Document:

exv10w6w7

 

Exhibit 10.6.7

	 	 	 	 	 
	
	 	State of New Jersey	 	 
	
	 	DEPARTMENT OF HUMAN SERVICES	 	 
	RICHARD J. CODEY
Acting Governor
	 	DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
	 	JAMES M. DAVY
Commissioner
	 
	 	P.O. Box 712
	 	 
	
	 	Trenton, NJ 08625-0712	 	 
	
	 	Telephone 1-800-356-1561	 	 
	 	 	 	 	 
	
	 	 	 	ANN CLEMENCY KOHLER
	
	 	 	 	Director

November 22, 2004

Norine Yukon

CEO/President

AMERIGROUP New Jersey, Inc.

399 Thornall Street, 9th Floor

Edison, NJ 08837

Dear Ms. Yukon:

Recently, the Office of Managed Health Care sent to you a contact amendment for your
signature that combined changes to the benefits available to certain populations and
changes to effect the enrollment of DYFS foster children. We have revised the amendment
process to include two separate amendments.

Since the DYFS foster care enrollment also requires changes to our waiver with CMS, we
felt that it was necessary to handle this in a separate amendment in order not to delay
the benefit changes projected for January 1, 2005.

There were no additional changes made to the contract language that you have already
received.

Please sign both signature sheets (five copies each) and return to our office by December
2, 2004.

Please feel free to contact me with any questions you may have.

	 	 	 
	

	 	Sincerely,
	 
	 	 
	

	 	Jill Simone, MD
	

	 	Executive Director
	

	 	Office of Managed Health Care

JS:RH:dv

c: John Koehn

New Jersey Is An Equal
Opportunity Employer

 

 

Exhibit 10.6.7

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 January 1, 2005 , as follows:

 

 

Exhibit 10.6.7

	 	1.  	Article 4, “Provision of Health Care Services”. Sections
4.1.2(A)9; 4.1.2(A)18; 4.1.3(A)9; 4.1.3(A)10 and 4.8.8(M)3(m)
(deleted), re-number remaining section, shall be amended as reflected
In Article 4, Sections 4.1.2(A)9; 4.1.2(A)18; 4.1.3(A)8; 4.1.3(A)10
and 4.8.8(M)3(m) attached hereto and incorporated herein.
	 
	 	2.  	Article 5, “Enrollee Services” Section 5.16.2(A)1
shall be amended as reflected in Article 5, Section 5.16.2(A)1
attached hereto and Incorporated herein.
	 
	 	3.  	Article 7, “Terms and Conditions” Section 7.16.5 shall
be amended as reflected In Article 7, Section 7.16.5 attached hereto
and incorporated herein.
	 
	 	4.  	Article 8, “Financial Provisions” Sections 8.8(A) and
8.8(M) shall be amended as reflected in Article 8, Sections 8.8(A)
and 8.8(M) attached hereto and incorporated herein.
	 
	 	5.  	Appendix, Section C, “Capitation Rates,” shall be
revised as reflected In SFY 2005 Capitation Rates attached hereto and
incorporated herein.

 

 

Exhibit 10.6.7

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/ Norine Yukon

	 	BY:	 
	 	 

	 	 	 
	 
	 	 
	

	 	 	 	Ann Clemency Kohler
	 
	 	 
	TITLE:   	 President & CEO 

	 	TITLE:  	 Director, DMAHS
	 	 
	 	 	 
	 
	 	 
	DATE:	 11/23/04

	 	DATE:	 
	 	 	 	 	 

	 	 	 	 
	APPROVED AS TO FORM ONLY
	 
	 
	 	 
	Attorney General
	 
	 
	 	 
	State of New Jersey
	 
	 
	 	 
	BY:
	 	   Deputy
	 
	 	Attorney General
	 
	 
	DATE:   
	 	 

 

 

Exhibit 10.6.7

	 	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.
	 
	 	10.  	Family Planning Services and Supplies
	 
	 	11.  	Audiology
	 
	 	12.  	Inpatient Rehabilitation Services
	 
	 	13.  	Podiatrist Services
	 
	 	14.  	Chiropractor Services
	 
	 	15.  	Optometrist Services
	 
	 	16.  	Optical Appliances
	 
	 	17.  	Hearing Aid Services
	 
	 	18.  	Home Health Agency Services - Not a contractor-covered benefit for the ABD population. All
other services provided to any enrollee in the home, including but not limited to pharmacy and
DME services, are the contractor’s fiscal and medical management responsibility.
	 
	 	19.  	Hospice Services-are covered in the community as well as in institutional settings. Room and
board services are included only when services are delivered in an institutional (non-private
residence) setting.
	 
	 	20.  	Durable Medical Equipment (DME)/Assistive Technology Devices in accordance with existing
Medicaid regulations.

	 	 	 
	Amended as January 1, 2005

	 	IV-5

 

 

Exhibit 10.6.7

	 	3.  	Outpatient Rehab - Physical therapy, occupational therapy, and speech pathology
services (For NJ FamilyCare Plans B & C enrollees, limited to 60 days per therapy per
year)
	 
	 	4.  	Abortions and related services including surgical procedure, cervical dilation,
insertion of cervical dilator, anesthesia including para cervical block, history and
physical examination on day of surgery; lab tests including PT, PTT, OB Panel (includes
hemogram, platelet. count, hepatitis B surface antigen, rubella antibody, VDRL, blood
typing ABO and Rh, CBC and differential), pregnancy test, urinalysis and urine drug
screen, glucose and electrolytes; routine venapuncture; ultrasound, pathological
examination of aborted fetus; Rhogam and its administration.
	 
	 	5.  	Transportation - lower mode (not covered for NJ FamilyCare Plans B and C)
	 
	 	6.  	Sex Abuse Examinations
	 
	 	7.  	Services Provided by New Jersey MH/SA and DYFS Residential Treatment Facilities
or Group Homes. For enrollees living in residential facilities or group homes where
ongoing care is provided, contractor shall cooperate with the medical, nursing, or -
administrative staff person designated by the facility to ensure that the enrollees
have timely and appropriate access to contractor providers as needed and to coordinate
care between those providers and the facility’s employed or contracted providers of
health services. Medical care required by these residents remains the contractor’s
responsibility providing the contractor’s provider network and facilities are utilized.
	 
	 	8.  	Family Planning Services and Supplies when furnished by a non-participating
provider.
	 
	 	9.  	Home health agency services for the ABD population.
	 
	 	10.  	Prescription drugs (legend and -non-legend covered by the Medicaid
program) for the ABD population.

	 	B.  	Dental Services. For those dental services specified below that are initiated by a Medicaid
non-New Jersey Care 2000+ provider prior to first time New Jersey Care 2000+ enrollment, an
exemption from contractor-covered services based on the initial managed care enrollment date
will be provided and the services paid by Medicaid FFS. The exemption shall only apply to
those beneficiaries who have initially received these services during the 60 or 120 day period
immediately prior to the initial New Jersey Care 2000+ enrollment date.

	 	 	 
	Amended
as of January 1, 2005

	 	IV-8

 

 

Exhibit 10.6.7

	 	   	initiated while-that individual was enrolled with
another contractor. The enrollee must continue enrollment in
the HMO where services were initiated until those services
were completed or until the member loses Medicaid/NJ
FamilyCare eligibility. Active treatment begins with the
placement of the orthodontic appliances (banding). Cases that
were authorized but not banded do not qualify for
continuation of care.
	 
	 	15.  	Podiatrist. Services — Excludes routine
hygienic care of the feet, including the treatment of corns
and calluses, the trimming of nails, and other hygienic care
such as cleaning or soaking feet, in the absence of a
pathological condition
	 
	 	16.  	Prosthetic appliances — Limited to the
initial provision of a prosthetic device that temporarily or
permanently replaces all or part of a external body part lost
or impaired as a result of disease, injury; or congenital
defect. Repair and replacement services are covered whets due
to congenital growth.
	 
	 	17.  	Private duty nursing — Only when authorized by the
contractor
	 
	 	18.  	Transportation Services - Limited to ambulance for
medical emergency only
	 
	 	19.  	Well child care including immunizations, lead screening
and treatments
	 
	 	20.  	Maternity and related newborn care
	 
	 	21.  	Diabetic supplies and equipment

	 	B.  	Services Available To NJ FamilyCare Plan D Under Fee-For-Service.
The following services are available to NJ FamilyCare Plan D enrollees under
foe-for-service:

	 	1.  	Abortion services
	 
	 	2.  	Outpatient Rehabilitation Services — Physical therapy,
Occupational therapy; and Speech therapy for non-chronic conditions and
acute illnesses and injuries. Limited to treatment for a 60-day (that is,
60 business days) consecutive period per incident of illness or-injury
beginning with the first day of treatment per contract year. Speech therapy
services rendered for treatment of delays in speech development, unless
resulting from disease, injury or congenital defects are not covered.

	 	 	 
	Amended
as of January 1, 2005

	 	IV-13

 

 

Exhibit 10.6.7

	 	l.  	Neonatal/Perinatal medicine - Alternative: none, refer out of
county.
	 
	 	m.  	Neurological Surgery - In-county alternative: none; out of county referral
applies to: Cape May, Cumberland, Gloucester, Hudson, Salem, Warren.
	 
	 	n.  	Plastic Surgery - In-county alternative: none; out of county
referral applies to: Cape May, Salem, Sussex, Warren.
	 
	 	o.  	Pulmonary Disease, pediatric - In-county alternative: Adult pulmonary
disease; out of county pediatric referral applies to: Burlington, Cape May,
Cumberland, Gloucester, Ocean, Warren.
	 
	 	p.  	Radiation Oncology - In-county alternative: none; out of county referral
applies to: Cape May, Salem, Sussex, Warren.
	 
	 	q.  	Rheumatology, pediatric - In-county alternative: adult rheumatology;
out of county pediatric referral applies to: all counties except Bergen and
Essex.
	 
	 	r.  	Thoracic surgery - In-county alternative: none, refer out of county for
Cape May, Hunterdon, Morris, Sussex, Warren.

	 	4.  	Hospitals. For .the following counties, the
contractor may limit its hospital provider network to one (1) hospital, which
must be a full service, acute care hospital including at least licensed
medical-surgical, pediatric, obstetrical, and critical care services: Cape
May, Cumberland, Gloucester, Hunterdon, Salem, Somerset, Sussex, and Warren.

4.8.9 DENTAL PROVIDER NETWORK REQUIREMENTS

	 	A.  	The contractor shall establish and maintain a dental provider network,
including primary and specialty care dentists, which is adequate to provide the full
scope of benefits. The contractor shall include general dentists and pediatric
dentists as primary care dentists (PCDs). A system whereby the PCD initiates and
coordinates any consultations or referrals for specialty care deemed necessary for the
treatment and care of the enrollee is preferred.
	 
	 	B.  	The dental provider network shall include sufficient providers able to meet the dental
treatment requirements of patients with developmental disabilities. (See Article
4.5.2E for details.)

	 	 	 
	Amended
as of January 1, 2005

	 	IV-116

 

 

Exhibit 10.6.7

	 	K.  	Hospitalizations. For any eligible person who applies for
participation in the contractor’s plan, but who is hospitalized prior to the
time coverage under the plan becomes effective, such coverage shall not
commence until the date after such person is discharged from the hospital and
DMABS shall be liable for payment for the hospitalization,, including any
charges readmission within forty-eight (48) hours of discharge for the same
diagnosis. If an enrollee’s disenrollment or termination becomes effective
during a hospitalization, the contractor shall be liable for hospitalization
until the date such person is discharged from the hospital, including any
charges for readmission within forty-eight (48) hours of discharge for the same
diagnosis. The contractor must notify DMAHS of these occurrences to facilitate
payment to appropriate providers.
	 
	 	L.  	Continuation of Benefits. The contractor shall continue benefits
for all enrollees for the duration of the contract period for which capitation
payments have been made, including enrollees in an inpatient facility until
discharge. The contractor shall notify DMAHS of these occurrences.
	 
	 	M.  	Drug Carve-Out Report. The DMAHS will provide the contractor with
a monthly electronic file of paid drug claims data for ABD enrollees.

	 
	 	N.  	MCSA Administrative Fee. The Contractor shall receive a monthly
administrative fee; PMPM, for its MCSA enrollees, by the fifteenth (15’th) day
of any month during which health care services will be available to an
enrollee.
	 
	 	O.  	Reimbursement for MCSA Enrollee Paid Claims. The DMAHS shall
reimburse the contactor for all claim paid on behalf of MCSA enrollees. The
contactor shall submit to DMAHS a financial summary report of claims paid on
behalf of MCSA enrollees on a weekly basis. The report shall be summarized by
category of service corresponding to the MCSA benefits and payment dates,
accompanied by an electronic file of all individual claim numbers for which the
State is being billed.
	 
	 	P.  	MCSA Claims Payment Audits. The contractor shall monitor and
audit claims payments to providers to identify payment errors, including
duplicate payments, overpayments, payments, and excessive payments. For such
payment errors (excluding underpayments), the contractor shall refund DMAHS the
overpaid amounts. The contractor shall report the dollar amount of claims with
payment errors on, a monthly basis, which is subject to verification by the
State. The contractor is responsible for collecting funds due to the State from
providers, either through cash payments or through offsets to payments due the
providers.

8.9 CONTRACTOR ADVANCED PAYMENTS AND PIPS TO PROVIDERS

	 	A.  	The contactor shall make advance payments to its providers,
capitation, FFS, or other financial reimbursement arrangement, based on a
provider’s historical

	 	 	 
	Amended
as of January 1, 2005

	 	VIII-19

 

 

Exhibit 10.6.7

	 	Q.  	The contractor shall periodically review and assess the knowledge
and performance of its marketing representatives.
	 
	 	R.  	The contractor shall assure culturally competent presentations by
having alternative mechanisms for disseminating information and must receive
acknowledgment of the receipt of such information by the beneficiary.
	 
	 	S.  	Individual Medicaid beneficiaries shall be able to contact the
contractor for information, and the contractor may respond to such a request.
	 
	 	T.  	Incentives.

	 	1.  	The contractor may provide an incentive program to its
enrollees based on health/educational activities or for compliance with
health related recommendations. The incentive program may include, but
is not limited to:

	 	a.  	Health related gift items
	 
	 	b.  	Gift certificates in exchange for
merchandise

	 	  Cash or redeemable coupons with a cash
value are prohibited.

	 	2.  	The contractor’s incentive program shall be proposed in
writing and prior approved by DMAHS.

	 	U.  	Periodic Survey of Enrollees.

	 	1.  	The contractor shall quarterly survey and report results to
DMAHS of new enrollees, in person, by phone, or other means, on a random
basis to verify the enrollees’ understanding of the contractor’s
procedures and. services availability.

	 	V.  	All marketing materials, plans and activities shall be prior approved by DMAHS.

5.16.2 STANDARDS FOR MARKETING REPRESENTATIVES

	 	A.  	General Requirements

	 	1.  	Only a trained marketing representative of the
contractor’s plan who meets the DHS, DHSS, and DBI requirements shall
be permitted to market and to enroll prospective NJ FamilyCare and ABD enrollees.
Delegation of enrollment functions, such
as to the office staff of a subcontracting provider of service, shall
not be permitted.

	 	 	 
	Amended
as of January 1, 2005

	 	V-45

 

 

Exhibit 10.6.7

	 	  	period. The difference shall be expressed in points. For example, if the contractor
only processed eighty-eight (88) percent of electronic claims within thirty (30) days and
eighty-eight (88) percent of manual claims within forty (40) days, it shall be considered to
be two (2) points short for that time period. The points that the contractor is short for
each of the three time periods shall be added together. This sum shall then be multiplied
times .0004 times the compensation received–by the contractor
during the quarter at issue to arrive at the liquidated damages amount.
	 
	 	   	No offset shall be given if a criterion is exceeded. DMAHS reserves the right to audit
and/or request detail and validation of reported information. DMAHS shall have the right to
accept or reject the contractor’s report and may substitute reports created by DMAHS if
contractor fails to submit reports or the contractor’s reports are found to be unacceptable.

7.16.6 CONDITIONS FOR TERMINATION OF LIQUIDATED DAMAGES

	 	   	Except as waived by the Contracting Officer, no liquidated damages imposed on the contractor
shall be terminated or suspended until the contractor issues a written notice of correction
to the Contracting Officer certifying the correction of condition(s) for which liquidated
damages were imposed and until all contractor corrections have been subjected to system
testing or other verification at the discretion of the Contracting Officer. Liquidated
damages shall cease on the day of the contractor’s certification only if subsequent testing
of the correction establishes that, indeed, the correction has been made in the manner and
at the time certified to by the contractor.

	 	A.  	The contractor shall provide the necessary system time to system test
any correction the Contracting Officer deems necessary.
	 
	 	B.  	The Contracting Officer shall determine whether the necessary level of
documentation has been submitted to verify corrections. The Contracting Officer
shall be the sole judge of the sufficiency and accuracy of any documentation.
	 
	 	C.  	System corrections shall be sustained for a reasonable period of at
least ninety (90) days from State acceptance; otherwise, liquidated, damages may
be reimposed without a succeeding grace period within which to correct.
	 
	 	D.  	Contractor use of resources to correct deficiencies shall not be
allowed to cause other system problems.

7.16.7 EPSDT & LEAD SCREENING PERFORMANCE STANDARDS

	 	A.  	EPSDT Screening

	 	1.  	The contractor shall ensure that it has achieved an eighty (80) percent
participation rate for the twelve (12)-month contract period. “Participation” is
defined as one initial or periodicity visit and will be

	 	 	 
	Amended as January 1, 2005

	 	VII-28

 

 

Exhibit 10.6.7

	 	6.  	The State will continue to pay Medicare Part A and Part B premiums for
Medicare/Medicaid dual eligibles and Qualified Medicare Beneficiaries.
	 
	 	7.  	Any references to Medicare coverage in this Article shall apply to
both Medicare/Medicaid dual eligibles and Qualified Medicare Beneficiaries.

	 	J.  	Other Protections for Medicaid Enrollees.

	 	1.  	The contractor shall not impose, or allow its participating
providers or subcontractors to impose, cost-sharing charges of any kind upon
Medicaid beneficiaries enrolled in the contractor’s plan pursuant to this
contract. This Article does not apply to individuals eligible solely through the
NJ FamilyCare Program Plan C, D, or H for whom providers will be required to
collect cost-sharing for certain services.
	 
	 	2.  	The contractor’s obligations under this Article shall not be
imposed upon the enrollees, although the contractor shall require enrollees to
cooperate in the identification of any and all other potential sources of
payment for services. Instances of non-cooperation shall be referred to the
State.
	 
	 	3.  	The contractor shall neither encourage nor require a Medicaid
enrollee to reduce or terminate TPL coverage.
	 
	 	4.  	Unless otherwise permitted or required by federal and State law,
health care services cannot be denied to a Medicaid enrollee because of a third
party’s potential liability to pay for the services, and the contractor shall
ensure that its cost avoidance efforts do not prevent an enrollee from receiving
medically necessary services.

8.8 COMPENSATION/CAPITATION CONTRACTUAL REQUIREMENTS

	 	A.  	Contractor Compensation. Compensation to the contractor is the gross amount
payable to the contractor and shall consist of monthly capitation payments,
supplemental payments per pregnancy outcome/delivery, certain blood products for
hemophilia factors VIII & IX disorders, and-payment for certain HIV/AIDS drugs, and
payments for the non-risk Managed Care Service Administrator product. (not applicable
to non-MCSA contract). Contractors must agree to enroll all non-exempt Aged, Blind and
Disabled and NJ FamilyCare beneficiaries to qualify to serve AFDC/TANF beneficiaries.
	 
	 	B.  	Capitation Payment Schedule. DMAHS hereby agrees to pay the capitation by the fifteenth
(15th) day of any month during which health care services will be available
to an enrollee; provided that information pertaining to enrollment and eligibility,
which is necessary to determine the amount of said payment, is received by DMAHS within
the time limitation contained in Article 5 of this contract.

	 	 	 
	Amended as January 1, 2005

	 	VIII-17exv10w6w8

 

Exhibit 10.6.8

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 January 1, 2005 , as follows:

	 	1.  	Article 5, “Enrollee Services” Sections 5.2(A)10 (new); 5.2(C); 5.3.1(B)8; 5.3.2(F)
(new) and 5.4(C) shall be amended as reflected in Article 5, Sections 5.2(A)10, 5.2(C),
5.3.1(B)8, 5.3.2(F) and 5.4(C) attached hereto and incorporated herein.

 

 

Exhibit 10.6.8

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/ Norine Yukon

	 	BY:	 
	 	 

	 	 	 
	 
	 	 
	

	 	 	 	Ann Clemency Kohler
	 
	 	 
	TITLE:  	 President & CEO 

	 	TITLE:   	 Director, DMAHS
	 	 
	 	 	 
	 
	 	 
	DATE:	 11/23/04

	 	DATE:	 
	 	 	 	 	 

	 	 	 	 
	APPROVED AS TO FORM ONLY
	 
	 
	 	 
	Attorney General
	 
	 
	 	 
	State of New Jersey
	 
	 
	 	 
	BY:
	 	   
	 
	 	Deputy Attorney General
	 
	 
	DATE:   
	 	 

 

 

Exhibit 10.6.8

5.2 AID CATEGORIES ELIGIBLE FOR CONTRACTOR ENROLLMENT

	 	A.  	Except as specified in Article 5.3, all persons who are not institutionalized,
belong to one of the following eligibility categories, and reside in any of the
enrollment areas, as identified in Article 5.1, are in mandatory aid categories and
shall be eligible for enrollment in the contractor’s plan in the manner prescribed by
this contract.

	 	1.  	Aid to Families with Dependent Children (AFDC)/Temporary
Assistance for Needy Families (TANF);
	 
	 	2.  	AFDC/TANF-Related, New Jersey Care...Special Medicaid Program for
Pregnant Women and Children;
	 
	 	3.  	SSI-Aged, Blind, Disabled, and Essential Spouses;
	 
	 	4.  	New Jersey Care...Special Medicaid programs for Aged, Blind, and
Disabled;
	 
	 	5.  	Division of Developmental Disabilities Clients including the
Division of Developmental Disabilities Community Care Waiver;
	 
	 	6.  	Medicaid only or SSI-related Aged, Blind, and Disabled;
	 
	 	7.  	Uninsured parents/caretakers and children who are covered under
NJ FamilyCare;
	 
	 	8.  	Uninsured adults and couples without dependent children under the
age of 23 who are covered under NJ FamilyCare.
	 
	 	9.  	Restricted alien parents, excluding pregnant women.

	 
	 	10.  	Children in DYFS custody residing in resource families.

	 	B.  	The contractor shall enroll the entire Medicaid case, i.e., all individuals
included under the ten digit Medicaid identification number.
	 
	 	C.  	DYFS. Individuals who are eligible through the Division of Youth and Family Services may
enroll voluntarily, except those children in DYFS custody residing in resource families are
required to enroll. All individuals eligible through DYFS shall be considered a unique
Medicaid case and shall be issued an individual 12 digit Medicaid identification number,
and may be enrolled in his/her own MCO.
	 
	 	D.  	The contractor shall be responsible for keeping its network of providers
informed of the enrollment status of each enrollee.
	 
	 	E.  	Dual eligibles (Medicaid-Medicare) may voluntarily enroll.

	 
	5.3 EXCLUSIONS AND EXEMPTIONS

	 
	 	
Persons who belong to one of the. eligible populations (defined in 5.2A) shall not be
subject to mandatory enrollment if they meet one or more criteria defined in this Article.
Persons who fall into an “excluded” category (Article 5.3.1A) shall not be eligible to

	 	 	 
	Amended as January 1, 2005

	 	VIII-2

 

 

Exhibit 10.6.8

	 	9.  	The following types of dual beneficiaries: Qualified Medicare Beneficiaries
(QMBs) not otherwise eligible for Medicaid; Special Low-Income Medicare
Beneficiaries (SLMBs); Qualified Disabled and Working Individuals (QDWIs); and
Qualifying Individuals 1 and 2.

	 	B.  	The following individuals shall be excluded from the Automatic Assignment
process described in Article 5.4C but may voluntarily enroll:

	 	1.  	Individuals whose Medicaid eligibility will terminate within
three (3) months or less after the projected date of effective enrollment.
	 
	 	2.  	Individuals in mandatory eligibility categories who live in a
county where mandatory enrollment is not yet required based on a phase-in
schedule determined by DMAHS.
	 
	 	3.  	Individuals enrolled in or covered by either a Medicare or
commercial HMO will not be enrolled in New Jersey Care 2000+ contractor unless
the New Jersey Care 2000+ contractor and the Medicare/commercial HMO are the
same.
	 
	 	4.  	Individuals in the Pharmacy Lock-in or Provider Warning or
Hospice programs.
	 
	 	5.  	Individuals in eligibility categories other than AFDC/TANF,
AFDC/TANF-related New Jersey Care, SSI-Aged, Blind and Disabled populations,
the Division of Developmental Disabilities Community Care Waiver population,
New Jersey Care - Aged, Blind and Disabled, or NJ FamilyCare Plan A.
	 
	 	6.  	Children awaiting adoption through a private agency.
	 
	 	7.  	Individuals identified as having more than one active eligible
Medicaid number.
	 
	 	8.  	DYFS Population.(Exception: Children in DYFS custody residing
in resource families.

	 	C.  	The following individuals shall be excluded from the Automatic Assignment
process:

	 	1.  	Individuals included under the same Medicaid Case Number where
one or more household member(s) are exempt.
	 
	 	2.  	Individuals participating in NJ FamilyCare Plans B, C, D, and H
[Managed Care is the only program option available for these individuals].

	 	 	 
	Amended as January 1, 2005

	 	VIII-4

 

 

Exhibit 10.6.8

	 	E.  	Individuals who do not have a choice of at least two (2) PCPs within thirty (30)
miles of their residence.
	 
	 	F.  	Children in DYFS custody residing in resource families. Resource families may
request an exemption for children:

	 	1.  	In short-term placements (up to 2 months)
	 
	 	2.  	In Special Home Service Provider (SHSP) homes
	 
	 	3.  	Whose doctors do not participate in any contractor’s plan
	 
	 	4.  	Who use many doctors that are not part of the same MCO
	 
	 	5.  	Without a HMO doctor in their area

5.4 ENROLLMENT OF MANAGED CARE ELIGIBLES

	 	A.  	Enrollment. The health benefits coordinator (HBC), an agent of DMAHS, shall
enroll Medicaid and NJ FamilyCare applicants. The HBC will explain the contractors’
programs, answer any questions, and assist eligible individuals or, where applicable,
an authorized person in selecting a contractor. The contractor may also enroll and
directly market to individuals eligible for Aged, Blind, and Disabled (ABD) benefits.
The contractor shall not enroll any other Medicaid-eligible beneficiary except as
described in Article 5.16.1.(A).2. Except as provided in 5.16, the contractor shall
not directly market to or assist managed care eligibles in completing enrollment
forms. The duties of the HBC will include, but are not limited to, education,
enrollment, disenrollment, transfers, assistance through the contractor’s
grievance/appeal process and other problem resolutions with the contractor, and
communications. The duties of the contractor, when enrolling ABD beneficiaries will
include education and enrollment, as well as other activities required within this
contract. The contractor shall cooperate with the HBC in developing information about
its plan for dissemination to Medicaid/NJ FamilyCare beneficiaries.
	 
	 	B.  	Individuals eligible under NJ FamilyCare may request an application via a
toll-free number operated under contract for the State, through an outreach source, or
from the contractor. The applications, including ABD applications taken by the
contractor, may be mailed back to a State vendor. Individuals eligible under Plan A
also have the option of completing the application either via a mail-in process or on
site at the county welfare agency. Individuals eligible under Plan B, Plan C, Plan D,
and Plan H have the option of requesting assistance from the State vendor, the
contractor or one of the registered servicing centers in the community. Assistance
will also be made available at State field offices (e.g. the Medical Assistance
Customer Centers) and county offices (e.g. Offices on Aging for grandparent
caretakers).

	 	 	 
	Amended as January 1, 2005

	 	V-6

 

 

Exhibit 10.6.8

	 	C.  	Automatic Assignment. Medicaid eligible persons who reside in enrollment areas
that have been designated for mandatory enrollment, who qualify for AFDC/TANF, ABD, New
Jersey Care...Special Medicaid programs eligibility categories, NJ FamilyCare Plan A,
Children in DYFS custody residing in resource families, and SSI populations,
who do not meet the exemption criteria, and who do not voluntarily choose enrollment in
the contractor’s plan, shall be assigned automatically by DMAHS to a contractor.

5.5 ENROLLMENT AND COVERAGE REQUIREMENTS

	 	A.  	General. The contractor shall comply with DMAHS enrollment procedures. The
contractor shall accept for enrollment any individual who selects or is assigned to
the contractor’s plan, whether or not they are subject to mandatory enrollment,
without regard to race, ethnicity, gender, sexual or affectional preference or
orientation, age, religion, creed, color, national origin, ancestry, disability,
health status or need for health services and will not use any policy or practice that
has the effect of discrimination on the basis of race, color, or national origin.
	 
	 	B.  	Coverage commencement. Coverage of enrollees shall commence at 12:00 a.m.,
Eastern Time, on the first day of the calendar month as specified by the DMAHS with
the exceptions noted in Article 5.5. The day on which coverage commences shall be the
enrollee’s effective date of enrollment.
	 
	 	C.  	The contractor shall accept enrollment of Medicaid/NJ FamilyCare eligible
persons within the defined enrollment areas in the order in which they apply or are
auto-assigned to the contractor (on a random basis with equal distribution among all
participating contractors) without restrictions, within contract limits. Enrollment
shall be open at all times except when the contract limits have been met. A contractor
shall not deny enrollment of a person with an SSI disability or New Jersey Care
Disabled category who resides outside of the enrollment area. However, such enrollee
with a disability shall be required to utilize the contractor’s established provider
network. The contractor shall accept enrollees for enrollment throughout the duration
of this contract.
	 
	 	D.  	Enrollment timeframe. As of the effective date of enrollment, and until the
enrollee is disenrolled from the contractor’s plan, the contractor shall be
responsible for the provision and cost of all care and services covered by the
benefits package listed in Article 4.1. Enrollees who become eligible to receive
services between the 1st through the end of the month shall be eligible for
Managed Care services in that month. When an enrollee is shown on the enrollment
roster as covered by a contractor’s plan, the contractor shall be responsible for
providing services to that person from the first day of coverage shown to the last day
of the calendar month of the effective date of disenrollment. DMAHS will pay the
contractor a capitation rate during this period of time.

	 	 	 
	Amended as January 1, 2005

	 	V-7

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00079-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00079-of-00352.parquet"}]]