N.J. Admin. Code § 10:74-2.1 - Contract requirements

(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.

(b) The contractor shall also comply with 42 CFR Part 438, as amended and supplemented.

(c) The contractor shall also comply with Titles XIX and XXI of the Social Security Act.

(d) The contractor shall also comply with the Federal Patient Protection and Affordable Care Act ( Pub. L. 111-148 ), as amended by the Federal Health Care and Education Reconciliation Act of 2010 ( Pub. L. 111-152 ), collectively known as the Affordable Care Act, incorporated herein by reference, as amended and supplemented.

Notes

N.J. Admin. Code § 10:74-2.1

Amended by 51 N.J.R. 1359(a), effective 8/19/2019