reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 6 - GENERAL ENROLLMENT › Section 10:74-6.1 - Enrollment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prior to implementation, the contractor
				shall obtain written approval from the Division of the method of enrollment and
				the enrollment forms to be used in enrolling Medicaid/NJ FamilyCare
				beneficiaries. The contractor shall adhere to the enrollment procedures
				required by the Division and detailed in the MCO contract.
(b) The contractor shall enroll Medicaid/NJ
				FamilyCare beneficiaries in the order in which they apply, or are assigned by
				the Division (in those Medicaid/NJ FamilyCare and Plan A cases where a
				selection is not made) without restrictions, up to contract limits.
(c) Enrollment shall be for the entire
				Medicaid/NJ FamilyCare "case" (family household).
(d) Enrollment shall be for an initial period
				not to exceed 12 months and in accordance with Section 1932(a)(4) of the Social
				Security Act (
				42 U.S.C. §
										1396u-
				2(a)(4)
				), with the exceptions indicated in N.J.A.C. 10:74-7. This fact shall be
				clearly stated on the enrollment package.
(e) For any person who applies for
				participation in the managed care program and who is hospitalized at the time
				this coverage becomes effective, such coverage shall not commence until the
				date such person is discharged from the hospital.
(f) Medicaid/NJ FamilyCare-Plan A enrollees
				shall be subject to a 12-month enrollment lock-in period and may initiate
				disenrollment/MCO transfer during the first three months after the effective
				date of initial managed care enrollment and every 12 months thereafter without
				cause.
(g) All other Medicaid/NJ
				FamilyCare enrollees (non-Plan A) shall be subject to a 12-month enrollment
				lock-in period.
(h) Enrollment
				lock-in shall not apply to beneficiaries who are aged, blind, and disabled,
				clients of DDD, or to CP&P clients.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 7 - DISENROLLMENT › Section 10:74-7.1 - Disenrollment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Disenrollment shall occur:
1. Upon death or whenever the enrollee is no
				longer Medicaid/NJ FamilyCare eligible, unless otherwise specified in the
				contract;
2. Except for the aged,
				blind, or disabled populations, whenever the enrollee moves outside of the
				MCO's enrollment area boundaries. The contractor shall remain responsible for
				the enrollee's care until the individual or the family/case has been
				disenrolled from the plan. Moving from the MCO's enrollment area does not
				negate a plan's responsibility to provide Medicaid/NJ FamilyCare benefits. If a
				plan is aware that a beneficiary who is not aged, blind, or disabled is
				residing outside its enrollment area, the contractor shall ask DMAHS to
				disenroll the beneficiary due to the change of residence;
3. Whenever the enrollee is admitted to a
				Residential Treatment Center;
4.
				Whenever the contract between the Department and the contractor is
				terminated;
5. Whenever granted
				through the formal grievance, in accordance with
				10:74-11.1;
6. Whenever a Medicaid/NJ FamilyCare enrollee
				who was determined eligible under NJ FamilyCare-Children's Program attains the
				age of 19 years;
7. Whenever a
				Medicaid/NJ FamilyCare enrollee becomes ineligible due to other health
				insurance coverage; or
8. Whenever
				a Medicaid/NJ FamilyCare-Plans B, C, or D participant loses program eligibility
				in accordance with
				N.J.A.C.
				10:79-7.1.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 8 - ENROLLEES › Section 10:74-8.1 - Mandatory managed care enrollment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medicaid
				eligible persons and NJ FamilyCare-Plan A children who reside in geographically
				defined enrollment areas designated for mandatory enrollment and who are not
				institutionalized, excluded or exempt, and who belong to one of the eligibility
				categories listed at (b) below shall enroll in an MCO of their choice, or, if a
				choice is not made, an MCO shall be assigned for them.
(b) The following Medicaid/NJ FamilyCare-Plan
				A eligibility groups shall enroll in a managed care organization:
1. Medicaid Special (covers children ages 19
				to 21, using AFDC standards);
2.
				Pregnant women and infants up to age one with incomes at or below 185 percent
				of the Federal Poverty Level who are eligible under New Jersey Care . . .
				Special Medicaid Programs;
3.
				Families who are eligible for Medicaid using the Aid to Families with Dependent
				Children (AFDC)-Related Medicaid rules at N.J.A.C. 10:69;
4. SSI aged, blind, and disabled, and
				essential spouses;
5. Aged, blind,
				and disabled eligible under New Jersey Care . . . Special Medicaid
				Programs;
6. Division of
				Developmental Disabilities clients, including those covered under the Division
				of Developmental Disabilities Community Care Waiver;
7. Medicaid only or SSI-related aged, blind
				or disabled eligible beneficiaries;
8. Uninsured children up to the age of 19 who
				qualify for the NJ FamilyCare-Plan A program; and
9. Children under CP&P supervision in
				resource family care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 8 - ENROLLEES › Section 10:74-8.2 - Enrollment exclusions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				persons shall be excluded from enrollment in the managed care program:
1. Individuals who are institutionalized in
				an inpatient psychiatric institution, a long term care nursing facility, or an
				inpatient psychiatric program for children under the age of 21 or in a
				residential facility including intermediate care facilities for individuals
				with intellectual disabilities (ICF/IID) with the following exception:
i. Individuals who are eligible through
				CP&P or individuals in a mental health or substance abuse residential
				treatment facility are not excluded from enrolling in the contractor's
				plan;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 8 - ENROLLEES › Section 10:74-8.3 - Voluntary managed care enrollment (allowed and not allowed)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				following individuals shall be excluded from the automatic assignment process
				but may enroll voluntarily:
1. Individuals
				whose Medicaid or NJ FamilyCare-Plan A eligibility will terminate within three
				months or less after the projected date of effective enrollment;
2. Individuals in mandatory eligibility
				categories who live in a county where mandatory enrollment is not yet required
				based on a phase-in schedule determined by DMAHS;
3. Individuals already enrolled in, or
				covered by, either a Medicare or commercial MCO, shall not be enrolled in a
				contractor's plan, unless the contractor and the Medicare or commercial MCO are
				the same;
4. Individuals in the
				Medicaid Pharmacy Lock-in, Provider Warning, or Hospice programs (see "Special
				Status" requirements at
				10:49-14.2, and general hospice
				requirements at N.J.A.C. 10:53A);
5. Individuals in Medicaid eligibility
				categories other than those specified in
				10:74-8.1;
6. Individuals eligible through Child
				Protection and Permanency (CP&P) who are not in resource family care:
i. All individuals eligible through CP&P
				shall be considered a unique case and shall be issued an individual 12-digit
				identification number and shall be enrolled in his or her own right.
7. Children awaiting adoption
				through a private agency;
8.
				Individuals identified as having more than one active eligible Medicaid/NJ
				FamilyCare number; and
9. Dual
				Medicare/Medicaid eligibles.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 8 - ENROLLEES › Section 10:74-8.5 - Coverage prior to enrollment

Current through Register Vol. 56, No. 14, July 15, 2024
If the beneficiary needs Medicaid/NJ FamilyCare-Plan A
				  covered services from the date of eligibility prior to the completion of the
				  enrollment process, care shall be given by fee-for-service providers enrolled
				  in the New Jersey Medicaid/NJ FamilyCare program. These providers shall bill
				  Medicaid/NJ FamilyCare under the normal fee-for-service system, in accordance
				  with N.J.A.C. 10:49-8.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 8 - ENROLLEES › Section 10:74-8.6 - Coverage after enrollment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The MCO shall
				issue an identification card to the beneficiary indicating the effective
				enrollment date in the MCO.
(b)
				Beneficiaries shall consult their primary care provider (PCP)/APN for necessary
				medical care and services.
(c) The
				PCP/APN shall provide all necessary treatment or make the appropriate
				referral.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 8 - ENROLLEES › Section 10:74-8.7 - Protecting managed care enrollees against liability for payment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If a
				fee-for-service or managed care provider, whether or not a participant in a
				program administered in whole or in part by the Division of Medical Assistance
				and Health Services (DMAHS), renders a covered service to a beneficiary of a
				program administered in whole or in part by DMAHS, including, but not limited
				to, the WorkFirst NJ/General Assistance, Medicaid/ NJ FamilyCare program, the
				provider's sole recourse for payment, other than collection of any authorized
				cost-sharing and/or third-party liability, shall be either DMAHS or the MCO
				with which DMAHS contracts that serves the beneficiary. A provider shall not
				seek payment from, and shall not institute or cause the initiation of
				collection proceedings or litigation against, a beneficiary, a beneficiary's
				family member, any legal representative of the beneficiary or anyone else
				acting on the beneficiary's behalf unless (a)1 below, or (a)2 through and
				including 7 below, apply:
1. The beneficiary
				has been paid for the service by a health insurance company or other third
				party (as defined in
				30:4D-3.m.), and the beneficiary
				has failed or refused to remit to the provider that portion of the third
				party's payment to which the provider is entitled by law; or
2. Either:
i. The service is not a covered
				service;
ii. The service is
				determined to be medically unnecessary before it is rendered; or
iii. The provider does not participate in the
				aforementioned programs either generally or for that service;
3. The beneficiary is informed in
				writing before the service is rendered that one or more of the conditions
				listed in (a)2 above exists and voluntarily agrees in writing before the
				service is rendered to pay for all or part of the provider's charges;
4. The service is not an emergency or related
				service covered by the provisions of
				42 U.S.C. §
											1396u-2(b)(2)(A)(i),
				42 CFR
				438.114,
				30:4D-6i and/or
				10:74-9.1;
5. The service is not a trauma service
				covered by the provisions of
				11:24-6.3(a)3 
				i;
6. The protections afforded to
				beneficiaries under
				42 U.S.C. §
											1396u-2(b)(6),
				42 CFR
				438.106,
				11:24-9.1(d)9 
				and/or 15.2(b)7ii do not apply; and
7. The provider has received no program
				payments from either DMAHS or the beneficiary's MCO for the service.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 9 - EMERGENCY SERVICES › Section 10:74-9.1 - Emergency services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contractor shall, on a 24-hour-a-day,
				seven-day-a-week basis, make available emergency services, that is, those
				services within or outside of the contractor's enrollment area, required to be
				provided to an enrollee as a result of an onset of a medical or behavioral
				condition, the onset of which is sudden, that manifests itself by symptoms of
				sufficient severity, including severe pain, that a prudent layperson, who
				possesses an average knowledge of medicine and health, could reasonably expect
				the absence of immediate medical attention to result in placing the health of
				the person or others in serious jeopardy; serious impairment to such person's
				bodily functions; serious dysfunction of any bodily organ or part of such
				person, or serious disfigurement of such person. With respect to a pregnant
				woman who is having contractions, an emergency exists when there is inadequate
				time to effect a safe transfer to another hospital before delivery or when such
				a transfer may pose a threat to the health or safety of the woman or unborn
				child. Emergency services shall also include:
1. Medical examinations at an emergency room
				for suspected physical/child abuse and/or neglect.
2. Medical examinations at an emergency room
				in accordance with
				10:122D-2.5(b) 
				when a foster home placement of a child occurs after business hours.
3. In regard to post-stabilization of care,
				the contractor shall comply with
				42
				CFR 422.113(c) incorporated
				herein by reference, as amended and supplemented. The contractor shall cover
				post-stabilization services without requiring authorization and regardless of
				whether the enrollee obtains the services within or outside the contractor's
				network, if:
i. The services were pre-approved
				by the contractor or its providers;
ii. The services were not pre-approved by the
				contractor because the contractor did not respond to the provider of
				post-stabilization care services' request for pre-approval within one hour
				after being requested to approve such care; or
iii. The contractor could not be contacted
				for pre-approval.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 10 - MEDICAL INFORMATION AND QUALITY ASSURANCE › Section 10:74-10.1 - Medical information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each contractor
				shall maintain medical information on each member who has received medical
				services while enrolled in the contractor's plan, and shall retain such records
				in accordance with 45 CFR Part 74 and applicable Federal and State law and
				rule.
(b) Each enrollee's medical
				information shall be kept in detail consistent with applicable Federal and
				State requirements and good medical and professional practice, based on the
				service provided.
(c) Each
				contractor shall conform to the standards of confidentiality of information
				mandated for Federal and State officials (Section 1902(a)(7) of the Federal
				Social Security Act, 42 CFR Part 438 as included herein by reference, as
				amended and supplemented,
				30:4D-7(g), and
				10:49-9.7 and 9.8).
(d) Medical information of enrollees shall be
				sufficiently complete to permit subsequent medical and quality audits. All
				required records, either originals or reproductions thereof, shall be
				maintained in legible form and readily available to appropriate Division
				professional staff or its agents, upon request for review, audit and evaluation
				by professional medical, nursing and investigative staff, in accordance with
				appropriate Federal and State laws, rules and regulations.
(e) The contractor shall release medical
				records/information of enrollees, as may be directed by authorized personnel of
				the Division, appropriate agencies of the State of New Jersey or the United
				States Government, consistent with the provisions of confidentiality ( 42 CFR
				Part 438, 30:4D-7(g)  and
				10:49-9.7 ).
(f) The contractor and/or its MCO
				participating servicing providers shall agree to release the comprehensive
				medical records/information of enrollees upon termination of their coverage, as
				may be directed by the enrollee, authorized personnel of the Division,
				appropriate agencies of the State of New Jersey or of the United States
				Government.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 10 - MEDICAL INFORMATION AND QUALITY ASSURANCE › Section 10:74-10.2 - Quality assurance

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division and the U.S. Department of
				Health and Human Services shall have the right to inspect or otherwise evaluate
				the quality, appropriateness and timeliness of services performed by the
				contractor in accordance with State and Federal requirements.
(b) The contractor shall offer assurances
				that all health services required by its enrollees shall meet quality standards
				within the appropriate medical practice of care, consistent with the medical
				community standards of care.
(c)
				The contractor shall submit to the Division for approval a detailed plan for
				establishing and maintaining an internal quality assurance system to assure
				that acceptable professional practice shall be followed by the organization and
				its subcontractors. This shall include a proposed system for continuing
				performance review and health care evaluation, that is, explanation of the
				methods that the contractor proposes to follow in guaranteeing that the
				services provided each enrollee shall meet criteria established by appropriate
				Federal and State statutes and regulations. (See 42 CFR Part 438.)
1. The contractor shall include in the
				written agreement with the subcontractor, the requirement that a subcontractor
				be prohibited from further subcontracting any of the obligations that they
				agreed to meet.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 11 - GRIEVANCE PROCEDURE › Section 10:74-11.1 - Grievance procedure

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contractor
				shall establish a grievance procedure for the receipt and adjudication of any
				and all complaints from enrollees or managed care providers on behalf of
				enrollees, with the enrollees' consent, relating to quality, scope, nature and
				delivery of services.
(b) The
				grievance procedure shall be communicated to the enrollees in writing and shall
				provide for expeditious resolution of grievances by the contractor's personnel
				who shall be at a decision-making level with authority to require corrective
				action.
(c) The contractor shall
				review the complaint procedure at reasonable intervals, but no less than
				annually, for the purpose of improving the procedure.
(d) Any amendment to the procedure shall be
				presented to the Division prior to the implementation of any change, and the
				Division's written approval shall be obtained, in accordance with 42 CFR Part
				438, Subpart F incorporated herein by reference, as amended and supplemented,
				in order to assure that enrollees are afforded an opportunity to be
				heard.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 11 - GRIEVANCE PROCEDURE › Section 10:74-11.2 - Medicaid/NJ FamilyCare fair hearing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contractor
				shall ensure that all Medicaid and NJ FamilyCare-Plan A and Plan D adult
				enrollees with incomes under 134 percent of the FPL, shall be informed, in a
				simple, brief statement, of their rights to a fair hearing in accordance with
				N.J.A.C. 10:49-10, and of the contractor's grievance review procedures. This
				may be accomplished by an annual mailing, as noted in
				10:74-5.1(c)3, a
				member handbook or any other method that shall not diminish the enrollees'
				opportunity to be heard. Enrollees of all other NJ FamilyCare plans shall not
				have access to the fair hearing process described in N.J.A.C. 10:49-10.
				However, these beneficiaries shall be accorded all appeal rights consistent
				with the appropriate rules of the Department of Banking and Insurance. See
				N.J.A.C. 11:20-20 and 11:24-8.
(b)
				The contractor shall report all grievances to the Division with a brief
				statement of the problem and resulting outcome on a quarterly basis.
(c) The MCO shall provide written analysis,
				representation and expert witness services in fair hearings and in any
				subsequent hearings in any other court regarding any actions the MCO has taken
				regarding a beneficiary. In the case of a MCO's denial, modification, or
				deferral of a prior authorization request, the MCO shall present its position
				for the denial, modification, or deferral of procedures during fair hearing
				proceedings.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 12 - REIMBURSEMENT › Section 10:74-12.1 - Contractor compensation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Compensation to
				the contractor for MCO enrollees shall consist of monthly capitation payments
				for each enrollee. These payments shall be for a defined scope of services to
				be furnished to a defined number of enrollees, for providing the services
				contained in the Benefits Package as described in N.J.A.C. 10:74-3. Such
				payments shall be actuarially sound and in accordance with
				42
				CFR 438.6, incorporated herein by reference,
				as amended and supplemented. In addition, supplemental fee-for-service payments
				may be made to the contractor for certain services, which shall be specified by
				contract in a manner determined by the Division of Medical Assistance and
				Health Services. In addition, certain high-cost, low-utilized drugs and blood
				products costs as specified by contract will be reimbursed to the MCO at the
				lesser of their cost or the current Medicaid/NJ FamilyCare fee-for-service
				payment amount.
(b) The monthly
				capitation payments plus supplemental payments and certain reimbursed costs
				provided under the contract shall constitute full and complete payment to the
				contractor and full discharge of any and all responsibility by the Department
				for the costs of all services that the contractor provides pursuant to its
				contract.
(c) Payment shall not be
				made on behalf of an enrollee to providers of health care services other than
				to the contractor for the covered benefits as described in this chapter and
				rendered during the term of the contract.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 12 - REIMBURSEMENT › Section 10:74-12.2 - Capitation rates

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Capitation
				rates shall be derived from MCO expenditure and encounter data.
(b) Adjustments to capitation rates shall be
				made to address certain features such as trends, program changes and risk
				factors associated with certain enrollee populations.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 12 - REIMBURSEMENT › Section 10:74-12.3 - Adjustment of capitation rates

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Capitation
				rates are prospective in nature and will not be adjusted
				retroactively.
(b) Capitation rates
				shall not be subject to renegotiation during the contract period, except when
				any changes in Federal and/or State laws, rules, regulations or covered
				services so require.
(c) Capitation
				rates will be paid only for eligible beneficiaries enrolled during the period
				for which the adjusted capitation payments are being made.
(d) Payments provided for under the contract
				will be denied for new enrollees when, and for so long as, payments for those
				enrollees are denied by CMS in accordance with
				42 CFR
				438.730.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 12 - REIMBURSEMENT › Section 10:74-12.4 - Payment of capitation to contractor

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The monthly
				capitation payments are due to the contractor from the enrollees' effective
				dates of enrollment until the effective dates of disenrollment or termination
				of the MCO's contract, whichever occurs first.
(b) When DMAHS's capitation payment
				obligation is computed, capitation payment for any partial month of enrollment
				is adjusted to reflect the number of days enrolled.
(c) Capitation payments for full month
				coverage shall be recovered from the contractor on a prorated basis if the
				individual moves out-of-State, from the individual's date of death or when an
				individual is admitted to a nursing or intermediate care facility in excess of
				30 days, or is admitted to an extended acute psychiatric care facility or other
				institution. The individual shall be disenrolled from the contractor's plan on
				the day prior to such admission, including incarceration.
(d) When an enrollee is shown on the
				enrollment roster as covered by a contractor's plan, the contractor shall be
				responsible for providing services to that person from the first day of
				coverage shown to the last day of the calendar month of the effective date of
				disenrollment, and DMAHS will pay the contractor its capitation rate during
				this period of time, except in cases of member's death, moving out-of-State or
				continuation of care in a nursing facility beyond 30 days, upon admission to a
				long-term psychiatric hospital or facility or an ICF/MR where capitation will
				be prorated back to the date of the event.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 12 - REIMBURSEMENT › Section 10:74-12.5 - Coverage of hospitalized person

Current through Register Vol. 56, No. 14, July 15, 2024
For any eligible person who applies for participation in the
				  contractor's plan, but who is hospitalized prior to the time coverage under the
				  plan becomes effective, such coverage shall not commence until the date such
				  person is discharged from the hospital, and DMAHS shall be liable for payment
				  for the hospitalization, including any charges for readmission within 48 hours
				  of discharge for the same diagnosis. If an enrollee's disenrollment or
				  termination becomes effective during a hospitalization, the contractor shall be
				  liable for hospitalization until the date such person is discharged from the
				  hospital, including any charges for readmission within 48 hours of discharge
				  for the same diagnosis. The contractor shall notify DMAHS within 180 days of
				  initial hospital admission.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 12 - REIMBURSEMENT › Section 10:74-12.7 - Situations where no payment will be made

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contractor
				shall not be responsible and shall not be paid when DMAHS has previously
				notified the contractor by mail specifying enrollee-months for which DMAHS is
				not responsible.
(b) If an enrollee
				is deceased and appears on the beneficiary file as active, the contractor shall
				promptly notify DMAHS. DMAHS will recover through offset all capitation
				payments made after the date of death.
(c) Newborn babies shall be the
				responsibility of the plan that covered the mother on the date of birth and for
				a minimum of 60 days after the birth, through the period ending at the end of
				the month in which the 60th day falls, unless the baby is determined eligible
				beyond that point. Any baby who is hospitalized during the first 60 days after
				the birth shall be the contractor's responsibility until discharge. Any baby
				who is readmitted to a hospital within 48 hours of discharge for the same
				diagnosis (other than "liveborn infant") shall also remain the contractor's
				responsibility. The contractor shall be responsible to notify DMAHS when a
				newborn has not been accreted to its enrollment roster after 12 weeks from the
				date of birth. DMAHS shall take action with the appropriate county board of
				social services to have the infant accreted to the eligibility file and
				subsequently to the enrollment roster following the notification. The mother's
				MCO is responsible for the hospital stay and subsequent services for the
				newborn following delivery.
(d)
				Newborn infants born to NJ FamilyCare-Plan B, C, and D mothers shall be the
				responsibility of the contractor that covered the mother on the date of birth
				for a minimum of 60 days after the birth through the period ending at the end
				of the month in which the 60th day falls unless the child is determined
				eligible beyond this time period. The managed care entity shall notify DMAHS of
				the birth immediately in order to assure payment for this period.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 13 - GENERAL REPORTING REQUIREMENTS › Section 10:74-13.1 - Reporting requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each contractor
				shall furnish such timely information and reports as the Division may find
				necessary, and on such forms or in such format as the Division may prescribe,
				as specified in the contract. Such reports shall include information sufficient
				for Division management, monitoring and evaluation purposes in at least the
				following areas, but not limited to:
1.
				Enrollment and disenrollment;
2.
				Encounter data at a level of detail specified in the contract, and enrollee
				identification data;
3. Utilization
				data for covered services provided under the contract;
4. Utilization data for family planning
				services;
5. Financial
				data;
6. Third-party liability
				(TPL) information as required by the contract;
7. Network adequacy; and
8. Quality indicators and
				measurements.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 14 - CONTRACT SANCTIONS › Section 10:74-14.1 - Contract sanctions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Provisions
				under federal law relating to imposition of penalties upon providers of health
				care services can be found at Section 1903(m)(5)(A) of the Social Security
				Act.
(b) Monetary damages shall be
				imposed by DHS for failure of the contractor to comply with the timeliness and
				accuracy of claims processing; timeliness and accuracy of data submittals;
				contract terms and conditions; performance standards; and any losses of funds
				incurred by the State due to the contractor's non-compliance. (See
				42 U.S.C. §
										1396b(m)(5)(A);
				30:4D-1; N.J.A.C. 10:49-1 and
				10:49-11.)
(c) The contractor shall
				submit a corrective action plan for any deficiency identified by the
				Department. The contractor shall implement the corrective action established by
				the Department. Damages will be applied for failure to implement the corrective
				action plan. (See
				42 U.S.C.
				1396 b(m)(5)(A);
				30:4D-1; N.J.A.C. 10:49-1 and
				10:49-11.)
(d) The contractor shall
				comply with all performance standards, which shall be defined as compliance
				with all requirements specified in the contract. Failure to do so will result
				in the following sanctions:
1. DMAHS may
				suspend the contractor's right to enroll new members, for any length of time
				specified by DMAHS;
2. DMAHS may
				notify enrollees of contractor non-performance and permit enrollees to transfer
				to another plan without cause;
3.
				DMAHS may terminate the contract, under the provisions of the contract;
				and/or
4. DMAHS may withhold all or
				part of the monthly capitation payments.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 1 - GENERAL PROVISIONS › Section 10:75-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter outlines the policies and
				procedures relevant to the provision of psychiatric residential treatment
				facility services to individuals under age 21 enrolled in Medicaid/NJ
				FamilyCare-Plan A. The rules of this chapter also apply to children/youth/young
				adults enrolled with the Division of the Children's System of Care (DCSOC),
				whether or not they are eligible for Medicaid/NJ FamilyCare.
(b) Unless otherwise stated herein, the rules
				of this chapter apply to psychiatric residential treatment facility (PRTF)
				services rendered to Medicaid and NJ FamilyCare beneficiaries under the
				Medicaid/NJ FamilyCare fee-for-service program. PRTF services which are
				provided by the beneficiary's selected managed care organization (MCO) are
				governed and administered by that MCO.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 1 - GENERAL PROVISIONS › Section 10:75-1.3 - Program participation criteria

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A psychiatric
				residential treatment facility (PRTF) that is not licensed as a hospital, but
				meets the requirements in 42 CFR Part 441 Subpart D and 42 CFR Part 483 Subpart
				G, shall be eligible for participation in the New Jersey Medicaid/NJ FamilyCare
				program.
(b) All PRTF providers
				shall be enrolled in the New Jersey Medicaid/NJ FamilyCare program as a
				residential treatment center providing services to children under the age of
				21. This includes the filing of a Medicaid/NJ FamilyCare Provider Application
				(FD-20), the signing of a Provider Agreement MCNH-38, and submittal of the
				CMS-1513, Ownership and Control Interest Disclosure. Provider applications and
				required forms can be obtained from and should be submitted to: Division of
				Medical Assistance and Health Services
Office of Provider Enrollment, Mail Code #9
PO Box 712
Trenton, New Jersey 08625-0712
(c) A PRTF located in New Jersey that
				provides services for New Jersey Medicaid/NJ FamilyCare or DCF/DCSOC
				beneficiaries under the age of 21 shall, in order to participate in the
				Medicaid/NJ FamilyCare program:
1. Be
				licensed by the New Jersey DCF Office of Licensing as a residential facility in
				accordance with N.J.A.C. 10:127 or 10:128 or other State agencies with the
				authority to license such facilities to provide care to children;
2. Be accredited as a PRTF by TJC or any
				other accrediting agency authorized by DHS and DCF; and
3. Provide a copy of their license and a copy
				of their accreditation to DCF/DCSOC.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 1 - GENERAL PROVISIONS › Section 10:75-1.4 - Beneficiary eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medicaid/NJ
				FamilyCare beneficiaries under age 21, and those non-Medicaid/NJ
				FamilyCare-eligible children who are enrolled with the DCSOC who require PRTF
				services, shall be eligible to receive services in a psychiatric residential
				treatment facility (PRTF).
(b) A
				Medicaid/NJ FamilyCare or DCSOC resident who was receiving services immediately
				prior to attaining age 21 may continue to receive services until they are no
				longer needed or until the resident reaches age 22, whichever occurs
				first.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 1 - GENERAL PROVISIONS › Section 10:75-1.5 - Recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(a) PRTFs shall keep such legible individual
				records for each resident as are necessary to fully disclose the kind and
				extent of services provided, as well as the medical necessity for those
				services. This information shall be available upon the request of the DHS
				and/or DCF/DCSOC or its authorized agents, including, but not limited to,
				DMAHS, the Care Management Organization (CMO) and/or the Contracted Systems
				Administrator (CSA), as well as the Department of Health, and the Centers for
				Medicare and Medicaid Services (CMS).
(b) An individual record shall be maintained
				for each Medicaid/NJ FamilyCare DCF/DCSOC resident. The record shall include
				the individual's medical, nursing, social, and related treatment and care in
				accordance with this chapter and all accepted professional standards.
(c) All clinical records of discharged
				residents shall be completed promptly and shall be filed and retained for a
				period of five years after the discharge of the resident.
(d) If the resident is transferred to or from
				another PRTF or program, a copy of the resident clinical record, or a summary
				of the record, shall accompany the resident.
(e) All information contained in the clinical
				records shall be treated as confidential and shall be disclosed only to
				authorized persons, including the Department and its agents, DCF/DCSOC, the
				CSA, and the CMO.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 1 - GENERAL PROVISIONS › Section 10:75-1.6 - Serious occurrences

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In the event of any serious occurrence,
				all PRTF providers shall report the occurrence to the appropriate authorities
				in accordance with
				42 CFR 483.374(b) and (b)
				through (d) below.
(b) All reports of serious occurrences shall
				include, at a minimum, the following information:
1. The name of the resident;
2. A detailed description of the
				occurrence;
3. The name, street
				address and telephone number of the facility; and
4. Any other information the PRTF is able to
				provide regarding the occurrence.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 2 - PROGRAM REQUIREMENTS › Section 10:75-2.1 - General requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursable
				PRTF services under the Medicaid/NJ FamilyCare/DCF/DCSOC programs shall be
				those services determined to be medically necessary, using professionally
				developed criteria and standards of care, and shall be provided under the
				direction of a physician in a facility that meets the requirements of
				10:75-1.3.
(b)PRTF services for Medicaid/NJ
				FamilyCare/DCF/DCSOC beneficiaries under age 21 shall meet the requirements of
				42 CFR 441.151.
				The services shall be provided:
1. Under the
				direction of a physician;
2. By a
				facility that is accredited by TJC or by an agency authorized by DHS and DCF;
				and
3. Before the beneficiary
				reaches age 21, or, if the beneficiary was receiving such services immediately
				before he or she reached age 21, services may be provided until the beneficiary
				no longer requires the services or the beneficiary reaches age 22, whichever
				event occurs earlier.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 2 - PROGRAM REQUIREMENTS › Section 10:75-2.2 - Certification of need for PRTF services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prior
				to admission to the facility, PRTF services shall be certified in writing to be
				necessary, in accordance with 42 CFR
				441.152. Certification of the need for
				services shall be made by an interdisciplinary team, composed of DCF/DCSOC,
				Care Management Organization (CMO), or the State's Contracted Systems
				Administrator (CSA) staff, who have knowledge of the child/youth/young adult's
				situation, are competent in the diagnosis and treatment of mental/behavioral
				health challenges, preferably in child psychiatry and include a physician.
1. For a beneficiary enrolled in the
				Medicaid/NJ FamilyCare/DCF/DCSOC program before the admission to the PRTF, the
				certification of need may be completed up to 45 days before admission. The form
				must be received by the facility prior to the admission of the
				child/youth/young adult.
2. For
				children/youth/young adults receiving services coordinated by the DCF/DCSOC,
				this certification may be completed by the child's CMO or the CSA, if the teams
				assembled by the CMO or the CSA meet the requirements of
				42 CFR 441.152.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 2 - PROGRAM REQUIREMENTS › Section 10:75-2.3 - Authorization for PRTF services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Authorization
				shall be required for all PRTF services rendered to children/youth/young adults
				who are enrolled with the DCF/DCSOC. The agency arranging for the
				child/youth/young adult's admission to the PRTF shall secure the authorization
				as indicated in (b) and (c) below, and shall document the authorization in the
				agency record.
(b) For
				children/youth/young adults who are enrolled with the DCF/DCSOC, upon review of
				an Individual Service Plan (ISP), authorization for services will be provided
				by the Department of Children and Families/Division of the Children's System of
				Care, or its designee, the State's Contracted Systems Administrator (CSA), with
				the certification of need.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 2 - PROGRAM REQUIREMENTS › Section 10:75-2.4 - Individual plan of care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) PRTF services
				shall include "active treatment" in accordance with
				42 C.F.R.
				441.154. Active treatment means the
				implementation of a professionally developed and supervised plan of care that
				is developed and implemented no later than 14 days after admission and designed
				to achieve the goal of the resident's appropriate discharge from the PRTF at
				the earliest possible date.
(b) The
				individual plan of care shall be based on a diagnostic evaluation that includes
				the examination of the medical, psychological, social, behavioral, and
				developmental aspects of the resident's current status and shall reflect the
				need for PRTF care. The appropriate professional personnel shall perform the
				evaluations.
1. For children/youth/young
				adults enrolled with the DCF/DCSOC, the plan of care and the diagnostic
				evaluations shall be completed as part of their Individual Service Plan (ISP)
				developed by the CMO and shared with the provider who will render the service.
				See 10:73-3.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 2 - PROGRAM REQUIREMENTS › Section 10:75-2.5 - Individual treatment teams

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each resident's
				individual treatment plan shall be developed by a treatment team comprised of
				physicians and other personnel responsible for rendering services to the
				resident in the PRTF. See
				42 C.F.R.
				441.156. The team shall:
1. Assess the long and short term therapeutic
				needs, developmental priorities, and the personal strengths and liabilities of
				the resident;
2. Assess the
				potential resources of the resident's family;
3. Set treatment objectives; and
4. Prescribe therapeutic modalities to
				achieve the objectives of the plan of care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 2 - PROGRAM REQUIREMENTS › Section 10:75-2.6 - Utilization Review (UR)

Current through Register Vol. 56, No. 14, July 15, 2024
In accordance with
				  42 C.F.R.
				  456.22, all Medicaid/NJ FamilyCare services
				  shall have procedures that provide for review of each resident's need for the
				  services. For the Utilization Review (UR), each PRTF shall perform on-going
				  evaluations of the necessity and appropriateness of PRTF services for each
				  resident. The UR shall include a review of the appropriateness of the
				  admission, individual plan of care, length of stay and discharge plan.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 2 - PROGRAM REQUIREMENTS › Section 10:75-2.7 - Temporary absence from the facility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A provider may
				seek reimbursement for a resident's temporary absence from the facility due to
				a hospital leave or therapeutic leave for periods of up to 14 continuous days
				per episode. If the beneficiary is present in the facility for any part of the
				day, beginning and ending at midnight, the HCPCS procedure codes for a day of
				service shall be used for that day. (See 10:75-5.2.)
(b) When anticipated, temporary absences
				shall first be approved by the resident's treatment team and included in the
				treatment plan. In the case of an unanticipated absence, the circumstances of
				the absence shall be documented in the resident's chart within 24 hours of the
				resident's departure from the facility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21 › Subchapter 3 - EMERGENCY SAFETY INTERVENTIONS › Section 10:75-3.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter describes the requirements of
				  42 CFR 483.350
				  through
				  483.376,
				  related to the use of restraints and seclusion, as these requirements are
				  applied to PRTF providers of Medicaid/NJ FamilyCare services.