New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 1 - GENERAL PROVISIONS › Section 10:74-1.4 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter,
				  shall have the following meanings, unless the context clearly indicates
				  otherwise:
"ABD" means those individuals who are determined to be
				  categorically eligible for Medicaid because they are aged, blind or disabled.
				  Eligibility shall be determined in accordance with N.J.A.C. 10:70, Medically
				  Needy, 10:71, Medicaid Only, or 10:72, New Jersey Care . . . Special Medicaid
				  Programs, as applicable.
"Administrative service(s)" means the obligations of the
				  contractor as specified in its contract with the Department that include, but
				  may not be limited to, utilization management, credentialing providers, network
				  management, quality improvement, marketing, enrollment, member services, claims
				  payment, management information systems administration, financial management,
				  reporting, fraud and abuse investigations and encounter data reporting.
"Advanced practice nurse" means a person licensed to practice
				  as a registered professional nurse who is certified by the New Jersey State
				  Board of Nursing in accordance with N.J.A.C. 13:37-7 and
				  45:11-24
				  and 45 through 52, or similarly licensed and certified by a comparable agency
				  of the state in which he or she practices.
"AFDC" means those families who are eligible for Medicaid
				  using the Aid to Families with Dependent Children program rules in effect as of
				  July 16, 1996.
"AFDC-related" refers to pregnant women and infants up to the
				  age of one year who are eligible under the New Jersey Care . . . Special
				  Medicaid Programs.
"AIDS Drug Distribution Program (ADDP)" means the Department
				  of Health (DOH) program, which provides life-sustaining and life-prolonging
				  medications to persons who are HIV-positive, or who are living with AIDS, and
				  who meet residency and income criteria for program participation.
"Benefits package" means the services which the contractor
				  has agreed to provide, arrange for, and be held fiscally responsible for, which
				  are set forth in N.J.A.C. 10:74-3.
"Behavioral health services" refers to the treatment and
				  amelioration of behavioral/mental health conditions, as well as efforts to
				  prevent and intervene in substance use disorder.
"Capitation rate" means the fixed monthly amount that the
				  contractor is paid by the Department for each enrollee to provide that enrollee
				  with the services included in the benefits package described in N.J.A.C.
				  10:74-3.
"Care management" means a set of enrollee-centered,
				  goal-oriented, culturally relevant and logical steps to assure that an enrollee
				  receives needed services in a supportive, effective, efficient, timely and
				  cost-effective manner. Care management emphasizes prevention, continuity of
				  care and coordination of care, which advocates for, and links enrollees to,
				  services as necessary across providers and settings. Care management is driven
				  by quality-based outcomes, such as: improved/maintained functional status,
				  improved/maintained clinical status, enhanced quality of life, enrollee
				  satisfaction, adherence to the care plan, improved enrollee safety, cost
				  savings and enrollee autonomy. Care management functions include:
1. Early identification of enrollees who have or may have
				  special needs;
2. Assessment of an enrollee's risk factors;
3. Development of a plan of care;
4. Referrals and assistance to ensure timely access to
				  providers;
5. Coordination of care actively linking the enrollee to
				  providers, medical services, residential, social, behavioral and other support
				  services where needed;
6. Monitoring;
7. Continuity of care; and
8. Follow-up and documentation.
"Centers for Medicare & Medicaid Services (CMS)" means
				  the agency within the U.S. Department of Health and Human Services which has
				  responsibility for administering the Medicaid and State Child Health Insurance
				  programs in accordance with Titles XIX and XXI of the Social Security
				  Act.
"Certificate of authority" means a license, issued by the New
				  Jersey Department of Banking and Insurance granting authority to operate an HMO
				  in New Jersey in compliance with
				  26:2J-3
				  and 4 and N.J.A.C. 11:24.
"Certified nurse-midwife (CNM)" means a registered
				  professional nurse licensed in New Jersey who, by virtue of added knowledge and
				  skill gained through an organized program of study and clinical experience,
				  receives certification by the American College of Nurse-Midwives. A CNM shall
				  be licensed by and registered with the New Jersey Board of Medical
				  Examiners.
"Child Protection and Permanency" (CP&P) means the child
				  protection and child welfare agency within the New Jersey Department of
				  Children and Families (DCF), which is responsible for the care, custody,
				  guardianship, maintenance, and protection of children and provides
				  comprehensive social services to ensure the safety, permanency, and well-being
				  of children and families.
" Cold-call marketing" means any unsolicited personal contact
				  with a potential enrollee by an employee or agent of the contractor, directly
				  or indirectly, for the purpose of influencing the individual to enroll with the
				  contractor. Marketing by an employee is considered direct and marketing by an
				  agent is considered indirect.
"Commissioner" means the Commissioner of the New Jersey
				  Department of Human Services or a duly authorized representative.
"Complaint" means a protest by an enrollee, or by a provider
				  on the enrollee's behalf, regarding the conduct of the contractor or any agent
				  of the contractor, or regarding an act or failure to act by the contractor or
				  any agent of the contractor, or regarding any other matter in which an enrollee
				  feels aggrieved by the contractor, that is communicated to the contractor and
				  resolved to the enrollee's satisfaction within five business days. In
				  accordance with the managed care contract, a complaint not resolved within five
				  business days shall be treated as a grievance.
"Comprehensive risk contract" means a risk contract that
				  covers comprehensive services, that is, inpatient hospital services and any of
				  the following services, or any three or more of the following:
1. Outpatient hospital services;
2. Rural health clinic services;
3. Federally qualified health center (FQHC) services;
4. Other laboratory and radiology services;
5. Nursing facility (NF) services;
6. Early and periodic screening, diagnostic and treatment
				  (EPSDT) services;
7. Family planning services;
8. Physician services; or
9. Home health services.
"Comprehensive Waiver" means the New Jersey 1115
				  Comprehensive Waiver Demonstration that consolidated several previously
				  existing Medicaid waivers for the purpose of:
1. Integrating primary care, acute care, behavioral health
				  care, and long-term services and supports;
2. Providing a wide array of services to individuals with
				  intellectual or developmental disabilities who are living at home with their
				  families;
3. Increasing community-based services for children who are
				  dually diagnosed with developmental disabilities and mental illness by
				  providing case management and behavioral and individual supports; and
4. Expanding managed care to individuals in need of long-term
				  services and supports, diverting more individuals from institutional placement
				  through increased access to home and community-based services (HCBS).
"Contractor" means a managed care organization as defined in
				  this section which contracts with the Department for the provision of
				  comprehensive health services to enrollees on a prepayment basis, or for the
				  provision of administrative services for a specified benefits package to
				  specified enrollees on a non-risk, reimbursement basis.
"Contractor's plan" means all services and responsibilities
				  undertaken by the contractor pursuant to this chapter concerning managed health
				  care services for Medicaid/NJ FamilyCare beneficiaries.
"County welfare agency (CWA)," formerly known as "county
				  board of social services (CBOSS)," means that agency of county government that
				  is responsible for determining eligibility for certain Medicaid/NJ FamilyCare
				  programs. CWA is the general term for the county agency; 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.
"CP&P clients" are children who are financially eligible
				  for Medicaid/NJ FamilyCare and are placed in resource homes or other
				  State-supported placements under the supervision of CP&P and children whom
				  CP&P has placed in private adoption agencies until they are legally adopted
				  or are in subsidized adoptions.
"Cultural competence" means acceptance of, and respect for,
				  cultural differences, sensitivity to how these differences influence
				  relationships with patients/clients and the ability to devise strategies to
				  better meet culturally diverse patients' needs and address racial health
				  disparities.
"Department" means the New Jersey Department of Human
				  Services.
"Department of Banking and Insurance" means the New Jersey
				  Department of Banking and Insurance.
"Department of Children and Families" means the New Jersey
				  Department of Children and Families.
"Department of Health" (DOH) means the New Jersey Department
				  of Health.
"Director" means the Director of the Division of Medical
				  Assistance and Health Services or a duly authorized representative.
"Disenrollment" means the process of removal of an enrollee
				  from the contractor's plan, not from the Medicaid/NJ FamilyCare
				  programs.
"Division" means the Division of Medical Assistance and
				  Health Services (DMAHS) of the Department of Human Services.
"Division of Developmental Disabilities (DDD)" means the
				  Division within the New Jersey Department of Human Services that provides
				  evaluation, functional and guardianship services to eligible persons. Services
				  include residential services, family support, contracted day programs, work
				  opportunities, social supervision, guardianship, and referral services.
"Dually eligible individual" means an individual who is
				  eligible for both Medicare and Medicaid/ NJ FamilyCare.
"Effective date of enrollment" means the date on which a
				  person can begin to receive services under the contractor's plan.
"Emergency medical condition" means a medical condition
				  manifesting itself by acute symptoms of sufficient severity (including severe
				  pain), such that a prudent layperson, who possesses an average knowledge of
				  health and medicine, could reasonably expect the absence of immediate medical
				  attention to result in placing the health of the individual (or, with respect
				  to a pregnant woman, the health of the woman or her unborn child) in serious
				  jeopardy; serious impairment to bodily functions; or serious dysfunction of any
				  bodily organ or part. With respect to a pregnant woman who is having
				  contractions, an emergency exists where there is inadequate time to effect a
				  safe transfer to another hospital before delivery or the transfer may pose a
				  threat to the health or safety of the woman or the unborn child.
"Emergency services" means those services that are furnished
				  by a provider who is qualified to furnish such services and are needed to
				  evaluate or stabilize an emergency medical condition.
"Enrollee" or "enrolled beneficiary" means an individual
				  residing within the defined enrollment area, who elects or has had elected on
				  his or her behalf by an authorized person, in writing, to participate in the
				  specific contractor's plan, whether through the mandatory managed care coverage
				  or on an individual, voluntary basis, and who meets specific Medicaid/NJ
				  FamilyCare eligibility requirements for Plan enrollment agreed to by the
				  Department and the contractor, at N.J.A.C. 10:74-6.
"Enrollment," for the mandatory managed health care program,
				  means the process whereby specified Medicaid/NJ FamilyCare-Plan A beneficiaries
				  are required to join an MCO to receive health services, unless otherwise
				  exempted or excluded. All other NJ FamilyCare beneficiaries, except for certain
				  newborns, are not exempt from mandatory enrollment.
"Enrollment" for the voluntary program means the process by
				  which certain Medicaid/NJ FamilyCare-Plan A eligible individuals voluntarily
				  enroll in an MCO for the provision of health services and by which such
				  application is approved.
"Enrollment area" means the geographic area bound by county
				  lines from which Medicaid/NJ FamilyCare eligible residents may enroll with an
				  MCO, unless otherwise specified in the MCO contract with the Department.
"Enrollment lock-in period" means the period between the
				  first day of the fourth month and the end of 12 months after the effective date
				  of enrollment in the contractor's plan, during which time the enrollee shall
				  have good cause in order to disenroll or transfer from the contractor's plan.
				  The enrollment lock-in period is not construed as a guarantee of eligibility
				  during the lock-in period. Lock-in provisions do not apply to clients of DDD or
				  SSI, New Jersey Care Special Medicaid Program--Aged, Blind, Disabled, and
				  CP&P enrollees.
"EPSDT" means the Early and Periodic Screening, Diagnosis and
				  Treatment program mandated by Title XIX of the Social Security Act.
"Excluded services" means services covered under the
				  fee-for-service Medicaid/NJ FamilyCare programs that are not included in the
				  managed care benefit package.
"Federal Poverty Level (FPL)" means the income level
				  designated by the United States Department of Health and Human Services in
				  accordance with
				  42
				  U.S.C. §§
										9902(2).
"Federally qualified HMO" means an HMO that has been
				  determined by CMS to be a qualified HMO in accordance with
				  42 U.S.C. §
										300e- 9(c).
"Fee-for-service (FFS)" means the method used by the Division
				  for reimbursement based on its payment for specific services covered by the
				  Division, but not covered by the MCO, which are rendered to an enrollee.
"Good cause" means reasons for disenrollment or transfer that
				  include, but are not limited to: failure of an MCO to provide services,
				  including providing physical access to the enrollee in accordance with the MCO
				  contract terms; failure of an MCO to respond to an enrollee's grievance within
				  a required time period; or failure of an MCO to respond to an enrollee's
				  grievance.
"Grievance" means a complaint or expression of
				  dissatisfaction about any matter that is orally communicated or submitted in
				  writing and that is not resolved within five business days of receipt.
"Grievance system" means the system that includes grievances
				  and appeals at the contractor level and provides access to the Medicaid fair
				  hearing process. (See
				  10:49-10.3 )
"Health benefits coordinator (HBC)" means an entity under
				  contract with the Department whose primary responsibility is to assist
				  Medicaid/NJ FamilyCare-eligible enrollees in the selection of and enrollment in
				  a managed care plan.
"Health care professional" means a physician, or other health
				  care professional, if coverage for the professional's services is provided
				  under the contractor's contract for the services. The term includes
				  podiatrists, optometrists, chiropractors, psychologists, dentists, physician
				  assistants, physical or occupational therapists and therapist assistants,
				  speech-language pathologists, audiologists, registered or licensed practical
				  nurses (including advanced practice nurses, certified registered nurse
				  anesthetists, and certified nurse midwives), licensed certified social workers,
				  registered respiratory therapists, and certified respiratory therapy
				  technicians.
"Health education services" means instruction to
				  beneficiaries about preventative health care and obtaining the health care they
				  need within an MCO, to medical providers about providing appropriate care
				  within the MCO structure, and to community organizations for assisting their
				  beneficiaries to achieve better health outcomes.
"Health maintenance organization (HMO)" means a public or
				  private organization, organized under State law, which:
1. Is a Federally qualified HMO (defined above); or
2. Meets the Division's definition of an HMO, which includes,
				  at a minimum, the following requirements:
i. Is organized primarily for the purpose of providing access
				  to health services;
ii. Makes the services it provides to its Medicaid/NJ
				  FamilyCare enrollees as accessible to them (in terms of timeliness, amount,
				  duration, and scope) as those services are to non-enrolled Medicaid/NJ
				  FamilyCare eligible individuals within the area served by the HMO;
iii. Makes provision against the risk of insolvency, and
				  assures that Medicaid/NJ FamilyCare enrollees will not be liable for the HMO's
				  debts if it does become insolvent; and
iv. Has a Certificate of Authority as defined in this
				  section, granted by the State of New Jersey to operate in all or selected
				  counties of New Jersey.
"HHS" or "DHHS" means the United States Department of Health
				  and Human Services.
"IPN" means Independent Practitioner Network, which is a type
				  of network used in an MCO operation. Services are provided for enrollees in the
				  individual offices of the contracting primary care providers (PCPs).
"Lower mode transportation" means curb-to-curb car or van
				  transportation provided to Medicaid/NJ FamilyCare beneficiaries who are
				  ambulatory and who do not require assistance or supervision to travel to and
				  from their medical appointments.
"Managed care entity (MCE)" means a managed care organization
				  described in Section 1903(m)(1)(A) of the Social Security Act (
				  42 U.S.C. §
										1396b(m) ), including Health
				  Maintenance Organizations (HMOs), organizations with section 1876 or Medicare +
				  Choice contracts, provider sponsored organizations, or any other public or
				  private organization meeting the requirements of section 1902(w) of the Social
				  Security Act (
				  42 U.S.C. §
										1396a(w) ), which has a
				  comprehensive risk contract and meets the other requirements of section
				  1902(w).
"Managed care organization (MCO)" means an entity that has,
				  or is seeking to qualify for, a comprehensive risk contract, and that
				  is:
1. A Federally-qualified HMO that meets the advance
				  directives requirements of 42 CFR Part 489, Subpart I incorporated herein by
				  reference, as amended and supplemented; or
2. A public or private entity that meets the advance
				  directives requirements of 42 CFR Part 489, Subpart I, incorporated herein by
				  reference, as amended and supplemented, and is determined to meet the following
				  conditions:
i. Makes the services it provides to its Medicaid/NJ
				  FamilyCare enrollees equally accessible (in terms of timeliness, amount,
				  duration, and scope) as those services that are provided to other Medicaid/NJ
				  FamilyCare beneficiaries within the area served by the entity; and
ii. Meets the solvency standards of
				  42 CFR
				  438.116 incorporated herein by reference, as
				  amended and supplemented.
"Managed care service administrator (MCSA)" means an entity
				  in a non-risk based financial arrangement that contracts to provide a
				  designated set of services for an administrative fee. Services provided may
				  include, but are not limited to: medical management, claims processing and
				  provider network maintenance.
"Managed long-term services and supports (MLTSS)" means
				  services that are provided under the New Jersey 1115 Comprehensive Waiver
				  through Medicaid/NJ FamilyCare MCO plans, the purpose of which is to support
				  clients who meet nursing home level of care in the most appropriate setting to
				  meet their specific needs, allowing them to remain at home in the community
				  instead of living in a nursing facility.
1. Individuals qualify for MLTSS by meeting established
				  Medicaid financial requirements and Medicaid clinical and age and/or disability
				  requirements for nursing facility services contained at N.J.A.C. 10:69, 70, 71,
				  or 72.
2. For children who meet the nursing home level of care, and
				  who are applying for MLTSS, there is no deeming of parental income or resources
				  in the determination of eligibility.
3. Once qualified to receive MLTSS, the individual must be
				  enrolled with a managed care organization (MCO) in order to receive MLTSS
				  services.
"Mandatory enrollment" means the process whereby an
				  individual eligible for Medicaid/NJ FamilyCare is required to enroll in an MCO,
				  unless otherwise exempt or excluded, to receive the services described in the
				  standard benefits package as approved by the Department of Human Services
				  pursuant to any necessary Federal waivers.
"Marketing" means any activity by, or means of communication
				  from, the MCO, its employees, affiliated providers, subcontractors, or agents,
				  or on behalf of the MCO by any person, firm, or corporation, by which
				  information about the MCO's plan is made known to Medicaid/NJ FamilyCare
				  eligible persons that can reasonably be interpreted as intended to influence
				  the individual to enroll in the MCO's plan or either to not enroll in, or to
				  disenroll from, another MCO's plan.
"Medicaid" refers to the program funded under Title XIX of
				  the Social Security Act, administered by the Department, to provide covered
				  health care services to eligible beneficiaries.
"Medicaid/NJ FamilyCare beneficiary" means an individual
				  eligible to receive services under the New Jersey Medicaid fee-for-service
				  program or any NJ FamilyCare plan in accordance with N. J.A.C. 10:69, 10:70,
				  10:71, 10:72, 10:78, or 10:79.
"Medically necessary services" means services or supplies
				  necessary to prevent, diagnose, correct, prevent the worsening of, alleviate,
				  ameliorate, or cure a physical or mental illness or condition; to maintain
				  health; to prevent the onset of an illness, condition, or disability; to
				  prevent or treat a condition that endangers life or causes suffering or pain or
				  results in illness or infirmity; to prevent the deterioration of a condition;
				  to promote the development or maintenance of maximal functioning capacity in
				  performing daily activities, taking into account both the functional capacity
				  of the individual and those functional capacities that are appropriate to
				  individuals of the same age; to prevent or treat a condition that threatens to
				  cause or aggravate a handicap or cause physical deformity or malfunction, and
				  there is no other equally effective, more conservative or substantially less
				  costly course of treatment available or suitable for the enrollee. The services
				  provided, as well as the treatment, the type of provider and the setting, are
				  reflective of the level of services that can be safely provided, are consistent
				  with the diagnosis of the condition and appropriate to the specific medical
				  needs of the enrollee and not solely for the convenience of the enrollee or
				  provider of service and in accordance with standards of good medical practice
				  and generally recognized by the medical scientific community as effective.
				  Course of treatment may include mere observation or, where appropriate, no
				  treatment at all. Experimental services or services generally regarded by the
				  medical profession as unacceptable treatment are deemed not medically
				  necessary. Medically necessary services provided are based on peer-reviewed
				  publications, expert pediatric, psychiatric, and medical opinion, and
				  medical/pediatric community acceptance. In the case of pediatric enrollees,
				  this definition applies, with the additional criteria that the services,
				  including those found to be needed by a child as a result of a comprehensive
				  screening visit or an inter-periodic encounter, whether or not they are
				  ordinarily covered services for all other Medicaid/NJ FamilyCare enrollees, are
				  appropriate for the age and health status of the individual and that the
				  service will aid the overall physical and mental growth and development of the
				  individual and the service will assist in achieving or maintaining functional
				  capacity.
"Medical screening" means an examination which is:
1. Provided on hospital property, and provided for that
				  patient for whom it is requested or required;
2. Performed within the capabilities of the hospital's
				  emergency room (including ancillary services routinely available to its
				  emergency room);
3. Performed purposely to determine if the patient has an
				  emergency medical condition; and
4. Performed by a physician (M.D. or D.O.) and/or by a nurse
				  practitioner, or physician assistant as permitted by State statutes and rules
				  and by hospital bylaws.
"Mental Health Parity and Addiction Equity Act of 2008
				  (MHPAEA)" means the Federal law (
				  Pub. L.
				  110-343 ), which provides participants who already
				  have benefits under mental health and substance use disorder (MH/SUD) coverage
				  parity with benefits limitations under their medical/surgical coverage.
				  Medicaid/NJ FamilyCare managed care organizations are subject to the MHPAEA
				  statute.
"Multilingual" means, at a minimum, English and Spanish plus
				  any other language that is spoken by 200 enrollees or five percent or more of
				  the enrolled Medicaid/NJ FamilyCare population in the contractor's plan,
				  whichever is greater.
"NJ FamilyCare Alternative Benefit Plan (ABP)" means the
				  eligibility package that provides comprehensive, managed care coverage to
				  parents of dependent children, and single or married adults without dependent
				  children. The beneficiary must be between the ages 19 to 64 and have an income
				  between the AFDC standard set forth at N.J.A.C. 10:69-10 and 138 percent of the
				  Federal poverty level.
"NJ FamilyCare-Plan A" means the State-operated program which
				  provides comprehensive, managed care coverage to uninsured children below the
				  age of 19 with family incomes up to and including 133 percent of the FPL, to
				  children under the age of one year and pregnant women eligible under the New
				  Jersey Care . . . Special Medicaid Programs, to uninsured pregnant women with
				  incomes up to 200 percent of the FPL and to beneficiaries who are in AFDC
				  work-related extensions of eligibility. In addition to covered managed care
				  services, Plan A enrollees may access certain other services which are paid
				  fee-for-service by the State and not covered by MCOs, as specified in this
				  chapter.
"NJ FamilyCare-Plan B" 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 133 percent and up to
				  and including 150 percent of the FPL. In addition to covered managed care
				  services, Plan B enrollees may access certain other services which are paid
				  fee-for-service and not covered by MCOs, as specified in this chapter.
"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 FPL. In addition to covered managed care
				  services, Plan C enrollees may access certain other services which are paid
				  fee-for-service and not covered by MCOs, as specified in this chapter. Plan C
				  enrollees, except American Indians and Alaska Natives (AI/AN), are required to
				  participate in cost-sharing in the form of monthly premiums and personal
				  contributions to care for certain services, as specified in this
				  chapter.
"NJ FamilyCare-Plan D" means the State-operated program that
				  provides managed care coverage to uninsured children below the age of 19 with
				  family incomes above 200 percent and up to and including 350 percent of the
				  FPL. In addition to covered managed care services, Plan D enrollees may access
				  certain services that are paid fee-for-service and not covered by MCOs, as
				  specified in this chapter. Plan D enrollees with incomes above 150 percent of
				  the FPL, except American Indians and Alaska Natives (Al/AN) below the age of
				  19, participate in cost-sharing in the form of monthly premiums and copayments
				  for services, as specified in this chapter.
"NJ FamilyCare beneficiary" means an individual eligible to
				  receive services under the New Jersey FamilyCare program or NJ FamilyCare -
				  Children's Program in accordance with N.J.A.C. 10:78 or 79.
"Network" means "provider network" as defined in this
				  section.
" Non-covered Medicaid/NJ FamilyCare services" means all
				  services not covered under the New Jersey State Plan for the Medicaid/NJ
				  FamilyCare program.
"Non-participating provider" means a provider of service that
				  does not have a contract or other arrangement in accordance with N.J.A.C. 11:24
				  with the contractor.
" Out-of-area services" means all services covered under the
				  contractor's benefits package included under the terms of the Medicaid/NJ
				  FamilyCare contract that are provided to enrollees outside the defined service
				  area.
" Out-of-plan services" means Medicaid/NJ FamilyCare covered
				  services that have not been included in the contractor's benefits package.
				  These services are provided under a fee-for-service arrangement through the
				  Division to Medicaid beneficiaries and certain NJ FamilyCare beneficiaries who
				  have enrolled in an MCO.
"Participating provider" means a provider that has entered
				  into a provider contract or other arrangement in accordance with N.J.A.C. 11:24
				  with the contractor to provider services.
"Personal contribution to care (PCC)" means the fixed
				  monetary amount paid by Plan C enrollees for certain services/items received
				  from MCO providers.
"Physician" means a doctor of medicine (M.D.) or osteopathy
				  (D.O.) licensed to practice medicine and surgery by the New Jersey State Board
				  of Medical Examiners, or similarly licensed by comparable agencies of the state
				  in which he or she practices.
"Post stabilization care services" means covered services
				  related to an emergency medical condition that are provided after an enrollee
				  is stabilized in order to maintain the stabilized condition or to improve or
				  resolve the enrollee's condition.
"Prevalent language" means a language other than English that
				  is spoken by a significant number or percentage of potential enrollees and
				  enrollees in the State.
"Primary care" means all health care services and laboratory
				  services customarily furnished by or through a general practitioner, family
				  physician, internal medicine physician, pediatrician, or by an advanced
				  practice nurse, to the extent that the furnishing of those services by a nurse
				  practitioner is legally authorized in the state in which the advanced practice
				  nurse furnishes them.
"Primary care dentist (PCD)" means a licensed dentist who is
				  the health care provider responsible for supervising, coordinating, and
				  providing initial and primary dental care to patients; for initiating referrals
				  for specialty care; and for maintaining the continuity of patient care.
"Primary care provider (PCP)" means a licensed medical doctor
				  (MD) or doctor of osteopathy (DO) or certain other licensed medical
				  practitioner who, within the scope of practice and in accordance with State
				  certification/licensure requirements, standards and practices, is responsible
				  for providing all required primary care services to enrollees, including
				  periodic examinations, preventive health care and counseling, immunizations,
				  diagnosis and treatment of illness or injury, coordination of overall medical
				  care, record maintenance, initiation of referrals to specialty providers
				  described in this chapter and for maintaining the continuity of patient care.
				  This definition includes general/family practitioners, pediatricians,
				  internists and may include specialist physicians, physician assistants, CNMs or
				  advanced practice nurses (APNs), provided that the practitioner is able and
				  willing to carry out all PCP responsibilities in accordance with this chapter
				  and with applicable licensure requirements.
"Provider" means any physician, hospital, facility or other
				  health care professional who is licensed or otherwise authorized to provide
				  healthcare services in the state or jurisdiction in which they are
				  furnished.
"Provider network," within the context of managed care, means
				  the servicing providers with whom an MCO has entered into a written agreement
				  to perform a specified part of the MCO's obligations. These obligations are for
				  the provision of professional medical and behavioral services or goods and
				  ensuring coverage of all required services included in the benefits package.
				  The provider network will include primary care and specialty physicians,
				  dentists, other health care professionals and entities, hospitals, laboratories
				  and medical suppliers.
"Referral services" means those health care services rendered
				  by a health professional other than the primary care provider, and who are
				  approved by the primary care provider, or by the contractor.
"Risk contract" means a contract under which the MCO assumes
				  risk for the cost of the services covered under the contract, and under which
				  the MCO may incur a loss if the cost of providing services exceeds the payments
				  made by the Department to the MCO for services covered under the
				  contract.
"Routine care" means treatment of a condition which would
				  have no adverse effects if not treated within 24 hours, or could be treated in
				  a less acute setting, for example, a physician's office, or by the patient
				  himself.
"Secretary" means the Secretary of the United States
				  Department of Health and Human Services (DHHS).
"Service area" means the geographic area in which the
				  contractor is obligated to provide covered services for its Medicaid/NJ
				  FamilyCare enrollees under its contract.
"Supplemental Security Income (SSI)" means the program which
				  provides cash assistance and full Medicaid benefits for individuals who meet
				  the definition of aged, blind, or disabled, and who meet the SSI financial
				  needs criteria.
"Staff model" means a type of MCO operation in which MCO
				  employees are responsible for both administrative and medical functions of the
				  plan. Health professionals, including physicians, are reimbursed on a salary or
				  fee-for-service basis. These employees are subject to all policies and
				  procedures of the MCO. In addition, the MCO may contract with external entities
				  to supplement its own staff resources.
"Standard service package" means the list of services, and
				  any limitations thereto, which are required to be provided by managed health
				  care providers to Medicaid/NJ FamilyCare beneficiaries. These packages differ
				  by program.
"Subcontract" means any written agreement between the
				  contractor and a third party to perform a specified part of the contractor's
				  obligations under the contract.
"Subcontractor" means any third party who has a written
				  agreement with the contractor to perform a specified part of the contractor's
				  obligations to the State, and is subject to the same terms, rights, and duties
				  as the contractor. A subcontractor shall not subcontract any obligations
				  contained in its written agreement with the contractor.
"Substantial contractual relationship" means any contractual
				  relationship that provides for one or more of the following services:
1. The administration, management, or provision of medical
				  services; or
2. The establishment of policies, or the provision of
				  operational support, for the administration, management, or provision of
				  medical services.
"Target population" means the population from which the
				  initial number of enrollees, not to exceed any limit specified in the contract,
				  will be drawn; that is, individuals eligible for Medicaid/NJ FamilyCare
				  residing within the stated enrollment area and belonging to one of the
				  categories of eligibility for Medicaid/NJ FamilyCare to be covered under the
				  contract.
"Termination" means the loss of Medicaid/NJ FamilyCare
				  eligibility and, therefore, automatic disenrollment of the beneficiary from the
				  MCO.
" Third-party liability (TPL)" means another party or entity,
				  such as an insurance company, which is, or may be, responsible to pay for all
				  or a part of the health care costs of a Medicaid/ NJ FamilyCare-Plan A
				  beneficiary.
"Urgent care" means treatment of a condition that is
				  potentially harmful to a patient's health and for which his or her
				  physician/CNP/CNS has determined it is medically necessary for the patient to
				  receive medical treatment within 24 hours to prevent
				  deterioration.