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Effective Date: April 1, 2009

Approval Date: ____________ 14

and the capitation payment paid to the participating plans are not amended for the Title XXI population to account for the copayments for children in families with income above 150% of the federal poverty level. Premiums are collected by a vendor on behalf of the State and, therefore, have no impact on managed care rates, although the premiums help to offset the total cost of the program. The premiums are not used as any part of the state share.

The services paid for on a fee-for-service basis are part of the purchased Medicaid package and are not counted as a contract with providers for direct service in computing the 10% cap. Essential, non-HMO covered services provided under Title XXI, however, are not equivalent to those provided under the Medicaid program (see Section 6 regarding benefits).

There are three significant advantages to this approach. First, it allows the State and Federal government to take advantage of the purchasing power of the Medicaid program, while providing a service package that moves closer to or, in the case of NJ FamilyCare-Children's Program Plan D, equals that provided by commercial plans. Second, it recognizes the need to develop a unified, managed care approach to the carved-out behavioral health services under the State's publicly financed programs. Third, it allows the State to take advantage of the stringent consumer protections and utilization control standards included in the Medicaid managed care contracts.

HMOs are required to have toll free telephone numbers, 24 hours a day, 7 days a week, for after-hours and urgent care needs. In addition, HMOs have case management systems, staffed by appropriate medical professionals, to assure that HMO members receive needed services in a supportive, effective, efficient, and cost-effective manner. Case management must be client-centered, goal- oriented, and culturally competent to assure appropriate provider/service linkages are made.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

Because Title XXI is not an entitlement program, enrollment and expenditures are monitored closely against the allotment. Enrollment will be stopped when total expenditures are projected to equal the available funding level. At any time that point is reached, additional applicants will be placed on a waiting list, with preference determined based on date of application and income. Appropriate referrals to other sources of care will be made and enrollment will resume as quickly as feasible given that the children will be without coverage in the interim. New Jersey does not have a waiting list currently.