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Effective Date: April 1, 2009

Approval Date: ____________ 48

copayment applies to primary care provider office visits rendered during off hours, home visits and for prescription drugs in excess of a 34-day supply. Mental health outpatient visits require a $25.00 copayment. The copayment for emergency room services is $35.00.

For NJ FamilyCare Plan C, no copayments will be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; lead screening and treatment; age-appropriate immunizations; preventive dental services; prenatal care; family planning visits; and pap smears, when appropriate. Other services (such as therapy visits, hearing aids, and eyeglasses) will not require a copayment. (See Attachment 6 for a detailed list of services and applicable copayment amounts).

For NJ FamilyCare Plan D, no copayments will be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; lead screening and treatment; age-appropriate immunizations; preventive dental services for children under 12; and prenatal care beyond the first visit. (See Section 6 for a detailed list of services and applicable copayment amounts).

A family that utilizes services that require copayment will pay more when measured as a percentage of family income, but in fixed dollar terms the copayment structure does not favor higher income families over lower income families.

For any family subject to cost-sharing (premiums and copayments), an annual limit equal to five percent of the family income will apply. When families reach this limit, they are no longer required to pay and will be provided with a letter to that effect, which they can use when accessing services. Please see attachment 6 for cost sharing associated with specific services.

8.3. Describe how the public will be notified, including the public schedule, of this cost-sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b)) General reference to the cost-sharing requirements will be included in all public communications concerning the Title XXI program. The specific requirements will be detailed in the implementing regulations, in all pamphlets and brochures developed for outreach purposes, on the application for participation, and as a supplement to the member’s handbook for all new plan enrollees. The letter that confirms eligibility and enrollment in the program will also address the cost-sharing requirements and indicate the family cap that applies based on reported income. Specifically, information regarding increases in cost sharing will be sent by letter to each family and will include the dollar amounts applicable to the individual family. Specific schedules will be published in the New Jersey Register, published as a legal