N.J. Admin. Code § 10:49-9.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:49-9.1 - NJ FamilyCare-Plan C personal contribution to care and Plan D copayments

(a) Under NJ FamilyCare-Plan C, personal contribution to care in the amounts indicated below shall be collected by the provider for the services indicated below:

1. Outpatient hospital clinic services: $ 5.00 personal contribution to care for outpatient visits. No personal contribution to care shall be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; lead screening and treatment; age-appropriate immunizations; prenatal care; preventive services; family planning services; or substance abuse treatment services. Specific policies are set forth at 10:52-4.7.

2. $ 10.00 personal contribution to care for each covered emergency room services visit which does not result in an inpatient hospital stay.

3. Physician services: $ 5.00 personal contribution to care per visit. No personal contribution to care shall be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; lead screening and treatment; age-appropriate immunizations; prenatal care; preventive or for family planning services, or substance abuse treatment services. Policies specific to physician personal contribution to care services are set forth at 10:54-4.1.

4. Clinic services: $ 5.00 personal contribution to care for clinic visits. No personal contribution to care shall be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; lead screening and treatment; age-appropriate immunizations; prenatal care; preventive or for family planning services, or substance abuse treatment services. Policies specific to clinic personal contribution to care policies are set forth at 10:66-1.6.

5. Podiatric services: $ 5.00 personal contribution to care for office visits. Specific policies regarding podiatric personal contribution to care are set forth at 10:57-1.7.

6. Optometric services: $ 5.00 personal contribution to care for professional vision care services. Specific policies are set forth at 10:62-1.6.

7. Chiropractic services: $ 5.00 personal contribution to care. Covered for spinal manipulation only.

8. Prescription drugs: $ 1.00 personal contribution to care for generics and $ 5.00 for brand name drugs. Includes insulin, needles and syringes. Specific policies regarding personal contribution to care for prescription drugs are set forth at 10:51-1.12.

9. Psychological services: $ 5.00 personal contribution to care. Specific policies for psychologists are set forth at 10:67-1.6.

10. Certified nurse-midwife services: $ 5.00 personal contribution to care. No personal contribution to care shall be charged for prenatal care, preventive care, or for family planning services. See 10:58-1.8 for specific policies related to certified nurse-midwife services.

11. Advanced practice nurse: $ 5.00 personal contribution to care. No personal contribution to care shall be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; lead screening and treatment; age-appropriate immunizations; prenatal care; preventive or for family planning services, or substance abuse treatment services. Special policies are set forth at 10:58A-1.6.

12. Dental services: $ 5.00 personal contribution to care applies, unless the visit is for preventive dentistry services. Specific policies are set forth at N.J.A.C. 10:57-1.7.

(b) Providers are required to collect the personal contribution to care for the NJ FamilyCare-Plan C services set forth in (a) above if the NJ FamilyCare Identification card indicates that a personal contribution to care is required and the beneficiary does not have a NJ FamilyCare letter which indicates that the beneficiary has reached his or her cost share limit and no further personal contributions to care are required until further notice. Personal contributions to care can not be waived.

(c) Under NJ FamilyCare-Plan D, copayments in the amounts indicated below shall be collected by the provider for services as follows, if copayment is indicated on the beneficiary's HMO card:

1. A $ 5.00 copayment per visit shall be required for the following services:

i. Primary care provider office visit during normal office hours;

(1) A $ 10.00 copayment shall apply for services rendered during non-office hours and for home visits.

(2) The $ 5.00 copayment shall apply only to the first prenatal visit;

ii. Physician, specialist, podiatrist, optometrist, certified nurse midwife, advanced practice nurse and psychologist office visit;

(1) Optometrist office visit for newborns covered under fee-for-service are not subject to the $ 5.00 copayment.

iii. Outpatient rehabilitation services, including physical therapy, occupational therapy and speech therapy;

iv. Hospital outpatient department visits, laboratory and X-rays services;

v. Routine eye examinations;

vi. Prescription drugs;

(1) If greater than a 34-day supply of a prescription drug is dispensed, a $ 10.00 copayment shall apply; and

vii. Outpatient substance abuse services for detoxification;

2. A $ 25.00 copayment per visit shall be required for outpatient mental health visits;

3. A $ 35.00 copayment per visit shall be required for outpatient emergency services, including services provided in an outpatient hospital department or an urgent care facility.

i. No copayment shall be required if the beneficiary was referred to the emergency room by his or her primary care provider for services that should have been rendered in the primary care physician's office, or if the beneficiary is admitted into the hospital;

4. A $ 10.00 copayment per visit shall be required for primary care providers, certified nurse midwives, physician specialists, and advance practice nurses for non-office hour visits and home visits; and

5. No copayment is required for well-child visits in accordance with the recommended schedule of the American Academy of Pediatrics, including lead screening and treatment, age appropriate immunizations, prenatal care and preventive dental services.

(d) Personal contributions to care under NJ FamilyCare-Plan C and copayments under NJ FamilyCare-Plan D shall be effective upon date of enrollment.

1. Exception: A personal contribution to care or copayment shall not apply to services rendered to a newborn until the newborn is enrolled in a managed care program.

(e) No personal contribution to care under NJ FamilyCare-Plan C shall be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; lead screening and treatment; age-appropriate immunizations; preventive dental services; prenatal care; for family planning services; or for substance abuse treatment services.

(f) No copayment under NJ FamilyCare-Plan D will be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; nor for lead screening and treatment; for age-appropriate immunizations; or for preventive dental services.

(g) No cost sharing shall be imposed on children who are American Indians/Alaska Natives. Proof of Federally recognized AI/AN tribal status shall be provided in the form of a tribal card or letter, in accordance with 42 C.F.R. 36a.16.

N.J. Admin. Code § 10:49-9.1

New Rule, R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Former N.J.A.C. 10:49-9.1, Civil Rights, recodified to N.J.A.C. 10:49-9.4.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 with changes, effective 9/21/1998.
Amended by R.1999 d.211, effective 7/6/1999 (operative August 1, 1999).
See: 31 N.J.R. 998(a), 31 N.J.R. 1806(a), 31 N.J.R. 2879(b).
Added a new (c); recodified former (c) and (d) as (d) and (e); added (f).
Amended by R.2002 d.371, effective 11/18/2002.
See: 34 N.J.R. 2244(a), 34 N.J.R. 2549(b), 34 N.J.R. 3978(c).
Added (g).
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
Special amendment, R.2003 d.98, effective 1/31/2003.
See: 35 N.J.R. 1303(a).
In (c), rewrote the introductory paragraph and deleted viii.
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
In (a)11, substituted "Advanced practice nurse" for "Clinical nurse practitioner"; in (c)1i, inserted "during normal office hours"; rewrote (c)1ii; in (c)1iv, substituted ", laboratory and x-rays services" for "and diagnostic testing"; in (c)2, deleted "and" from the end; in (c)3i, substituted a semicolon for a period at the end; rewrote (c)4, and added (c)5.