of 17/31 is 0 month age)

Age on February 1st - 0 months (an additional count of 1 goes into 0 month age)

Age on March 1st - 1 month (count of 1 for 1 month age)

Age on April 1st - 2 months (count of 1 placed in 2 month age)

Sum = Newborn Member Months (through example expect to have average 2.5
newborn member months per delivery)




			
	 	 	 
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This is consistent with the logic that DMAHS uses when making a capitation payment. If it is
easier for the Contractor to count in whole numbers in the 0 month age cell (replace the pro-rated
17/31 with a count of 1). If this logic is utilized, the Contractor must note the counting
methodology.



Revenue




Line 1 — Capitated Premiums—Revenue recognized on a prepaid basis for enrollees for provision
of a specified range of health services over a defined period of time, generally one month. If
advance payments are made to the Contractor, for more than one reporting period, the portion of
the payment that has not been earned must be treated as a liability (Unearned Premiums). Refer to
Part S3 for reconciliations.



Line 2 — Supplemental Premiums—Revenue paid to the Contractor in addition to capitated
premiums for certain services provided. See Lines 2a through 2f below.



Line 2a — Maternity1—Supplemental payment per pregnancy outcome. This line item shall
only be included in Part R1 (Maternity) and Part S2 (All Rate Cell Groupings).



Line 2b — Reimbursable HIV/AIDS Drugs and Blood Products—Supplemental payment for HIV/AIDS Drugs
(protease inhibitors and, effective 7/1/01 other anti-retrovirals) and clotting factor VIII and
IX blood products.



Line 2c — Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Incentive
Payment—Supplemental payment for EPSDT services.



Line 2d—Reimbursable Medical and Hospital—Supplemental-payment-for- medical and hospital expenses
for FamilyCare Adults 0—100 percent of FPL, Health Access
individuals without-dependent children,
and Adult-Restricted Aliens (excluding pregnant women) populations who are under a MCSA program.
This revenue shall only bo included in Part U (FamilyCare Adults 0—100 percent of FPL) and Part V
(Adult Restricted Aliens), and is not-be-included in Part S2 (All Rate Cell Groupings).



Line-2e—Managed Care Service Administrator Premium—Supplemental-payment for administrative expenses
for FamilyCare Adults 0—100 percent of FPL, Health Access individuals without dependent children,
and Adult Restricted Aliens (excluding pregnant women) populations who are under a-MCSA program.
This revenue shall only be





 




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





			
	 	 	 
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included
in Part U (FamilyCare Adults 0—100 percent of FPL), and Part V (Adult
Restricted Aliens), and is not be included in Part S2 (All Rate
Cell Groupings).



Line 2fd — Other—Any other revenue paid by DMAHS to the Contractor in addition to capitation for
covered services that is not included in Lines 2a, 2b, 2c, 2d, or 2e above.



Line 3 — Total Premiums—All Medicaid/NJ FamilyCare premiums paid to the Contractor reported on
lines 1, 2a, 2b, 2c, 2d, 2e, and 2f. A detailed reconciliation of total premiums received and
reported on the Income Statement in Part S2 shall be included on Table 19, Part S3. Information
about any differences shall be explained in a note to the reports.



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



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



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



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



Line 8 — Total Revenue — Total revenue (the sum of lines 3 through 7).



Expenses



Medical and Hospital




Line 9 — Inpatient Hospital—Code 01—See the Managed Care Category of Service Codes.



Line 10 — Primary Care—Code 10P— See the Managed Care Category of Service Codes



Line 11 — Physician Specialty Services—Code 10S— See the Managed Care Category of Service Codes




Line 12 — Outpatient Hospital (excludes ER)—Code 04N— See the Managed Care Category of
Service Codes.



Line 13 — Other Professional Services—Codes 14, 15S, 17, PAS— See the Managed Care Category of
Service Codes.



			
	 	 	 
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Line 14 — Emergency Room—Code 04E— See the Managed Care Category of Service Codes.



Line 15 — DME/Medical Supplies—Codes 30, 31, 32— See the Managed Care Category of Service
Codes.



Line 16 — Prosthetics and Orthotics—Code 18— See the Managed Care Category of Service Codes.



Line 17 — Covered Dental—Code 11— See the Managed Care Category of Service Codes.



Line 18 — Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products)—Code 20N-
See the Managed Care Category of Service Codes.



Line 19 — Reimbursable HIV/AIDS Drugs and Blood Products—Code 20H— See the Managed Care Category
of Service Codes.



Line 20 — Home Health, Hospice, PDN—Codes 40, 50, PDN— See the Managed Care Category of Service
Codes.



Line 21 — Transportation—Code 70— See the Managed Care Category of Service Codes.



Line 22 — Lab & X-ray—Codes 60, 65— See the Managed Care Category of Service Codes.



Line 23 -Vision Care including Eyeglasses—Codes 09,13— See the Managed Care Category of Service
Codes.



Line 24 — Mental Health/Substance Abuse—Codes MH, SA— See the Managed Care Category of Service
Codes.



Line 25 — Reinsurance Expenses—Expenses for reinsurance or “stop-loss” insurance made to a
contracted reinsurer.



Line 26 — EPSDT Medical & PDN —Codes 08D, EPM— See the Managed Care Category of Service
Codes.



Line 27 — EPSDT Dental —Code EPD— See the Managed Care Category of Service Codes.



Line 28 — Family Planning—Code FP— See the Managed Care Category of Service Codes.



			
	 	 	 
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Line 29 — Other Medical—Code XM— See the Managed Care Category of Service Codes.



Line 30
— Total Medical and Hospital—The total of all medical and
hospital expenses.
(sum of lines
9 through 29)



Administration




Administrative expenses are only required to be reported on designated forms for the MCSA
populations (Parts U and V) and the forms for all rate cell groupings Table 19 (Part S2). Except
for the MCSA rate cell groupings, tThis eliminates the need to allocate these costs across the
remaining rate cell groupings, although the Contractor has the option of reporting this
allocation. As DMAHS has the responsibility for financial risk for medical costs of tho NJ
FamilyCare Adults 0—100 percent of FPL, Health Access individuals without dependent children, and
Adult Restricted Aliens (excluding pregnant women) populations, the administrative expenses for
these populations shall be excluded from Part S2. The
administration expenses for these
populations shall be reported-separately in Parts U—V.Administration must also be reported on
Part T if the Contractor provides any non-State Plan services. Costs associated with the overall
management and operation of the Contractor including the following components:



Line 31 — Compensation—All expenses for administrative services including compensation and fringe
benefits for personnel time devoted to or in direct support of administration. Include expenses for
management contracts. Do not include marketing expenses here.



Line 32 — Occupancy, Depreciation, and Amortization.



Line 33 — Interest expense—Interest paid during the period on loans.



Line 34 — Education/Outreach and Marketing—Expenses incurred for education and outreach activities
for enrollees. Expenses directly related to marketing activities including advertising, printing,
marketing salaries and fringe benefits, commissions, broker fees, travel, occupancy, and other
expenses allocated to the marketing activity.



Line 35 — Sanctions—Expenses related to events where DMAHS finds the contractor to be out of
compliance with the program standards, performance standards, or the terms and conditions of the
Medicaid managed care contract.



Line 36 — Corporate Overhead Allocations—All expenses for management fees, and other allocations of
corporate expenses. Methodologies for allocated expenses may include PMPM, percent of revenue,
percent of head counts and/or full-time equivalents (FTE), etc. Include an explanation of the
expenses included and the basis of methodology in the notes to the financial reports.



			
	 	 	 
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Line 37 — Subcontracted/Delegated Administrative Services—Administrative portion of
delegated administrative expenses such as Pharmacy Benefits Manager (PBM) or Third Party
Administrators (TPA) payments that cover costs such as claims processing and medical management of
the PBM/TPA. An example of TPA expenses includes dental subcontractors and delegated case
management administrative expenses.



Line 38 — Other Costs which are not appropriately assigned to the health plan
administration categories defined in lines 31 to 37 above.



Line 39 — Total Administration—The total of costs of administration (the sum of lines 31 through
38).



Line 40
— Total Expenses—The sum of Total Medical and Hospital Expenses (line 30) and Total
Administration (line 39).



Line 41 — Operation Income (Loss)—Excess or deficiency of Total Revenue (line 8) minus Total
Expenses (line 40).



Line 42 — Extraordinary Item—A non-recurring gain or loss.



Line 43 — Provision for State, Federal, and Other Governmental Income Taxes—All income taxes
for the period.



Line 44 — Other than Income Taxes—Expenses other than state or federal income taxes (i.e. State
assessments irrespective of profit position).



Line 45 — Adjustment for prior period IBNR estimates—Shall include a
reconciliationreconciliation within Part S3, an explanation of prior period IBNR estimates,
and a detailed calculation within Table 20, Parts A through D. A contra-expense would be
reported if IBNR estimates exceeded actual expenses.



			
	 	 	 
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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 for 12 Month Ending	 	Example using
	 	 	06/30/20xx Reporting Period	 	Dollars
	Claims paid in the period

	 	Claims paid in 12 Month ending

06/30/20xx
	 	$	48,000,000	 
	 
	+ IBNR at the end of the period

	 	+ IBNR as of 06/30/20xx
	 	+ $	11,000,000
	 
	 
	- IBNR at the end of the prior period

	 	-IBNR as of 03/31/20xx
	 	- $	9,000,000
	 
	 
	+ Subcapitation Payments, Pharmacy
Rebates, Settlements at the end of
the period

	 	+ Subcapitation Payments,
Pharmacy Rebates, Settlements as
of 06/30/20xx
	 	+ $	500,000

	 
	- Subcapitation Payments, Pharmacy
Rebates, Settlements at the end of
the prior period

	 	- Subcapitation Payments,
Pharmacy Rebates, Settlements as
of 03/31/20xx
	 	- $	450,000	 
	 
	Claims incurred in the period

	 	Claims incurred in 12 Month

ending 06/30/20xx
	 	$	50,050,000	 






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






In the example, claims incurred in the 12 month ending 06/30/20xx are $50.45 million. This is
the amount that would be shown on Report
#2S19S2 line 30; the Statewide Total Hospital and Medical
Expense for the 3-12 months ended 06/30/20xx. The negative $0.4 million would be reported on line
45 Adjustment for prior period IBNR estimates. This is the effect of the estimation error for the
prior year-end IBNR. Such estimation errors are to be expected, since the actual amount of unpaid
claims will never exactly match the estimate made earlier.



The sum of the amounts on lines 30 and 45 shall be consistent with the statutory accounting amount
of claims recognized as incurred in the period, $50 million in the example above. Any non-claim
adjustments for prior periods which are not to be grouped into Line 45, but in line 46, and shall
be explained in a note to the reports. A detailed reconciliation of prior period IBNR shall be
included on Table 19, Part S3.



Line 46 — Non-claim adjustments for prior periods.



Line 47
— Net Income (Loss)—Operation Income (Loss) (line 41) minus
Lines 42, 43, 44, 45, and 46.



			
	 	 	 
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Table 21: Maternity Outcome Counts

Submission Due at Each Quarter End




This report provides counts of second and third trimester maternity outcomes2 for the
current period and year-to-date. Please refer to the report specifications of Table 19: Income
Statement by Rate Cell Grouping in the member month section regarding newborn member months
relative to this report.



The Contractor will provide counts for the following:





	§	 	Live births






	 	–	 	Cesarean Section deliveries
	 
	 	–	 	Vaginal deliveries






	§	 	Non-live births





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



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

	 	Statewide






Multiple births should be counted as one maternity outcome.





 




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





			
	 	 	 
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Table 4:
Claims Processing Lag Report (Parts A & B)
Submission
Due at Each Quarter End



This report is meant to provide a detailed summary of manual and electronic submitted claims
that were processed during the quarter.



Table 4A




Use Table
4A, to report manually submitted claims that were processed during the quarterly
period. Claims submitted and processed electronically must be reported separately on Table 4B.
Manual claims submission shall be processed within 40 days of receipt. Report amounts for each
consolidated category of service and total listed in Column 1 in the following columns:



Column 2 — Non-Processed Claims from Prior Quarters — Enter the number of
manually
submitted claims on-hand that were unprocessed as of the closing date of the last
quarterly period. The number shall be the same as was reported in Column 16 of the
prior quarterly report.



Column 3 — Claims Received During Quarter—Enter the amount of all manually submitted
claims that were received during the quarterly period being reported.



Column 4 — Total Claims — Enter the sum of Columns 2 and 3.




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





Column 6 — 01-40 Days — Enter the number of manually submitted claims that were processed (either
paid or denied) within 40 days of their receipt. Note: The number of days required to process a
claim is calculated by comparing the date the claim was received by the contractor to the date the
claim was paid or denied by the contractor (See Article 7.16.5 of the contract for further
detail).



Column 7 — Percent of Total — Enter the percentage of manually submitted claims processed within
40 days (Compared to total claims processed. Divide Column 6 by Column 5 to arrive at percent.)



Column 8 — 41-60 Days — Enter the number of manually submitted claims that were processed (either
paid or denied) between 41-60 days of their receipt.



Column 9 — Percent of Total — Enter the percentage of manually submitted claims processed between
41-60 days (Compared to total claims processed. Divide Column 8 by Column 5 to arrive at percent.)



			
	 	 	 
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Column 10 — 61-90 Days — Enter the number of manually submitted claims that were processed
(either paid or denied) between 61-90 days of their receipt.



Column 11 — Percent of Total — Enter the percentage of manually submitted claims processed
between 61-90 days (Compared to total claims processed. Divide Column 10 by Column 5 to arrive at
percent.).



Column 12—91—120 Days — Enter the number of manually submitted claims that were processed (either
paid or denied) between 91-120 days of their receipt.



Column 13 — Percent of Total — Enter the percentage of manually submitted claims processed between
91-120 days of their receipt (Compared to total claims processed. Divide Column 12 by Column 5 to
arrive at percent.)



Column 14 — >120 Days — Enter the number of manually submitted claims that were processed
(either paid or denied) after 120 days of their receipt.



Column 15 — Percent of Total — Enter the percentage of manually submitted claims processed after
120 days (Compared to total claims processed. Divide Column 14 by Column 5 to arrive at percent.)



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



Column 17 — Percent of Claims Not Processed at End of Quarter — Divide Column 16 by Column 4 to
arrive at percent.



Table 4B




Use Table
4B to report electronically submitted claims that were processed during the
quarterly period. Claims submitted and processed manually must be reported separately on Table 4A.
Electronic claims submission shall be processed within 30 days of receipt. Report amounts for each
consolidated category of service and total listed in Column 1 in the following columns:



Column 2 — Non-Processed Claims from Prior Quarters — Enter the number of electronically submitted
claims on-hand that were unprocessed as of the closing date of the last quarterly period. The
number should be the same as was reported in Column 16 of the prior quarterly report.



Column 3 — Claims Received During Quarter— Enter the amount of all electronically submitted claims
that were received during the quarterly period being reported.



			
	 	 	 
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Column 4 — Total Claims — Enter the sum of Columns 2 and 3.



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



Column 6 — 01-30 Days — Enter the number of electronically submitted claims that were processed
(either paid or denied) within 40 days of their receipt. Note: The number of days required to
process a claim is calculated by comparing the date the claim was received by the contractor to
the date the claim was paid or denied by the contractor (See Article 7.16.5 of the contract for
further detail).



Column 7 — Percent of Total — Enter the percentage of electronically submitted claims processed
within 40 days (Compared to total claims processed. Divide Column 6 by Column 5 to arrive at
percent.)



Column 8 — 31-60 Days — Enter the number of electronically submitted claims that were processed
(either paid or denied) between 41-60 days of their receipt.



Column 9 — Percent of Total — Enter the percentage of electronically submitted claims processed
between 41-60 days (Compared to total claims processed. Divide Column 8 by Column 5 to arrive at
percent.)



Column 10 — 61-90 Days — Enter the number of electronically submitted claims that were
processed (either paid or denied) between 61-90 days of their receipt.



Column 11 — Percent of Total — Enter the percentage of electronically submitted claims processed
between 61-90 days (Compared to total claims processed. Divide Column 10 by Column 5 to arrive at
percent.)



Column
12—91-120 Days — Enter the number of electronically submitted claims that were
processed (either paid or denied) between 91-120 days of their receipt.



Column 13 — Percent of Total — Enter the percentage of electronically submitted claims processed
between 91-120 days of their receipt (Compared to total claims processed. Divide Column 12 by
Column 5 to arrive at percent.)



Column 14 — >120 Days — Enter the number of electronically submitted claims that were
processed (either paid or denied) after 120 days of their receipt.



Column 15 — Percent of Total — Enter the percentage of electronically submitted claims processed
after 120 days (Compared to total claims processed. Divide Column 14 by Column 5 to arrive at
percent.)



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



Column 17 — Percent of Claims Not Processed at End of Quarter— Divide Column 16 by Column 4 to
arrive at percent.



			
	 	 	 
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Table 7: Stop Loss Summary (Parts A — C)

Submission Due at Each Quarter End




The contractor shall identify reinsurance coverage in effect during the calendar year for
the reporting period ending December 31 of each year. For each of the designated eligibility
categories, the contractor shall report the total number of enrollees that exceeded the stop-loss
threshold and the total net expenditures exceeding the stop-loss threshold during the period.



			
	 	 	 
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Table 10: Third Party Liability and Fraud/Abuse Collections

Submission Due at Each Quarter End




The Contractor shall report quarterly the categories of all third party liability
collections and shall include the amounts and nature of all third party payments recovered for
Medicaid/ NJ FamilyCare enrollees, including but not limited to, payments for services and
conditions which are:




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





The Contractor shall report quarterly all fraud and abuse collections recovered through the
Contractor’s Fraud and Abuse (FA) unit for Medicaid/NJ FamilyCare enrollees. The contractor shall
report the elimination of provider contracts that resulted from the FA unit investigations.



The Contractor shall note if third party liability collections and fraud and abuse
collections are reflected as income or negative claims within Tables 19 and 20.



			
	 	 	 
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Table 11: Utilization and Unit Cost Information (Parts A — B)

Annual Submission Due at September 30 Quarter End




The Contractor shall submit on an annual basis a detailed summary of utilization and unit
cost information during the year.



Cost & Utilization by AFDC Rate Cell Grouping




The Contractor shall complete the Excel template labeled “11 A” providing a year-over-year
comparison of the current and preceding state fiscal year incurred claims experience. This
information will be provided on the first fiscal quarter
endingthe annual supplemental reports
(September 30). The information shall include all data with incurred dates through the previous
and most recent state fiscal year, with paid data through September 30 (incurred in 12 months,
paid in 27 months for previous state fiscal year, and 15 months for recent state fiscal year.)
Besides quarter ending September 30, this information is not required for any other quarter ending
time periods. Data must reconcile to the consolidated financial submissions.



Cost & Utilization by FamilyCare Rate Cell Grouping




The Contractor shall complete the Excel template labeled “11B” providing a year-over-year
comparison of the current and preceding state fiscal year incurred claims experience. This
information will be provided on the first fiscal quarter
endingannual supplemental reports
(September 30). The information shall include all data with incurred dates through the previous
and most recent state fiscal year, with paid data through September 30 (incurred in 12 months,
paid in 27 months for previous state fiscal year, and 15 months for recent state fiscal year.) .
Besides quarter ending September 30, this information is not required for any other quarter ending
time periods. Data must reconcile to the consolidated financial submissions.



Definitions of key utilization measures are provided in Appendix B.



			
	 	 	 
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Table 14: Supplemental Data (Parts A—C)

Annual Submission Due at September 30 Quarter End




The Contractor shall submit on the fiscal quarter year ending reports (September 30) a
detailed summary of administrative and claims expense information during the year. Besides quarter
ending September 30, this information is not required for any other quarter ending time periods.



Documentation




The Contractor shall provide with Table 14 a chart of general ledger expense accounts and a
crosswalk mapping of these accounts to the reporting manual’s rate cell grouping costs. Detail
shall include the following:




	§	 	account name,






	§	 	account description,






	§	 	SFY-end, total year-ending balance,






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





	§	 	designation between medical and administrative expense account.






The Contractor shall provide all corporate cost allocation schedules and methodologies for
allocated Contractor expenditures and corporate administrative allocations to each line of
business. In addition, the Contractor shall provide all allocation schedules and the methodology
used to allocate administrative expenditures to general ledger accounts that are not directly
chargeable to a specific account. Note: If there are no changes since last year’s submission, the
Contractor shall indicate as such and provide no additional information.



Administrative Contracts and Related Party Charges




The Contractor shall provide a copy of all administrative services contracts and management
agreements (including price page) delegating administrative functions to a third party, including
related or affiliated parties. In addition, the Contractor shall provide all contracts with related
or affiliated parties applicable during any part of SFY-end. Note: If there are no changes since
last year’s submission, the Contractor shall indicate as such
and shall not provide the contracts.
If the Contractor does not wish to send contracts, the Contractor shall provide a detailed list of
such contracts, the total cost, and the amount charged to Medicaid/NJ FamilyCare program for
SFY-end. For each contract the Contractor shall also provide the total cost of the contract and the
amount charged to Medicaid/NJ FamilyCare program for SFY-end. This shall include, but not be
limited to, the following:




	§	 	management service agreements,






	§	 	PBM services agreement,






	§	 	delegated CM/DM agreements,





			
	 	 	 
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	§	 	delegated member/provider services agreements,






	§	 	claims processing agreements,






	§	 	integrated delivery system agreements,






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






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





Member Month and Income Statement Information




The Contractor shall complete and submit the Excel template labeled “Table 14A-Member Months &
Income Statement”.



Administrative Cost Detail




Table 14B
is broken out by the various administrative expense components from
Table 19.
DMAHS recognizes that certain administrative expenses may be under a combination of departmental
functions and, consequently, requests that each expense component is broken out to its specific
administrative cost category (department) to replicate that which was reported for the SFY-end,
Table 19. The Contractor shall reconcile the amount reported per the SFY-end, Table 19, with the
information being submitted in Table 14B.




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





In
addition, the Contractor shall provide written explanations of any difference between the total
administrative expense from Table 19, and the data entered into Table 14B.



Capitation Arrangements




Depending on the arrangement with providers, a Contractor shall include either the entire portion
of the capitation payment in a medical expense line, or it will break out a portion of the
capitation amount and report that in an administrative expense line. Examples of services that may
be capitated have been provided. However, if there are other capitated services, the Contractor
shall include these services on the worksheet. Based upon the above information, the Contractor
shall complete Table 14C for each service that the Contractor contracts with providers on a
capitated basis.



			
	 	 	 
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Equipment and Systems




The Contractor shall provide a list of nonrecurring equipment and system upgrades during SFY-end
and the amount charged in the SFY-end Table 19, and Medicaid/NJ FamilyCare program.



Non-Pharmacy Claim Processing




The Contractor shall provide the following information as it relates to the administration of the
Medicaid/NJ FamilyCare program:



§ If the Contractor outsources any portion of its non-pharmacy claims processing?





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





			
	 	 	 
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Appendix A




IBNR Methodology




IBNRs are difficult to estimate because the quantity of service and exact service cost are
not always known until claims are actually received. Since medical claims are the major expenses
incurred by the Contractors, it is extremely important to accurately identify costs for outstanding
unbilled services. To accomplish this, a reliable claims system and a logical IBNR methodology are
required.



Selection of the most appropriate system for estimating IBNR claims expense requires judgment based
on a Contractor’s own circumstances, characteristics, and the availability and reliability of
various data sources. A primary estimation methodology along with supplementary analysis usually
produces the most accurate IBNR estimates. Other common elements needed for successful IBNR systems
are:




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






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





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



Accurate, complete, and timely claims data shall be monitored, collected, compiled, and evaluated
as early as possible. Whenever practical, claims data collection and analysis shall begin before
the service is provided (i.e., prior authorization records). This prospective claims data,
together with claims data collected as the services are provided, shall be used to identify claims
liabilities. Claims data shall also be segregated to permit analysis by major rate code,
region/county, and consolidated category of service.



Subcontractor agreements shall clearly state each party’s responsibility for claims/encounter
submission, prior notification, authorization, and reimbursement rates. These agreements shall
be in writing, clearly understood and followed consistently by each party.



The individual IBNR amounts, once established, shall be monitored for adequacy and adjusted as
needed. If IBNR estimates are subsequently found to be significantly inaccurate, analysis shall be
performed to determine the reasons for the inaccuracy. Such an analysis shall be used to refine a
Contractor’s IBNR methodology if applicable.



There are several different methods that can be used to determine the amount of IBNRs. The
Contractor shall employ the one that best meets its needs and accurately estimates its IBNRs. If a
Contractor is utilizing a method different from the methods included herein, a detailed description
of the process must be submitted to DMAHS for approval. This process may be described in the “Notes
to Financial Reports” section. The IBNR methodology used by the Contractor must be evaluated by the
Contractor’s independent accountant or actuary for reasonableness.



Case Basis Method




Accruals are based on estimates of individual claims and/or episodes. This method is
generally used for those types of claims where the amount of the cost will be large, requiring
prior authorization. The final estimated cost could be made after the services have been authorized
by the Contractor. For example, if a Contractor knows how many hospital days were authorized for a
certain time period, and can incorporate the contracted reimbursement arrangement(s) with the
hospital(s), a reasonable estimate should be attainable. This is also the most common and can be the
most accurate method for small and medium sized organizations.



			
	 	 	 
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Average Cost Method




As the name suggests, average costs of services are used to estimate total expense. Two
primary average cost methods are discussed below. It is important to note that each method may be
used by a Contractor to estimate different categories of IBNRs (i.e., hospitalization vs. other
medical). Also, either method may be utilized in conjunction with other IBNR methodologies
discussed in this document.



PMPM Averages




Under this method the average costs are based on the population of each rate code (or group
of homogenous rate codes) over a given time period, in this case one month. The average cost may
cover one or more service categories and is multiplied by the number of members in the specific
population to estimate the total expense of the service category. Any claims paid are subtracted
from the expense estimate that results in the IBNR liability estimate for that service category.



Per Diem or Per Service Averages




Averages for this method are of specific occurrences known by the Contractor at the time of
the estimation. Therefore, it is first necessary to know how many hospital days, procedures or
visits were authorized as of the date for which the IBNR is being estimated. Again, once the total
expense has been estimated, the amount of related paid claims shall be subtracted to get the IBNR
liability. This method is primarily used for hospitalization IBNRs as Contractors know the amount
of hospital days authorized at any given time.



Lag Tables




Lag tables are used to track historical payment patterns. When a sufficient history exists
and a regular claims submission pattern has been established, this methodology can be employed. All
Contractors shall use lag information as a validation test for accruals calculated using other
methods, if it is not the primary methodology employed. Typically, the information on the schedules
is organized according to the month claims are incurred on the horizontal axis and the month claims
are paid by the Contractor on the vertical axis.



			
	 	 	 
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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.



			
	 	 	 
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Appendix B




Key Utilization Definitions

The definitions of key utilization measures are provided below.




	 	 	 	 	 	 	 
	 	 	 	 	TYPE OF	 	 
	CATEGORY OF	 	 	 	UTILIZATION/	 	 
	SERVICE MEASURE	 	MEASURE	 	PROXY FOR	 	DEFINITIONS
	 
	Inpatient Hospital

	 	Inpatient Hospital Days
	 	Quantity/Days
	 	Days are calculated
as follows:
	 
	 

	 	 	 	 	 	Number of days
between Admit and
Discharge date
(Exclude admit and
denied days.
Include discharge
day). If dates are
equal, inpatient
day is counted as
one (1).
	 
	 	 	 	 	 	 
	 

	 	 	 	 	 	Days counted should
be all paid days of
service, regardless
of year, for each
discharge that
occurred in the
year. If the
admission and
discharge do not
occur in the same
year, all days are
counted as
occurring in the
year in which the
discharge occurs.
	 
	 	 	 	 	 	 
	 

	 	 	 	 	 	Include data for
which you are both
the primary payor
and the secondary
payor.






			
	 	 	 
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	 	 	 	 	TYPE OF	 	 
	CATEGORY OF	 	 	 	UTILIZATION/	 	 
	SERVICE MEASURE	 	MEASURE	 	PROXY FOR	 	DEFINITIONS
	 
	Primary Care Services

	 	Primary Care Visits
	 	Quantity/Services
	 	A visit is defined
as one or more
professional
contacts between a
patient and unique
service provider on
a unique date of
service.
	 
	 	 	 	 	 	 
	Physician Specialty Services

	 	Physician Specialty Visits
	 	Quantity/Services
	 	A visit is defined
as one or more
professional
contacts between a
patient and a
unique service
provider on a
unique date of
service.
	 
	 	 	 	 	 	 
	Emergency Room

	 	Emergency Room Visits
	 	Quantity/Services
	 	This measure
summarizes
utilization of
Emergency
Department Visits
and Observation
Room Stays that
result in
discharge.
Observation and/or
Emergency Room
Stays resulting in
an inpatient
admission should
not be counted on
this report.
	 
	 	 	 	 	 	 
	 

	 	 	 	 	 	Each visit to an
Emergency
Department that
does not result in
an admission should
be counted once,
regardless of the
intensity of care
required during the
stay or the length
of stay. Patients
admitted to the
hospital from the
Emergency
Department should
not be included in
counts of visits.
Visits to urgent
care centers should
be counted.
	 
	 	 	 	 	 	 
	Dental

	 	Dental Visits
	 	Claim Count/Visits
	 	A visit is defined
as one or more
professional
contacts between a
patient and a
unique service
provider on a
unique date of
service.






			
	 	 	 
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	 	 	 	 	TYPE OF	 	 
	CATEGORY OF	 	 	 	UTILIZATION/	 	 
	SERVICE MEASURE	 	MEASURE	 	PROXY FOR	 	DEFINITIONS
	 
	Pharmacy

	 	Prescriptions
	 	Claim 

Count/Prescriptions
	 	A prescription is
defined as one fill
of a prescription
that is filled by a
pharmacist based on
the written order
to supply a
particular
medication for a
specific patient
with instructions
for its use.
	 
	 	 	 	 	 	 
	Outpatient Facility

	 	Outpatient Facility Visits
	 	Quantity/Services
	 	A visit is defined
as one or more
professional
contacts between a
patient and a
unique service
provider on a
unique date of
service.
	 
	 	 	 	 	 	 
	 

	 	 	 	 	 	The visit can be to
a free standing or
a hospital
outpatient
department.
	 
	 	 	 	 	 	 
	DME/Medical Supplies &

Orthotics/Prosthetics

	 	DME/Medical Supplies &

Orthotics/Prosthetics

Units
	 	Claim Count/Claims
	 	A unit is counted
as one for each
unique claim.
	 
	 	 	 	 	 	 
	Home Health Care

	 	Home Health Care Services
	 	Quantity/Services
	 	A service is
defined as one or
more professional
contacts between a
patient and a
unique service
provider on a
unique date of
service.
	 
	 	 	 	 	 	 
	Laboratory & Radiology

	 	Laboratory & Radiology

Units
	 	Claim Count/Claims
	 	A unit is counted
as one for each
unique claim.
	 
	 	 	 	 	 	 
	Transportation

	 	Transportation Units
	 	Claim 
Count/Transports
	 	A unit is counted
as one for each
unique claim. 



Round
trip transportation
is considered one
unit.
	 
	 	 	 	 	 	 
	All Other Practitioners and
Services

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






			
	 	 	 
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Appendix C



Managed Care Category of Service Codes




The definitions of managed care category of service codes are defined in a matrix in the
contract.




			
	 	 	 
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Appendix D



Report Forms



12-Month Period End Reports Due Each Quarter




This section includes copies of the forms to be completed electronically by the
Contractor for each quarter end.




	§ 	 	Certification Statement at Each Quarter End






	§ 	 	Table 4: Claims Processing Lag Report






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






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






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





			
	 	 	 
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	 	–	 	Part T: Non-State Plan Services






	§ 	 	Table 20: Lag Report






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


	 
	 	–	 	

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




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




Annual Supplemental Reports Due



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





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






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






	§ 	 	Table 20: Lag Report






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





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






	§	 	General Ledger for period ending June 30 Excluding MCSA Populations 



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





			
	 	 	 
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Appendix E



Certification Statement at Each Quarter End




The Certification Statement is located on the following pages.



The Certification Statement shall be submitted quarterly to David Moran, the Director,
HMO Financial Reporting, on the same due dates as required in the General Instructions.




Certification Statement — Annual Reports




The Certification Statement is located on the following pages.



A Certification Statement shall be submitted annually to David Moran, the Director, HMO
Financial Reporting, -on the same due dates as required in the General Instructions.




			
	 	 	 
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CERTIFICATION STATEMENT AT EACH QUARTER END




OF




 





(Contractor Name)




TO THE




NEW JERSEY DEPARTMENT OF HUMAN SERVICES 

DIVISION OF MEDICAL ASSISTANCE AND
HEALTH SERVICES




FOR THE PERIOD ENDED




 






(Month/Day/Year)




	 	 	 
	Name of Preparer
	 	 
	 

	 	 
	 
	 	 
	Title
	 	 
	 

	 	 
	 
	 	 
	Phone Number
	 	 
	 

	 	 




Please check which tables are included with this packet:




	 	 	 	 	 
	0 Table 4

	 	0 Table 19A-R, S2, S31
	 	0 Notes
0 Table 20
	0 Table 7

	 	0 Table 20 A-DE14
	 	0 Table 21 
	0 Table 10

	 	0 Table 2119
	 	 






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



	 	 	 	 	 
	 

	 	 
	 	 
	Date

	 	Chief Financial Officer
	 	Signature






			
	 	 	 
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	Contractor Financial Reporting Manual
	 	State of New Jersey






CERTIFICATION STATEMENT AT EACH SEPTEMBER 30 QUARTER END




OF





 






(Contractor Name)




TO THE




NEW JERSEY DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES




FOR THE PERIOD ENDED




 






(Month/Day/Year)




	 	 	 
	Name of Preparer
	 	 
	 

	 	 
	 
	 	 
	Title
	 	 
	 

	 	 
	 
	 	 
	Phone Number
	 	 
	 

	 	 





Please check which tables are included with this packet:




	 	 	 	 	 
	0 Table 11 A

	 	0 Table 14 B
	 	0 Table 20 A-DE
	0 Table 11 B

	 	0 Table 14 C
	 	0 GL at 06/30
	0 Table 14 A

	 	0 Table 19A-R, S3
	 	0 Notes





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




			
	 	 	 
	Date Effective: July 1, 20076
	 	49







 









 








			
	 	 	 
	Contractor Financial Reporting Manual
	 	State of New Jersey






	 	 	 	 	 
	Date

	 	Chief Financial Officer
	 	Signature






			
	 	 	 
	Date Effective: July 1, 20076
	 	50







 









 








			
	 	 	 
	Contractor Financial Reporting Manual
	 	State of New Jersey






NOTES TO FINANCIAL REPORTS



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




			
	 	 	 
	Date Effective: July 1, 20076
	 	51







 









 












 









 













 









 













 









 













 









 













 









 













 









 













 









 














 










 












 









 














 









 













 









 








FOR MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #19 — Part S3 — Income Statement by Rate
Cell Grouping



Reconciliations




	 	 	 	 	 	 	 	 	 
	FOR THE SFY ENDING 6-30-07

	 	 	 	 	 	FOR	 	 
	 

	 	 
	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	(HMO Name)






Revenue Reconciliation




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








 




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




 









 










FOR MEDICAID/NJ FAMILYCARE
 MANAGED

CARE REPORTING ONLY




Table #19 — Part S3 — Income Statement by Rate Cell Grouping



Reconciliations




	 	 	 	 	 	 	 	 	 
	FOR THE SFY ENDING 6-30-07

	 	 	 	 	 	FOR	 	 
	 

	 	 
	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	(HMO Name)






Lag Triangle and Income Statement Reconciliation for Twelve Month End




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









 




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




 









 










FOR MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #19 — Part S3 — Income Statement by Rate Cell Grouping



Reconciliations




	 	 	 	 	 	 	 	 	 
	FOR THE SFY ENDING 6-30-07

	 	 	 	 	 	FOR	 	 
	 

	 	 
	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	(HMO Name)






Prior
Period IBNR Reconciliation for Twelve Month End




	 	 	 	 	 
	 	 	Incurred in Twelve Months Prior to
	1 Claims Paid in Most Recent Twelve Month End
	 	$	—	 
	2 +
IBNR as of Most Recent Twelve Months 
(line 43 of #2A-D lag triangles)
	 	$	—	 
	3 - IBNR as of Prior Twelve Month End
	 	$	—	 
	4 +
Subcapitation Payments, Pharmacy Rebates, Settlements as of Most
Recent. Twelve Months

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








 




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




 









 

















 









 















 









 














 









 













 









 








FOR
MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #11A — Cost & Utilization by AFDC Rate Cell Grouping



For
Inpatient Hospital, Primary Care Services, Physician Specialty Services, Emergency Room,
Dental, Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products), Outpatient
Facility, D Supplies, Home Health Care, Laboratory and Radiology, Transportation, and All Other
Practitioners & Services




	 	 	 	 	 	 	 	 	 
	 

	 	FOR THE STATE FISCAL-ENDING AT 09/30:	 	 	 	 	 	 
	 

	 	 	 	 
	 	 	 	 
	 

	 	 	 	 	 	 	 	(HMO Name)






 









 






FOR
MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #11A — Cost & Utilization by AFDC Rate Cell Grouping



For Inpatisnt Hospital, Primary Care Services, Physician Specialty Services, Emergency Room,
Dental, Pharmacy (not to include Reimbursable HIV/AIDS Drugs and Blood Products), Outpatient
Facility, D Supplies, Home Health Care, Laboratory and Radiology, Transportation, and All Other
Practitioners & Services




	 	 	 	 	 	 	 	 	 
	 
	 	FOR THE STATE FISCAL-ENDING AT 09/30:	 	 	 	 	 	 
	 

	 	 	 	 
	 	 	 	 
	 

	 	 	 	 	 	 	 	(HMO Name)






Notes:




				
	1.
	This will be used for AFDC allocation in capitation rates.

	2.
	COS from Financials

	 	COS from this Submission
	 	Inpatient Hospital

	 	Inpatient Hospital
	 	Primary Care

	 	Primary Care Services
	 	Physician Specialty Services

	 	Physician Specialty Services
	 	Outpatient Hospital

	 	Outpatient Facility
	 	Other Professional Services

	 	All Other Practitioners and Services
	 	Emergency Room

	 	Emergency Room
	 	DME/Medical Supplies

	 	DME/Medical Supplies & Orthotics/Prosthetics
	 	Prosthetics & Orthotics

	 	DME/Medical Supplies & Orthotics/Prosthetics
	 	Dental

	 	Dental
	 	Pharmacy

	 	Pharmacy
	 	Home Health Care

	 	Home Health Care
	 	Transportation

	 	Transportation
	 	Lab & X-ray

	 	Laboratory & Radiology
	 	Vision Care

	 	All Other Practitioners and Services
	 	Menial Health/Substance Abuse

	 	All Other Practitioners and Services
	 	Other Medical

	 	All Other Practitioners and Services







 









 










 









 










 









 






FOR MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table
#11B- Cost — Utilization by FamilyCare Parents Rate Cell Grouping



For Inpatient Hospital, Primary Can Services, Physician Specialty Services, Emergency Room,
Dental, Pharmacy (not to Include Reimbursable HIV/AIDS Drugs and Blood Products), Outpatient
Facility, DME/Medical Supplies, Home Health Care, Laboratory and Radiology, Transportation, and
All Other Practitioners & Services




	 	 	 	 	 	 
	FOR
THE STATE FISCAL-ENDING AT 09/30:
	 	 	 	 	 
	 

	 	 
	 	 	 
	 

	 	 	 	 	(HMO Name)







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






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






Reconciliations
to Table 19 A - C




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






Notes:




					
	1.	 	This will be used for FamilyCare Parents allocation In capitation rates.
	2.

	 	COS from Financials
	 	COS from this Submission
	 

	 	Inpatient Hospital
	 	Inpatient Hospital
	 

	 	Primary Care
	 	Primary Care Services
	 

	 	Physician Specialty Services
	 	Physician Specialty Services
	 

	 	Outpatient Hospital
	 	Outpatient Facility
	 

	 	Other Professional Services
	 	All Other Practitioners and Services
	 

	 	Emergency Room
	 	Emergency Room
	 

	 	DME/Medical Supplies
	 	DME/Medical Supplies & Orthotics/Prosthetics
	 

	 	Prosthetics & Orthotics
	 	DME/Medical Supplies & Orthotics/Prosthetics
	 

	 	Dental
	 	Dental
	 

	 	Pharmacy
	 	Pharmacy
	 

	 	Home Health Care
	 	Home Health Care
	 

	 	Transportation
	 	Transportation
	 

	 	Lab & X-ray
	 	Laboratory & Radiology
	 

	 	Vision Care
	 	All Other Practitioners and Services
	 

	 	Mental Health/Substance Abuse
	 	All Other Practitioners and Services
	 

	 	Other Medical
	 	All Other Practitioners and Services







 









 








FOR MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #14A — Member Months & Income Statement




	 	 	 	 	 	 	 
	FOR THE STATE FISCAL-ENDING AT 09/30:
	 	 	 	 	 	 
	 

	 	 
	 	 	 	 
	 

	 	 	 	(HMO Name)
	 	 






MEMBER MONTHS




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











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






Income Statement by Line of Business




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





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




 









 















 









 







FOR MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table
#14C – Capitation Arrangements

Current State Fiscal Year End




	 	 	 	 	 	 	 
	FOR THE STATE FISCAL-ENDING AT 09/30:
	 	 	 	 	 	 
	 

	 	 
	 	 	 	 
	 

	 	 	 	(HMO Name)
	 	 






CAPITATED SERVICES




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








 




			
	Notes:	 	 
	 
	1.	 	Gray highlighted cells denotes calculation.






 









 








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





 









 








FOR MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY


NOTES TO FINANCIAL REPORTS


	 	 	 	 	 	 	 
	FOR
THE SFY ENDING 6-30-08
	 	 	FOR 	 	 	 
	 

			 	 	 	 
	 

	 	 	 	(HMO Name)
	 	 





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




	 
	Table #11

	– Part A — Cost and Utilization by AFDC Rate Cell Grouping

	– Part B — Cost and Utilization by FamilyCare Parents/Adults Rate Cell Grouping

	 

	Table #14

	– Part A — Member Months and Income Statement

	– Part B — Administrative Cost Detail

	– Part C — Capitation Arrangements

	 

	Table #19

	– Parts A-S2 — Income Statement By Rate Cell Grouping

	 

	Table #20

	– Part A — Lag Report for Inpatient Hospital Payments

	– Part B — Lag Report for Physician Payments

	– Part C — Lag Report for Pharmacy Payments

	– Part D — Lag Report for Other Medical Payments








 









 










 









 













 









 













 









 













 









 















 









 













 









 













 









 













 









 













 









 













 









 













 









 








FOR MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #19 – Part S3 – Income Statement by Rate Cell Grouping



Reconciliations




	 	 	 	 	 	 	 	 	 
	FOR THE TWELVE MONTHS ENDING

	 	 	 	FOR
	 	 	 	 
	 

	 	 
	 	 	 	 	 	 
	 

	 	 	 	 	 	(HMO Name)	 	 






Revenue Reconciliation




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








 




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






 









 





FOR
MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #19 — Part $3 — Income Statement by Rate Cell Grouping




Reconciliations





	 	 	 	 	 	 	 	 	 	 	 
	FOR THE TWELVE MONTHS ENDING

	 	 	 	 	 	FOR	 	 	 	 
	 

	 	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	(HMO Name)	 	 






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








 




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














 










FOR
MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #19 — Part S3 — Income Statement by Rate Cell Grouping




Reconciliations




	 	 	 	 	 	 	 	 	 	 	 
	FOR THE TWELVE MONTHS ENDING

	 	 	 	 	 	FOR	 	 	 	 
	 

	 	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	(HMO Name)	 	 





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








 




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














 










FOR
MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #19 — Part T — Non-State Plan Service Expenses by Rate Cell Grouping




          Non-State
Plan Services1, 2



	 	 	 	 	 	 	 	 	 	 	 
	FOR THE TWELVE MONTHS ENDING

	 	 	 	 	 	FOR	 	 	 	 
	 

	 	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	(HMO Name)	 	 





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








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





Non-State Plan Services Description



1

2

3

4

5

6

7

8

9

10





*if medical and hospital claim
costs exist for non-State Plan
services, then must have some
amount of administration for
non-State Plan services













 





FOR
MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table
#19 — Part T — Non-State Plan Service Expenses by Rate Cell Group




          Non-State
Plan Services1, 2




FOR THE TWELVE MONTHS ENDING
                                       &n
bsp;                    




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








 




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





Non-State Plan Services Description



1

2

3

4

5

6

7

8

9

10





*If medical and hospital claim
costs exist for non-State Plan
services, then must have some
amount of administration for
non-State Plan services













 





FOR
MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #19 — Part T — Non-State Plan Service Expenses by Rate Cell Group




          Non-State
Plan Services1, 2




FOR THE TWELVE MONTHS
ENDING                                      &n
bsp; 




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








 




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





Non-State Plan Services Description



1

2

3

4

5

6

7

8

9

10





*If medical and hospital claim costs exist for non-State Plan services, then
must have some amount of administration for non-state Plan services













 





FOR
MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #19 — Part T — Non-State Plan Service Expenses by Rate Cell Group




          Non-State
Plan
Services1,
2




FOR THE TWELVE MONTHS ENDING
                                       &n
bsp;                    




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








 




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





Non-State Plan Services Description



1

2

3

4

5

6

7

8

9

10





*If medical and hospital claim costs exist for
non-State Plan services, then must have some
amount of administration for non-State Plan
services













 





FOR
MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #19 — Part T — Non-State Plan Service Expenses by Rate Cell Group




          Non-State
Plan Services1, 2




FOR THE TWELVE MONTHS ENDING
                                       &n
bsp;                    




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








 




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





Non-State Plan Services Description



1

2

3

4

5

6

7

8

9

10





*If medical and hospital claim costs exist for
non-State Plan services, then must have some
amount of administration for non-State Plan
services













 





FOR
MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




Table #21 — Maternity Outcome Counts 1





	 	 	 	 	 	 	 
	         FOR THE TWELVE MONTHS ENDING

	 	 	 FOR 	 	 	 
	 

	 	 
	 	 	 	 
	 

	 	 	 	(HMO Name)	 	 






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






 




			
	Notes:
	 
	1 —   Only outcomes on or after the thirteenth week of gestation should be included in this report, excluding elective abortions.

	2 —   It is expected that there shall be approximately 2.5 newborn member months reported for each delivery as the newborn
time period is on average 75 days. Any variation from 2.5 member months may suggest a
reporting inconsistency.
















 










 









 













 









 













 









 








FOR MEDICAID/NJ FAMILYCARE

MANAGED CARE REPORTING ONLY




NOTES TO FINANCIAL REPORTS




	 	 	 	 	 	 	 	 	 	 	 
	FOR THE TWELVE MONTHS ENDING

	 	 	 	 	 	FOR	 	 	 	 
	 

	 	 

	 	 	 	 	 	 

(HMO Name)
	 	 






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






 









 





B.4.11 Special Child Health Services Network



The contractor shall utilize the following DHSS website to access an updated list of Special
Child Health Services County Case Management Units:



http://www.state.nj.us/health/fhs/socasemg.htmsch/sccase.shtml




 









 





SECTION C

CAPITATION RATES




C-1









 





STATE OF NEW JERSEY

FAMILYCARE

SFY08 CAPITATION RATES




			
	 
	 	SFY08 Rates — Version 1.3a

Contract Period: 07/01/07 — 06/30/08






	 	 	 	 	 	 	 	 	 	 	 
	Category	 	Age/Sex	 	Northern	 	Central	 	Southern	 	Statewide
	AFDC / DYFS/ KidCare A / New Jersey Care Children

	 	Newborn	 	 	 	 	 	 	 	 
	AFDC / DYFS / KidCare A / New Jersey Care Children

	 	75 dys - 2yrs M&F	 	 	 	 	 	 	 	 
	AFDC / DYFS / KidCare A / New Jersey Care Children / NJCPW

	 	2 - 20.99 M&F	 	 	 	 	 	 	 	 
	AFDC / NJCPW

	 	 21 - 44.99 Female	 	 	 	 	 	 	 	 
	AFDC

	 	21 - 44.99 Male 	 	 	 	 	 	 	 	 
	AFDC / NJCPW

	 	45 + M&F	 	 	 	 	 	 	 	 
	Aged with Medicare

	 	All	 	 	 	 	 	 	 	 
	Blind/Disabled with Medicare and Other Dual Eligibles

	 	< 45 M&F	 	 	 	 	 	 	 	 
	Blind/Disabled with Medicare and Other Dual Eligibles	 	45+ M&F	 	*****REDACTED*****

	Maternity

	 	All	 	 	 	 	 	 	 	 
	ABD-DDD with Medicare and Other Dual Eligibles

	 	All	 	 	 	 	 	 	 	 
	ABD (including AIDS & DDD) without Medicare1

	 	All	 	 	 	 	 	 	 	 
	Non ABD-DDD

	 	All	 	 	 	 	 	 	 	 
	KidCare B&C

	 	Newborn	 	 	 	 	 	 	 	 
	KidCare B&C

	 	 < 2 M&F	 	 	 	 	 	 	 	 
	KidCare B&C

	 	Youth	 	 	 	 	 	 	 	 
	KidCare D

	 	Newborn	 	 	 	 	 	 	 	 
	KidCare D

	 	 < 2 M&F	 	 	 	 	 	 	 	 
	KidCare D

	 	Youth	 	 	 	 	 	 	 	 
	FamilyCare Parents 0-200% / FamilyCare Adults & Hlth Access / Adult Restricted Aliens

	 	< 45 Female	 	 	 	 	 	 	 	 
	FamilyCare Parents 0-200% / FamilyCare Adults & Hlth Access / Adult Restricted Aliens

	 	< 45 Male	 	 	 	 	 	 	 	 
	FamilyCare Parents 0-200% / FamilyCare Adults & Hlth Access / Adult Restricted Aliens

	 	45+ M&F	 	 	 	 	 	 	 	 
	AIDS-ABD with Medicare and Other Dual Eligibles

	 	All	 	 	 	 	 	 	 	 
	AIDS-Non-ABD

	 	All	 	 	 	 	 	 	 	 
	AIDS-ABD with Medicare and Other Dual Eligibles DDD (incl. Behavioral Health Add-On)

	 	All	 	 	 	 	 	 	 	 
	AIDS-Non-ABD DDD (including Behavioral Health Add-On)

	 	All	 	 	 	 	 	 	 	 






 









 







	 	 	 	 	 
	 
	 		 	 
	

Jon S. Corzine

Governor
	 	State of New Jersey

Department of Human Services 


Division of Medical Assistance and Health Services


P.O. Box 712

Trenton, NJ 08625-0712

Telephone 1-800-356-1561
	 	

Jennifer Velez

Acting Commissioner






	 	 	 	 	 
	 
	 	 
	 	John R. Guhl

Director






May 9, 2007




Peter D. Haytaian

President and CEO

AMERIGROUP New Jersey, Inc.

399 Thornall Street, 9th Floor

Edison, NJ 08837




Dear Mr. Haytaian:



Enclosed is an amendment to the managed care contract. This amendment, which
will become effective on July 1, 2007, will modify language regarding medical
cost ratio. The language change is necessary to appropriately reflect Division
intent and avoid the negative impact on the State’s collection of imposed taxes
and the proper assessment of insolvency deposits.



Please sign the five signature pages and return to our office by close of
business on May 18, 2007.




	 	 	 	 	 
	 

	 	 	 	 
	 

	 	Sincerely,	 	 
	 

	 		 	 
	 

	 	Jill Simone, MD	 	 
	 

	 	Executive Director	 	 
	 

	 	Office of Managed Health Care	 	 






JS:H:dv





			
	c:	 	John Koehn

Jennifer Langer





New Jersey Is An Opportunity Employer




 









 




STATE OF NEW JERSEY




DEPARTMENT OF HUMAN SERVICES




DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES




AND




AMERIGROUP NEW JERSEY, INC.




AGREEMENT TO PROVIDE HMO SERVICES



In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract between AMERIGROUP New
Jersey, Inc. and the State of New Jersey, Department of Human Services, Division of Medical
Assistance and Health Services (DMAHS), effective date October 1, 2000, all parties agree that the
contract shall be amended, effective July 1, 2007, as follows:





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





 









 







Medical Cost Ratio Damages 7/2007



All other terms and conditions of the October 1, 2000 contract and subsequent amendments remain
unchanged except as noted above.



The contracting parties indicate their agreement by their signatures.




	 	 	 	 	 	 	 	 	 	 	 
	 

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

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

	 	 
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Peter D. Haytaian
	 	 	 	 	 	    John R. Guhl
	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	TITLE: President & CEO	 	 	 	TITLE: Director, DMAHS	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	DATE: May 17, 2007	 	 	 	DATE:                                         	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	APPROVED AS TO FORM ONLY	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Attorney General	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	State of New Jersey	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	BY:
	 	 	 	 	 	 	 	 	 	 
	 

	 	 

	 	 	 	 	 	 	 	 
	 

	 	Deputy Attorney General	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	DATE:                                         	 	 	 	 	 	 	 	 






 









 






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




Calculation of MCR. The calculation of MCR will be made using information submitted by the
contractor on the quarterly reports — Income Statement by Rate Cell Grouping (Section A.7.21 of
the Appendices, Table 19, ). The costs related to 8.4.1.A 1-3 are to be reported on Table 6 and
the allowable amount will be added to the calculation of Medical and Hospital Expenses. The sum of
all applicable quarters in the SFY for which the MCR is calculated for Total Medical and Hospital
Expenses less Coordination of Benefits (COB) and less reinsurance recoveries will be divided by
the sum of all applicable quarters of Medicaid/NJ FamilyCare premiums to arrive at the ratio. In
addition, the DMAHS will allow for any applicable premium adjustments in the MCR calculation. At
its sole discretion, the State reserves the right to recompute the MCR to determine direct medical
expenditures of eighty (80) percent for a period of up to three (3) years prior to the close of
the state fiscal year under review for MCR determination and apply damages recover the
underexpenditure as delineated in Article 8.4.3.




8.4.2 RESERVED




8.4.3 DAMAGESDAMAGESRECOVERY OF UNDEREXPENDITURE



The Department shall have the right to impose damages on a contractor that has failed to keep
maintain the required MCR. recover tho amount of payments from the State not spent on medical
costs as defined above.



If at 180 days after the SFY end the MCR is below 80.0%, the State shall recover 100% of the
underexpenditure. If the contractor fails to meet the MCR requirement and a penalty is
applied, recovery is made, a plan of corrective action shall be required.




8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS