N.J. Admin. Code § 10:79-1.2 - Definitions

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

Words and terms used in this chapter shall have the meanings specified below, unless specifically defined otherwise in this chapter, or the context clearly indicates otherwise.

"Authorized agent" means a parent, guardian, caretaker or any other individual 18 or older who has sufficient information to assist in making an application for NJ FamilyCare-Children's Program children, including, but not limited to:

1. A staff member of a public or private welfare or social service agency of which the child for whom assistance is sought is a client and who has been designated by the agency to act as the child's agent;

2. An attorney or physician of the person seeking NJ FamilyCare-Children's Program benefits;

3. A staff member of an institution or facility in which the individual is receiving care and who has been designated by the institution or facility to so act; or

4. A legal guardian.

"Caretaker" or "caretaker adult" means the responsible adult or adults residing with the child or children for whom the application or redetermination for NJ FamilyCare-Children's Program is being made. This term does not impose a blood relationship to the caregiver as a prerequisite for applying for services on behalf of a child.

"Child" is an individual from birth through the age of 18 who is otherwise not eligible for Medicaid pursuant to N.J.A.C. 10:69, 10:71 or 10:72.

"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 Supplemental Nutrition Assistance Program (SNAP), and NJ FamilyCare 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.

"Copayment" means a specified dollar amount required to be paid by or on behalf of the beneficiary in connection with benefits as specified in N.J.A.C. 10:49-9.

"DMAHS" means Division of Medical Assistance and Health Services.

"Eligibility determination agency" means an entity, including, but not limited to, a public or private agency, either governmental, non-profit, or for profit, with which the Division of Medical Assistance and Health Services has a contract or agreement to perform some or all of the eligibility-related functions for NJ FamilyCare-Children's Program.

"Eligibility for coverage" means a child would be covered under a health insurance policy if an application had been made on the child's behalf.

"Governing unit" means any state, municipal, or local authority, including school boards, water and sewage authorities, as well as any state university and college system that is required or authorized by statute to provide a group health plan for active or retired employees.

"Group health plan" means an employee health benefit plan, whether the group health plan is self-funded or insured by a carrier that covers services for the diagnosis, cure, mitigation, treatment or prevention of disease or other problems in the structure or function of the body, and for transportation primarily for and essential to the provision of such medical care.

"Health Access New Jersey" means the subsidized insurance program authorized pursuant to N.J.S.A. 26:2H-18.6 5, and rules promulgated pursuant thereto (N.J.A.C. 8:91), which may also be referred to as the Access Program. This program stopped accepting applications on January 1, 2001.

"Health Benefits Identification (HBID) Card" means a permanent, plastic identification card issued to each Medicaid or NJ FamilyCare beneficiary. The card is for identification purposes only; providers must verify eligibility in accordance with N.J.A.C. 10:49-2 before they provide services. The front of the card will include the beneficiary's name and a 16-digit Card Control Number (CCN). The back of the card will include a magnetic strip, which electronically stores the beneficiary's name and CCN.

"Health insurance" means benefits or services provided for the diagnosis, cure, mitigation, treatment, or prevention of disease or other problems with the structure or function of the body, and transportation primarily for and essential to the provision of such medical care, provided pursuant to the terms of a contract issued to an individual or group health plan by a carrier or other "third party" within the meaning of N.J.S.A. 30:4D-3m.

"Health joint insurance fund" means a fund for the provision of health care services or benefits authorized in accordance with 40A:10-36 et seq. (Joint Insurance), and N.J.A.C. 11:15-3 (Joint Insurance Funds for Local Governmental Units Providing Group Health and Term Life Insurance Benefits), regardless of whether the benefits and services are self-funded by the participants or purchased under a contract of health insurance.

"Managed Care Organization" (MCO) shall have the same meaning as that contained in the definitions section at N.J.A.C. 10:74-1.4, as amended and supplemented.

"NJ FamilyCare Advantage Program" means a State program offering affordable health insurance for uninsured, dependent children under the age of 19 whose family's income exceeds 350 percent of the Federal Poverty Level under the authority of 30:4J-8 et seq., and P.L. 2008, c. 38.

"NJ FamilyCare-Children's Program" means the program administered by the Division of Medical Assistance and Health Services, which provides health care benefits to certain children under the authority of N.J.S.A. 30:4D et seq. and P.L. 1997, c. 272.

"Personal contribution to care" means a payment, similar to a copayment, which is a responsibility incurred by the enrollee for the cost of certain services as specified in N.J.A.C. 10:49-9.

"Third party liability" means any third party that is liable to pay part or all of the medical costs of the child. This includes, but is not limited to, medical insurance, tort and no-fault auto insurance (PIP) payments.

Notes

N.J. Admin. Code § 10:79-1.2
Amended by 49 N.J.R. 203(a), effective 1/17/2017

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