Medicaid and NJ FamilyCare Selected HMO Contract Provisions
Out-of-Area Coverage. The HMO must provide or arrange for out-of-area covered benefits “in emergency situations and non-emergency situations when travel back to the service area is not possible, is impractical, or when medically necessary services could not be provided elsewhere.” However, except for full-time students, the HMO is not responsible for routine care if the enrollee resides out of state for more than 30 days. This also does not apply when the individual is receiving out-of-state care that has been authorized by the HMO--for example, prolonged hospital care for transplants. (Note: Full time students attending school and residing outside of the U.S. will not be covered.)
Routine Physicals. The HMO shall provide for routine physical exams “required for employment, school/camp, or other entities/programs that require such examinations as a condition of employment or participation.” These exams must be scheduled to occur within four weeks.
Non-Participating Providers. The HMO must pay for services from a non-participating provider if the enrollee was referred there by his/her HMO Primary Care Provider (PCP), even if the referral was in error. However, an enrollee is responsible for the cost of care by a non-participating provider if the enrollee started the care without a referral or authorization.
Second Opinions. Each HMO is to have a Second Opinion program that can be “utilized at the enrollee’s option for diagnosis and treatment of serious medical conditions, such as cancer and for elective surgical procedures.”
Existing Plans of Care. The HMO shall pay for plans of care for new enrollees, including prescriptions, durable medical equipment, medical supplies, prosthetic and orthotic appliances, and any other on-going services that began before enrollment in the HMO. These services will be continued until the enrollee is evaluated by his/her PCP and a new plan of care is established.
Protection of Enrollee-Provider Communications. The HMO’s doctors and other health care providers are not prohibited from advising their patients about the medical services the patients may need, whether or not they are services that are covered by the HMO.
*The current 500+ page, two-volume contract between the Division of Medical Assistance and Health Services (NJ Medicaid) can be found online:
This information last reviewed 10/26/11 |
