New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 1 - INTRODUCTION › Section 10:79-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
Words and terms used in this chapter shall have the meanings
				  specified below, unless specifically defined otherwise in this chapter, or the
				  context clearly indicates otherwise.
"Authorized agent" means a parent, guardian, caretaker or any
				  other individual 18 or older who has sufficient information to assist in making
				  an application for NJ FamilyCare-Children's Program children, including, but
				  not limited to:
1. A staff member of a public or private welfare or social
				  service agency of which the child for whom assistance is sought is a client and
				  who has been designated by the agency to act as the child's agent;
2. An attorney or physician of the person seeking NJ
				  FamilyCare-Children's Program benefits;
3. A staff member of an institution or facility in which the
				  individual is receiving care and who has been designated by the institution or
				  facility to so act; or
4. A legal guardian.
"Caretaker" or "caretaker adult" means the responsible adult
				  or adults residing with the child or children for whom the application or
				  redetermination for NJ FamilyCare-Children's Program is being made. This term
				  does not impose a blood relationship to the caregiver as a prerequisite for
				  applying for services on behalf of a child.
"Child" is an individual from birth through the age of 18 who
				  is otherwise not eligible for Medicaid pursuant to N.J.A.C. 10:69, 10:71 or
				  10:72.
"County welfare agency (CWA)" means that agency of county
				  government, which is charged with the responsibility for determining
				  eligibility for public assistance programs, including AFDC-Related Medicaid,
				  Temporary Assistance to Needy Families (TANF), the Supplemental Nutrition
				  Assistance Program (SNAP), and NJ FamilyCare and Medicaid. Depending on the
				  county, the CWA might be identified as the board of social services, the
				  welfare board, the division of welfare, or the division of social
				  services.
"Copayment" means a specified dollar amount required to be
				  paid by or on behalf of the beneficiary in connection with benefits as
				  specified in N.J.A.C. 10:49-9.
"DMAHS" means Division of Medical Assistance and Health
				  Services.
"Eligibility determination agency" means an entity,
				  including, but not limited to, a public or private agency, either governmental,
				  non-profit, or for profit, with which the Division of Medical Assistance and
				  Health Services has a contract or agreement to perform some or all of the
				  eligibility-related functions for NJ FamilyCare-Children's Program.
"Eligibility for coverage" means a child would be covered
				  under a health insurance policy if an application had been made on the child's
				  behalf.
"Governing unit" means any state, municipal, or local
				  authority, including school boards, water and sewage authorities, as well as
				  any state university and college system that is required or authorized by
				  statute to provide a group health plan for active or retired employees.
"Group health plan" means an employee health benefit plan,
				  whether the group health plan is self-funded or insured by a carrier that
				  covers services for the diagnosis, cure, mitigation, treatment or prevention of
				  disease or other problems in the structure or function of the body, and for
				  transportation primarily for and essential to the provision of such medical
				  care.
"Health Access New Jersey" means the subsidized insurance
				  program authorized pursuant to N.J.S.A. 26:2H-18.6 5, and rules promulgated
				  pursuant thereto (N.J.A.C. 8:91), which may also be referred to as the Access
				  Program. This program stopped accepting applications on January 1, 2001.
"Health Benefits Identification (HBID) Card" means a
				  permanent, plastic identification card issued to each Medicaid or NJ FamilyCare
				  beneficiary. The card is for identification purposes only; providers must
				  verify eligibility in accordance with N.J.A.C. 10:49-2 before they provide
				  services. The front of the card will include the beneficiary's name and a
				  16-digit Card Control Number (CCN). The back of the card will include a
				  magnetic strip, which electronically stores the beneficiary's name and
				  CCN.
"Health insurance" means benefits or services provided for
				  the diagnosis, cure, mitigation, treatment, or prevention of disease or other
				  problems with the structure or function of the body, and transportation
				  primarily for and essential to the provision of such medical care, provided
				  pursuant to the terms of a contract issued to an individual or group health
				  plan by a carrier or other "third party" within the meaning of N.J.S.A.
				  30:4D-3m.
"Health joint insurance fund" means a fund for the provision
				  of health care services or benefits authorized in accordance with
				  40A:10-36 et seq. (Joint
				  Insurance), and N.J.A.C. 11:15-3 (Joint Insurance Funds for Local Governmental
				  Units Providing Group Health and Term Life Insurance Benefits), regardless of
				  whether the benefits and services are self-funded by the participants or
				  purchased under a contract of health insurance.
"Managed Care Organization" (MCO) shall have the same
				  meaning as that contained in the definitions section at
				  N.J.A.C.
				  10:74-1.4, as amended and
				  supplemented.
"NJ FamilyCare Advantage Program" means a State program
				  offering affordable health insurance for uninsured, dependent children under
				  the age of 19 whose family's income exceeds 350 percent of the Federal Poverty
				  Level under the authority of
				  30:4J-8 et seq., and
				  P.L.
				  2008, c. 38.
"NJ FamilyCare-Children's Program" means the program
				  administered by the Division of Medical Assistance and Health Services, which
				  provides health care benefits to certain children under the authority of
				  N.J.S.A. 30:4D et seq. and
				  P.L.
				  1997, c. 272.
"Personal contribution to care" means a payment, similar to a
				  copayment, which is a responsibility incurred by the enrollee for the cost of
				  certain services as specified in N.J.A.C. 10:49-9.
"Third party liability" means any third party that is liable
				  to pay part or all of the medical costs of the child. This includes, but is not
				  limited to, medical insurance, tort and no-fault auto insurance (PIP)
				  payments.