New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 2 - CRITERIA FOR CONTRACTING WITH THE DEPARTMENT › Section 10:74-2.1 - Contract requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contractor
				shall:
1. Comply with the requirements of the
				New Jersey Certificate of Authority statutes and rules ( P.L. 1973, c. 337,
				26:2J-1 et seq., and N.J.A.C.
				11:24);
2. Provide to the Division
				of Medical Assistance and Health Services, Department of Human Services, a copy
				of the approved Certificate of Authority and application document on
				request;
3. Furnish the Department
				with data, information and reports and maintain records as required by the
				Department and other State or Federal agencies. Such reports shall include, but
				are not limited to, enrollment data, encounter data, provider network data,
				quality control and quality assurance, utilization review, financial statements
				and service utilization;
4. Enroll
				individuals and provide services without reference to race, sex, age, religion,
				creed, color, national origin, ancestry, disability, or on the basis of health
				status or need for health services, other than those services specifically
				excluded from coverage as defined in the standard service package;
5. Assure that the provider network used for
				private, commercial business be equally available to Medicaid/NJ FamilyCare
				enrollees. Such provider network shall consist of hospitals, physicians,
				dentists, laboratories, and all other providers of services covered under the
				contract, and shall ensure that the providers meet, at a minimum, all standards
				of practice and credentialing as required by Title XIX Medicaid and Title XXI
				of the Social Security Act, and shall maintain a comprehensive network of
				providers sufficient to meet the needs of the general population within the
				counties in which the MCO has a certificate of authority to operate;
6. Instruct medical and dental providers
				regarding MCO health services in respect to:
i. Appropriate medical and dental procedures
				and treatment;
ii. Delivery of
				culturally competent care;
iii.
				Advances in medical science;
iv.
				Responsibility to notify beneficiaries when they are due to receive certain
				periodic services, for example, antenatal visits for pregnant women, and EPSDT
				examinations for children;
v.
				Advances in electronic health records; and
vi. Responsibility for assisting the MCO in
				coordinating the care of enrollees;
7. Have a contract which has been approved by
				CMS and the New Jersey Departments of Health and Senior Services and Banking
				and Insurance;
8. Have the
				organizational and administrative capabilities to carry out its duties and
				responsibilities, which shall include, at a minimum, the following:
i. A full-time administrator to manage
				day-to-day business activities of the contractor and to be the responsible
				contract officer. (This does not require a full-time administrator to be
				dedicated solely to the Medicaid/NJ FamilyCare contract.);
ii. Data reporting capabilities sufficient to
				provide necessary reports and data as specified in the contract between the MCO
				and Department, and to assure orderly and timely flow of information to the
				Department. Such reports shall include, but are not limited to, enrollment
				data, encounter data, provider network data, quality control, quality
				assurance, utilization review and financial statements and service
				utilization;
iii. Financial records
				and books of accounts maintained in accordance with generally accepted
				accounting principles which are sufficient to disclose fully the disposition of
				all program funds received; and
iv.
				An annual independent audit arranged for by the contractor and performed by a
				certified public accountant;
9. Advise the Department of its
				administrative organization and changes thereto, which shall include the
				functions and responsibilities of each principal, an organizational chart and a
				list of all personnel and providers used either directly by the contractor or
				through subcontractual arrangements. For each principal and each provider not
				previously reported, the following information shall be included:
i. Full name;
ii. Business address;
iii. Social Security number;
iv. IRS employer number;
v. Professional license number (when
				applicable);
vi. Medical specialty
				(when applicable);
vii.
				Professional degree, if applicable; and
viii. Board eligibility/certification, if
				applicable.
10. Comply
				with eligibility requirements of the program, which shall include, but shall
				not be limited to, enrolling only individuals who are covered under specified
				Medicaid/NJ FamilyCare categories of assistance;
11. Identify and provide financial disclosure
				of subcontractors with whom it has had business transactions in excess of $
				25,000 per year, and any significant business transactions with such
				subcontractors. Transactions that shall be reported include:
i. Any sale, exchange or leasing of
				property;
ii. Any furnishing for
				consideration of goods, services, or facilities (but not employee salaries);
				and
iii. Any loans or extensions of
				credit;
12. When
				specifically requested, make available, in the form of a consolidated financial
				statement, any information reported to the State, to the following:
i. The Secretary of the U.S. Department of
				Health and Human Services;
ii. The
				Office of the Inspector General;
iii. The Comptroller General;
iv. The Office of the State Comptroller,
				Medicaid Fraud Division; and
v. The
				enrollees of the MCO;
13. Shall comply and disclose to the Division
				in accordance with 42 CFR 455.100-106 the required information concerning
				ownership and control interest, related business transactions and persons
				convicted of a crime, including the identity of each person with a controlling
				interest and of any person(s) having ownership of five percent or
				more;
14. Not employ or contract
				with:
i. Any individual or entity excluded
				from Medicaid or other Federal health care program participation under Sections
				1128 (
				42
				U.S.C. §
												1320a-7 ) or 1128A of the
				Social Security Act (
				42 U.S.C. §
												1320a-7a ) or under N.J.A.C. 10:49-11 for the
				provision of health care, utilization review, medical social work, or
				administrative services; or who could be excluded under Section 1128(b)(8) of
				the Social Security Act (
				42
				U.S.C. §
												1320a- 7(b)(8) ) as being
				controlled by a sanctioned individual;
ii. Any entity for the provision of such
				services (directly or indirectly) through an excluded individual or
				entity;
iii. Any individual or
				entity discharged or suspended from doing business with the State of New
				Jersey; or
iv. Any entity that has
				a substantial contractual relationship (direct or indirect) with an individual
				convicted of certain crimes as described in Section 1128(b)(8) of the Social
				Security Act (
				42
				U.S.C. §
												1320a- 7(b)(8) ); and
15. Establish and implement
				policies and procedures for identifying, investigating, and taking corrective
				action against fraud and abuse on the provision of health services.