New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:49-1.3 - 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.
"Adult mental health rehabilitation services provided in/by
				  community residence programs" means community residential mental health
				  services provided in/by any community residential program licensed by, and
				  under contract with, the Division of Mental Health Services (DMHS), which
				  provides services in accordance with N.J.A.C. 10:37A. These services include
				  assessment and evaluation; individual service coordination; training in daily
				  living skills; residential counseling; life support services and crisis
				  intervention services.
"AFDC" means the former Aid to Families with Dependent
				  Children program.
"AFDC-related Medicaid" means medical assistance provided to
				  families who would otherwise qualify for AFDC or would be deemed to qualify for
				  AFDC if the program would be deemed still in existence.
"American Indian/Alaska Native (AI/AN)" means a member of a
				  Federally recognized Indian tribe, band, or group; an Eskimo or Aleut or other
				  Alaska Native enrolled by the Secretary of the Interior pursuant to the Alaska
				  Native Claims Settlement Act, 43 C.F.R. 1601 et seq.; or a person who is
				  considered by the Secretary of the Interior as meeting the requirements of
				  tribal membership in accordance with 42 C.F.R. 36a.16.
"Beneficiary or eligible beneficiary" means any person
				  meeting the definition of recipient as defined below.
"Centers for Medicare and Medicaid Services (CMS)" means the
				  agency of the Federal Department of Health and Human Services which is
				  responsible for the administration of the Medicaid program in the United
				  States.
"Commissioner of DHS" means the Commissioner of the
				  Department of Human Services.
"Community residences for mentally ill adults" means any
				  community residential program licensed by the Division of Mental Health
				  Services in accordance with N.J.A.C. 10:37A. "Community residences for mentally
				  ill adults" does not include supportive housing residences as defined at
				  10:37A-1.2 and
				  10:77A-1.2.
"Copayment" means a specified dollar amount required to be
				  paid by or on behalf of the beneficiary in connection with benefits as
				  specified in
				  10:49-9.1.
"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 Food Stamp program 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.
"Department" or "DHS" means the Department of Human Services.
				  The Department of Human Services is the single State agency designated by
				  30:4D-3 in accordance with 42 CFR
				  412.30 for the administration of the New Jersey Medicaid/NJ FamilyCare
				  program.
"Department of Children and Families" or "DCF" means the New
				  Jersey Department of Children and Families, created by
				  P.L.
				  2006, c. 47.
"DHSS" means the Department of Health and Senior
				  Services.
"Division" or "DMAHS" means the Division of Medical
				  Assistance and Health Services.
"DMHS" means the Division of Mental Health Services within
				  the New Jersey Department of Human Services.
"Dual eligibles" means those Medicaid/NJ FamilyCare
				  beneficiaries who are also eligible for Medicare benefits under Title XVIII of
				  the Social Security Act.
"DYFS" means the Division of Youth and Family Services within
				  the New Jersey Department of Children and Families.
"Fiscal agent" means an entity that processes and adjudicates
				  provider claims on behalf of programs administered in whole or part by the
				  Division.
"Managed care service administrator" 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.
"Medicaid" means medical assistance provided to certain
				  persons with low income and limited resources as authorized under Title XIX
				  (Medicaid) of the Social Security Act.
"Medicaid Agent" means, under Reorganization Plan No.
				  001-1996, either DHSS or DMAHS, acting as administrators of the Medicaid
				  program.
"Mental health rehabilitation services" means psychiatric and
				  psychological services, including emotional and/or behavioral treatment, drug
				  and alcohol dependency treatment, psychiatric treatment, psychotherapy and
				  related nursing services.
"NJ FamilyCare" means the health insurance coverage program
				  administered by DMAHS under the provisions of Title XIX and Title XXI of the
				  Social Security Act.
"NJ FamilyCare-Plan A" means the State-operated program,
				  which provides comprehensive, managed care coverage, including all benefits
				  provided through the New Jersey Care . . . Special Medicaid Programs, to
				  eligible children below the age of 19 with family incomes up to and including
				  133 percent of the Federal poverty level, children under the age of one year,
				  pregnant women eligible under the New Jersey Care . . . Special Medicaid
				  Programs, pregnant women up to 200 percent of the Federal poverty level,
				  AFDC-related children under age 21 and TANF/AFDC-RELATED Medicaid parents. In
				  addition to covered managed care services, eligibles may access certain other
				  services, which are paid fee-for-service.
"NJ FamilyCare-Plan B" means the State-operated program which
				  provides comprehensive, managed care coverage to uninsured children through the
				  age of 18 with family incomes above 133 percent and not in excess of 150
				  percent of the Federal poverty level. In addition to covered managed care
				  services, eligibles may access mental health and substance abuse services and
				  certain other services which are paid fee-for-service.
"NJ FamilyCare-Plan C" means the State-operated program which
				  provides comprehensive, managed care coverage to uninsured children through the
				  age of 18 with family incomes above 150 percent and not in excess of 200
				  percent of the Federal poverty level. In addition to covered managed care
				  services, eligibles may access mental health and substance abuse services and
				  certain other services which are paid fee-for-service. Eligibles are required
				  to participate in cost-sharing in the form of monthly premiums and personal
				  contributions to care for certain services.
"NJ FamilyCare-Plan D" means the State-operated program,
				  which provides managed care coverage to uninsured children through the age of
				  18 with gross family incomes above 200 percent and not in excess of 350 percent
				  of the Federal poverty level, parents/caretakers with income up to 200 percent
				  of the Federal poverty level who applied on or before June 14, 2002, and as a
				  result, were subsequently and continuously enrolled in the program,
				  parents/caretakers with incomes less than or equal to 133 percent of the
				  Federal poverty level who were enrolled in the program pursuant to
				  P.L.
				  2005, c. 156, adults
				  with incomes up to and including 250 percent of the Federal poverty level
				  formerly covered by the Health Access Program and restricted alien parents
				  formerly covered under NJ FamilyCare Plan H. In addition to covered managed
				  care services, eligibles may access certain services including mental health
				  and substance abuse services, with limitations, which are paid fee-for-service.
				  Eligibles participate in cost-sharing in the form of monthly premiums and
				  copayments for most services.
"NJ FamilyCare Plan D for adults" means the State-operated
				  program which provides a benefit package through managed care organizations,
				  supplemented by services provided on a fee-for-service basis, to specified
				  parents/caretakers of children enrolled in NJ FamilyCare, in accordance with
				  10:49-5.7,
				  10:78-7.1 and this chapter.
"NJ FamilyCare Plan I" means the State-operated program which
				  provides a Plan D benefit package on a fee-for-service basis to specified
				  parents/caretakers of children enrolled in NJ FamilyCare, in accordance with
				  10:78-7.1 and this chapter.
"Prepaid health plan" means an entity that provides medical
				  services to enrollees under a contract with DMAHS on the basis of prepaid
				  capitation fees but which does not necessarily qualify as an HMO. For rules
				  concerning prepaid health care services, see
				  10:49-1.1. For Medicaid Managed
				  Care Program--New Jersey Care 2000, see N.J.A.C. 10:49-21.
"Program" means the New Jersey Medicaid program.
"Programs" means the New Jersey Medicaid program and the NJ
				  FamilyCare program.
"Programs of Assertive Community Treatment (PACT)" means
				  mental health rehabilitative services which are delivered in a self-contained
				  treatment program, provided by a service delivery team and managed by a
				  qualified program director, that merge clinical and rehabilitative expertise to
				  provide mental health treatment, rehabilitation, and support services which are
				  individualized and tailored to the unique needs and choices of the individual
				  receiving the services.
"Provider" means any individual, partnership, association,
				  corporation, institution, or any other public or private entity, agency, or
				  business concern, meeting applicable requirements and standards for
				  participation in the New Jersey Medicaid Program, other Special programs, and
				  where applicable, holding a current valid license, and lawfully providing
				  medical care, services, goods and supplies authorized under N.J.S.A. 30:4D-l et
				  seq. and amendments thereto.
"Qualified applicant" means a person who is a resident of
				  this State and is determined to need medical care and services as provided
				  under the Medical Assistance and Health Services Act,
				  30:4D-1 et seq., and who meets one
				  of the eligibility criteria set out therein.
"Recipient" means a qualified applicant receiving benefits
				  under the Medical Assistance and Health Services Act,
				  30:4D-1 et seq.
"Temporary Assistance to Needy Families (TANF)" means that
				  program administered by the Division of Family Development within the
				  Department of Human Services in accordance with N.J.A.C. 10:90.