N.J. Admin. Code § 10:54-4.2

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:54-4.2 - Personal contribution to care requirements for NJ FamilyCare-Children's Program-Plan C and copayments for NJ FamilyCare-Plan D

(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Children's Program-Plan C and copayments for NJ FamilyCare-Plan D are set forth at N.J.A.C. 10:49-9.

(b) Personal contribution to care for NJ FamilyCare-Children's Program-Plan C services is $5.00 a visit for office visits, except when the service is provided for preventive care, prenatal care, family planning services or substance abuse treatment services.

1. An office visit is defined as a face-to-face contact with a medical professional under the supervision of the physician, which meets the documentation requirements codified at N.J.A.C. 10:52-2.6 through 2.12.

2. Office visits include physician services provided in the office, patient's home, or any other site excluding hospital where the child may have been examined by the physician. Generally, these procedure codes are in the 90000 HCPCS series of reimbursable codes codified at N.J.A.C. 10:54-9.3.

3. Physician services which do not meet the requirements of an office visit as defined in this chapter, such as surgical services, immunizations, laboratory or x-ray services, do not require a personal contribution to care.

(c) Physicians shall not charge a personal contribution to care for services provided to newborns, who are covered under fee-for-service for Plan C; for family planning services; for substance abuse treatment services; for prenatal care or for preventive services, including appropriate immunizations.

(d) The copayment for primary care and specialist physician services under NJ FamilyCare-Plan D shall be $5.00 per office visit;

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.

(e) Physicians shall collect the copayment specified in (d) above except for those situations outlined in (f) below. Copayments shall not be waived.

(f) Physicians shall not charge a copayment under Plan D for services provided to newborns, who are covered under fee-for-service for Plan D; or for preventive services, including well child visits, lead screening and treatment, or age-appropriate immunizations.

N.J. Admin. Code § 10:54-4.2

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. 10:54-4.2, Use of physician reimbursement codes, recodified to N.J.A.C. 10:52-4.3.
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 without change.
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).
In (a), added reference to copayments for NJ KidCare-Plan D; added (d) through (f).
Amended by R.2006 d.237, effective 7/3/2006.
See: 38 N.J.R. 907(a), 38 N.J.R. 2803(a).
Section was "Personal contribution to care requirements for NJ KidCare-Plan C and copayments for NJ KidCare-Plan D". In (a), substituted "FamilyCare-Children's Program" for first occurrence of "KidCare" and "FamilyCare" for second occurrence of "KidCare"; in (b), substituted "FamilyCare-Children's Program" for "KidCare"; and in (d), substituted "FamilyCare" for "KidCare".