N.J. Admin. Code § 10:78-9.15 - Five percent of gross family income annual limit on cost-sharing (out-of-pocket) expenditures

Current through Register Vol. 54, No. 7, April 4, 2022

(a) If, during the course of a regular plan year (January 1 to December 31), the beneficiary and/or any other eligible family members incur cost sharing expenditures (copayments, co-insurance and deductibles) that are not directly reimbursable by the Premium Support Program (PSP), and that exceed five percent of the individual's or family's gross annual income, they may submit proof of such expenditures to the PSP for review and possible reimbursement, in accordance with the provisions of this section. If the beneficiary chooses an employer-sponsored plan which costs more than the basic plan approved by the Premium Support Program for that employee and/or any other eligible family members, the difference between the approved premium and the actual premium:
1. Will not be reimbursed by the Premium Support Program; and
2. Will not be included in the five percent cost sharing calculation (see 10:49-9.3 ).
(b) The annual limit on cost sharing expenditures shall be five percent of the individual's or family's gross annual income.
(c) The PSP will review all submitted medical expenditures made during the course of a plan year, and will determine those expenses that are allowable. If the allowable expenditures are equal to or greater than five percent of the individual's or family's gross annual income, all future cost sharing expenditures for the remainder of the plan year will be payable by the PSP.
1. Allowable expenses, for the purpose of the annual limit on cost-sharing (out-of-pocket) expenditures, shall be those expenses for services covered under the beneficiary's service package.
(d) The PSP will authorize such expenses by indicating a message on the NJ FamilyCare monthly ID Card waiving payment of such expenses for the remainder of the plan year. The provider will then bill the PSP for the amount of the cost share or the beneficiary may submit a bill to the PSP for reimbursement.

Notes

N.J. Admin. Code § 10:78-9.15

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