reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 3 - PERSONAL CARE ASSISTANT (PCA) SERVICES › Section 10:60-3.3 - Covered personal care assistant services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Hands-on personal care assistant services are described as follows:
1. Activities of daily living (ADL) shall be performed by a personal care assistant, and include, but are not limited to:
i. Care of the teeth and mouth;
ii. Grooming, such as care of hair, including shampooing, shaving, and the ordinary care of nails if the need for such assistance is due to the beneficiary's upper extremities or motor skills being affected by a disability, or whose level of cognitive disability requires such assistance regardless of mobility level of the upper extremities;
iii. Bathing in bed, in the tub or shower;
iv. Using the toilet or bed pan;
v. Changing bed linens with the beneficiary in bed;
vi. Ambulation indoors and outdoors, when appropriate;
vii. Helping the beneficiary in moving from bed to chair or wheelchair, in and out of tub or shower;
viii. Assistance with eating, including, but not limited to, placing food and/or liquids into mouth, and assistance with swallowing difficulties;
ix. Dressing; and
x. Accompanying the beneficiary, for the purpose of providing personal care assistance services, to clinics, physician/practitioner office visits, and/or other trips made for the purpose of obtaining medical diagnosis or treatment, or to otherwise serve a therapeutic purpose.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 3 - PERSONAL CARE ASSISTANT (PCA) SERVICES › Section 10:60-3.4 - Certification of need for personal care assistant services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To qualify for payment of personal care assistant services by the New Jersey Medicaid/NJ FamilyCare fee-for-service program, the beneficiary's need for services shall be certified in writing to the health care services firm by a physician/practitioner as medically necessary, at the time of initial application for services and annually thereafter for recertification. The nurse shall immediately record and sign verbal orders and obtain the physician's/practitioner's counter signature within 30 days.
(b) The certification of need for services must be on file in the beneficiary record at the service provider agency before the home health aide begins providing services for the beneficiary. For those cases that originate while a beneficiary is enrolled in a New Jersey Medicaid/ NJ FamilyCare managed care plan, the managed care plan authorization is based on medical necessity and shall serve as the certification of medical necessity for personal care assistant services. Services provided during a period where a beneficiary temporarily loses managed care eligibility, but is expected to reenroll the following month, shall be provided fee-for-service until the beneficiary is reenrolled in his or her managed care plan as a continuation of services without the need to obtain any additional certification.
(c) The physician's/practitioner's certification as described at (a) above must confirm that the home care assistance for the beneficiary is medically necessary. Such certification may be contained in a physician/practitioner's order, a prior authorization by a Medical Director in a managed care plan, a prescription, or documentation in the beneficiary Plan of Care (POC).
(d) A recertification of the beneficiary's need for services may be required more frequently in the event of a change in the disability status of the beneficiary enrolled in the PCA program.
(e) For fee-for-service beneficiaries, a recertification of the beneficiary's need for services shall be required in situations in which a certification was obtained from the beneficiary's attending physician/practitioner, and the beneficiary changes his or her physician/practitioner. Managed care plans can recertify the continued need for PCA services through continued prior authorization of services.
(f) For fee-for-service beneficiaries, if a beneficiary is approved to transfer his or her PCA services to another provider agency pursuant to N.J.A.C. 10:60-3.10, the new agency is responsible to obtain a new physician/practitioner's certification.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 3 - PERSONAL CARE ASSISTANT (PCA) SERVICES › Section 10:60-3.5 - Duties of the registered professional nurse

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The duties of the registered professional nurse in the PCA program are as follows:
1. The registered professional nurse, in accordance with the physician's/practitioner's certification of need for care, shall perform an assessment and prepare a plan of care for the personal care assistant to implement. The assessment and plan of care shall be completed at the start of service. However, in no case shall the nursing assessment and plan of care be done more than 48 hours after the start of service. The plan of care shall include the tasks assigned to meet the specific needs of the beneficiary, hours of service needed, and shall take into consideration the beneficiary's strengths, the needs of the family and other interested persons. The plan of care shall be dated and signed by the personal care assistant and the registered nurse and shall include short-term and long-term nursing goals. The personal care assistant shall review the plan, in conjunction with the registered professional nurse.
2. Direct supervision of the personal care assistant shall be provided by a registered nurse at a minimum of one visit every 60 days, initiated within 48 hours of the start of service, at the beneficiary's place of residence during the personal care assistant's assigned time. The purpose of the supervision is to evaluate the personal care assistant's performance, to determine that the plan of care has been properly implemented, and to document that hands-on personal care is being provided. At this time, appropriate revisions to the plan of care shall be made as needed. Additional supervisory visits shall be made as the situation warrants, such as a new PCA, nurse delegation, or in response to the physical or other needs of the beneficiary. In situations in which multiple personal care assistants are assigned to a case, the in-home supervisory visits shall be rotated until all staff have been assessed during each covered shift. All shift visits must be performed to allow face-to-face supervision of the aide being assessed.
3. A personal care assistant nursing reassessment visit shall be provided at least once every beneficiary is enrolled in a Medicaid/ NJ FamilyCare managed care plan, completing the State-approved PCA Assessment tool and subsequent authorization of hours shall be the responsibility of the managed care plan.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 3 - PERSONAL CARE ASSISTANT (PCA) SERVICES › Section 10:60-3.6 - Clinical records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Recordkeeping for personal care assistant services shall include the following:
1. Clinical records and reports shall be maintained for each beneficiary, covering the medical, nursing, social, and health-related care in accordance with accepted professional standards. Such information shall be readily available, as required, to representatives of the Division or its agents.
2. Clinical records shall contain, at a minimum:
i. Nursing assessments completed by the nursing agency. The most recent nursing assessment shall be retained in the beneficiary's active chart; the previous three years of assessments shall be retained onsite.
ii. A beneficiary-specific plan of care;
iii. Signed and dated progress notes describing the beneficiary's condition;
iv. Documentation of the supervision provided to the personal care assistant every 60 days;
v. A personal care assistant assignment sheet signed and dated weekly by the personal care assistant;
vi. Documentation that the beneficiary has been informed of rights to make decisions concerning his or her medical care;
vii. Documentation of the formulation of an advance directive; and
viii. Documentation of approved nurse delegated tasks and documentation of training on performance of those tasks.
3. All clinical records shall be signed and dated by the registered professional nurse, in accordance with accepted professional standards, and shall include documentation described in (a)2 above.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 3 - PERSONAL CARE ASSISTANT (PCA) SERVICES › Section 10:60-3.7 - Basis of payment for personal care assistant services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Personal care assistant services shall be reimbursed on a per unit, fee-for-service basis for weekday, weekend, and holiday services. Nursing assessment and reassessment visits under this program shall be reimbursed on a per visit, fee-for-service basis.
1. When provided to beneficiaries who are not enrolled in a managed care organization, personal care assistant (PCA) services shall be reimbursed on a fee-for-service basis and a unit of service is defined as 60 minutes. When PCA services are provided to the same beneficiary on the same date of service multiple times throughout the day, the provider shall add non-continuous units of time together to reach a billing total. The initial service visit shall be rounded up to one full unit of service. Beyond the initial unit of service, all service times shall be added together and service times totaling more than 30 minutes shall be rounded up to one unit and service times totaling 30 minutes or less shall be rounded down.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 3 - PERSONAL CARE ASSISTANT (PCA) SERVICES › Section 10:60-3.8 - Limitations on personal care assistant services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medicaid/NJ FamilyCare reimbursement shall not be made for personal care assistant services provided to Medicaid/NJ FamilyCare-Plan A beneficiaries in the following settings:
1. A residential health care facility;
2. A Class C boarding home;
3. A hospital;
4. A nursing facility;
5. DDD group homes, skill development homes, supervised apartments or other congregate living programs where personal care assistance is provided as part of a service package which is included in the living arrangement;
6. Adult day health care and pediatric day health care centers;
7. TBI community residential service facilities; and
8. Adult Family Care, Assisted Living Program, and Assisted Living Residence.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 3 - PERSONAL CARE ASSISTANT (PCA) SERVICES › Section 10:60-3.9 - Prior authorization for personal care assistant (PCA) services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All personal care assistant (PCA) services shall be prior authorized, regardless of the number of hours requested per week.
(b) Prior approval for PCA services shall be obtained in accordance with the following procedures:
1. For fee-for-service cases, a registered nurse employed by the PCA provider agency shall complete a face-to-face evaluation of the beneficiary, at the beneficiary's home, and shall complete the State- approved PCA Assessment form, including information regarding the beneficiary's:
i. Supportive service/living environment needs;
ii. Cognitive/mental status;
iii. Ambulation/mobility;
iv. Ability to transfer (for example, from wheelchair to bed);
v. Ability to feed himself or herself;
vi. Ability to bathe himself or herself;
vii. Ability to toilet himself or herself;
viii. Ability to perform grooming and dressing tasks;
ix. Ability to perform housekeeping and shopping tasks; and
x. Ability to perform laundry tasks.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 3 - PERSONAL CARE ASSISTANT (PCA) SERVICES › Section 10:60-3.10 - Transfer of beneficiary to a different service agency provider

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Beneficiaries may be approved for a transfer of service agency provider for good cause situations, including, but not limited to:
1. The current provider agency is unable to staff the case at the level of care approved by the Division; that is, staffing shortages, staffing cases with multiple home health aides when it is determined to be inappropriate;
2. The current provider agency is unable to staff the case due to a beneficiary change of residence; or
3. The current provider agency is unable to staff the case due to language or cultural barrier.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 5 - PRIVATE DUTY NURSING (PDN) SERVICES › Section 10:60-5.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Private duty nursing (PDN) services shall be provided by a licensed certified home health agency, licensed hospice agency or an accredited healthcare services firm approved by DMAHS. The healthcare services firm shall be accredited, initially and on an ongoing basis, by an accreditation organization approved by the Department.
1. A healthcare services firm shall contract with an accreditation organization to complete a comprehensive on-site organizational audit a minimum of once every three years.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 5 - PRIVATE DUTY NURSING (PDN) SERVICES › Section 10:60-5.2 - Basis for reimbursement for EPSDT/PDN

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To be considered for EPSDT/PDN services, the beneficiary shall be under 21 years of age, enrolled in the Medicaid/NJ FamilyCare program and referred by a parent, primary physician/practitioner, hospital discharge planner, Special Child Health Services case manager, Division of Disability Services (DDS), Child Protection and Permanency (CP&P), Division of Mental Health and Addiction Services (DMHAS), or current PDN provider. Requests for services shall be submitted to the Division of Medical Assistance and Health Services (DMAHS) using a "Request for EPSDT Private Duty Nursing Services (FD-389)" form, incorporated herein by reference (see N.J.A.C. 10:60 Appendix C). The Request shall be completed and signed by the referring physician/practitioner and agreed to and signed by a parent or guardian. All sections of the Request shall be completed and a current comprehensive medical history and current treatment plan, completed by the referring physician/practitioner, shall be attached. The comprehensive medical history, current treatment plan, and other documents submitted with the request shall reflect the current medical status of the beneficiary and shall document the need for ongoing (not intermittent) complex skilled nursing interventions by a licensed nurse. Incomplete requests shall be returned to the referral source for completion prior to further action by DMAHS.
(b) Upon receipt of the fully completed Request (FD-389), a DMAHS Regional Staff Nurse shall conduct an assessment of the need for PDN services, as well as the level (LPN or RN) and amount of service required. A letter notifying the family and the person who referred the individual of the decision following the assessment shall be issued by DMAHS. When the child is found to be eligible for EPSDT/PDN services, the number of hours approved, the level of services, and the length of time of the approval (up to a maximum of six months) shall be noted.
(c) The PDN provider agency, selected by the family, shall submit a request to DMAHS for the PDN services on the "Prior Authorization Request Form (FD-365)" which contains a pre-printed prior authorization (PA) number. Telephone requests for prior authorization (PA) can be accommodated in an emergency but shall be followed immediately by a written request.
(d) Requests for continuation, or modification of PDN services during the treatment period, shall be submitted by the PDN agency, in writing, to DMAHS on the "Prior Authorization Request Form (FD-365)" In an emergency, requests for modification of services may be made by telephone but shall be followed immediately by a written prior authorization (PA) request.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 5 - PRIVATE DUTY NURSING (PDN) SERVICES › Section 10:60-5.3 - Eligibility for Early and Periodic Screening Diagnosis and Treatment/Private Duty Nursing (PDN) Services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Individuals under 21 years of age who are enrolled in the Medicaid/NJ FamilyCare programs, and who require private duty nursing services, which will allow them to be cared for in a community setting, may be referred for EPSDT/PDN services.
1. Individuals eligible for Medicaid services through the Medically Needy program are not eligible for EPSDT services, in accordance with 10:49-5.3(a)2.
2. For individuals who are enrolled in Medicaid/NJ FamilyCare managed care, private duty nursing is authorized and provided by the MCO.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 5 - PRIVATE DUTY NURSING (PDN) SERVICES › Section 10:60-5.4 - Limitation, duration, and location of EPSDT/PDN

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following requirements shall apply to EPSDT/PDN services:
1. Private duty nursing shall be provided for eligible FFS beneficiaries in the community only and not in hospital inpatient or nursing facility settings.
2. DMAHS shall determine and approve the total PDN hours for reimbursement, in accordance with N.J.A.C. 10:60-5.2(b).
3. The determination of the total EPSDT/PDN hours approved shall take into account the primary caretaker's ability to provide care, as well as alternative sources of PDN care available to the caregiver, such as medical day care or a school program.
4. In emergency situations, for example, when the sole caregiver has been hospitalized, DMAHS may authorize, for a limited time, additional hours beyond the authorized amount.
5. DMAHS may also approve, for a limited time, additional hours when a change in the child's medical condition requires additional training for the primary caregiver to address changes in the care needs of the beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 5 - PRIVATE DUTY NURSING (PDN) SERVICES › Section 10:60-5.5 - Determination of medical necessity for EPSDT/PDN Services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An initial on-site nursing assessment is necessary in order to review the complexity of the child's care. A hands-on examination of the child is not included in the assessment. The nursing assessment shall include an hour-by-hour inventory of all care-related activities over a 24-hour period, which accurately describes the child's current care. The assessment shall be completed by a registered nurse employed by a licensed certified home health agency, an accredited healthcare services firm, or licensed hospice agency approved by DMAHS.
(b) The assessor shall describe the specific elements of care, and the individual who rendered the service. Frequency of skilled nursing interventions shall be noted, for example, indicating whether suctioning is occasional, or frequently required or regularly scheduled with chest PT, such as twice a day or every six hours.
(c) Activities that constitute skilled nursing interventions shall be identified by the assessor, separate from non-skilled nursing activities. The presence and intensity of skilled nursing interventions shall determine whether EPSDT/PDN hours should be authorized.
(d) The presence or absence of alternative care, such as medical day care, private duty nursing services provided by private insurance, or private duty nursing services provided by the child's school, shall be identified and recorded, and those hours shall be deducted from the total hours of EPSDT/PDN services to be authorized in accordance with N.J.A.C. 10:60-5.4.
(e) If EPSDT/PDN hours are authorized, the assessor shall indicate the duration of the prior authorization (PA) period (not to exceed six months) and the time frame for reassessment.
(f) A nursing reassessment shall be conducted by the nurse assessor prior to the end of the PDN authorization period, in accordance with the following:
1. The reassessment will be conducted in the beneficiary's home, in order to determine the on-going medical necessity of EPSDT/PDN services, and shall include a 24-hour inventory of needed services.
2. The nurse assessor shall utilize the reports from the provider agency for documentation of specific functions performed by the provider agency nurse(s).
3. Any changes in the child's status or circumstances, including the frequency and type of interventions required, shall be noted. These changes shall be clearly identified in the reassessment summary, and shall be used to support any decision to continue, reduce or increase PDN hours.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 5 - PRIVATE DUTY NURSING (PDN) SERVICES › Section 10:60-5.6 - Clinical records and personnel files

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An individual clinical record shall be maintained for each beneficiary receiving private duty nursing service. The record shall address the physical, emotional, nutritional, environmental and social needs according to accepted professional standards.
(b) Clinical records maintained at the agency shall contain, at a minimum, the following:
1. A referral source;
2. Diagnoses;
3. A physician's/practitioner's treatment plan and renewal of treatment plan every 90 days;
4. Interim physician/practitioner orders, as necessary, for medications and/or treatment;
5. An initial nursing assessment by a registered nurse within 48 hours of initiation of services;
6. A six-month nursing reassessment;
7. A nursing care plan;
8. Signed and dated progress notes describing beneficiary's condition; and
9. Evidence that beneficiary was given information regarding advance directives.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 5 - PRIVATE DUTY NURSING (PDN) SERVICES › Section 10:60-5.7 - Payment for EPSDT/PDN

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Claims for payment for PDN services shall be submitted on the CMS 1500 Claim Form. The PA number shall be noted on the claim form. Providers shall bill each date of service on a separate line (FIELD 24A) of the claim form. If more than one procedure code is billed for the same date of service, separate lines shall be used when billing each procedure code. Providers shall not span dates of service on a line of the claim form.
1. Private duty nursing provider charges may vary but reimbursement cannot exceed the maximum rates allowed by the DMAHS in accordance with 10:60-11.2(e).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 5 - PRIVATE DUTY NURSING (PDN) SERVICES › Section 10:60-5.8 - Eligibility for managed long-term supports and services (MLTSS)/private duty nursing (PDN) services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) MLTSS/private duty nursing is available only to a beneficiary who meets nursing facility level of care criteria (see N.J.A.C. 10:60-6.2), is based on medical necessity, and is prior approved by the NJ FamilyCare MCO in a plan of care prepared by a MLTSS care manager. Private duty nursing is individual, continuous nursing care in the home, and is a service available to a beneficiary only after enrollment in MLTSS.
(b) MLTSS/PDN services are only appropriate when the following requirements are satisfied:
1. An individual must exhibit a severity of illness that requires complex skilled nursing interventions on a continuous ongoing basis.
i. "Ongoing" means that the beneficiary requires the provision of skilled nursing intervention on an ongoing basis, up to 24 hours per day/seven days per week.
ii. "Complex" means the degree of difficulty and/or intensity of treatment/procedures.
iii. "Skilled nursing interventions" means procedures that require the knowledge and experience of licensed nursing personnel, or a trained primary caregiver.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 5 - PRIVATE DUTY NURSING (PDN) SERVICES › Section 10:60-5.9 - Limitation, duration, and location of MLTSS/PDN services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) MLTSS/PDN services shall be provided in the community only and not in an inpatient hospital or nursing facility setting. Services shall be provided by a registered nurse (RN) or a licensed practical nurse (LPN).
1. Private duty nursing services rendered during hours when the beneficiary's normal life activities take him or her outside the home will be reimbursed. If a beneficiary seeks to obtain MLTSS/PDN services to attend school or other activities outside the home, but does not need such services in the home, there is no basis for authorizing MLTSS/PDN services. Only those MLTSS/PDN beneficiaries who require, and are authorized by the MCO and the MLTSS care manager to receive, private duty nursing services in the home may utilize the approved hours outside the home during those hours when normal life activities take the beneficiary out of the home.
2. Due to safety concerns, the nurse shall not be authorized to engage in non-medical activities while accompanying the client, including the operation of a motor vehicle.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 5 - PRIVATE DUTY NURSING (PDN) SERVICES › Section 10:60-5.10 - Basis for reimbursement for MLTSS/PDN services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A provider of private duty nursing services shall be reimbursed by the New Jersey Medicaid/ NJ FamilyCare program on a fee-for-service basis for services provided as authorized by the individual's service plan prepared by the waiver case manager. Providers shall be precluded from receiving additional reimbursement for the cost of these services above the fee established by the Medicaid/NJ FamilyCare program.
1. All costs associated with the provision of private duty nursing services by home health agencies shall be included in the routine Medicare/Medicaid cost-reporting mechanism.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 5 - PRIVATE DUTY NURSING (PDN) SERVICES › Section 10:60-5.11 - Prior authorization of MLTSS/PDN services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There is no 24-hour coverage except for a limited period of time under the following emergency circumstances and when prior authorized by the MCO:
1. For brief post-hospital periods while the caregiver(s) adjust(s) to the new responsibilities of caring for the discharged beneficiary; or
2. In emergency situations such as the illness of the caregiver when private duty nursing is currently being provided. In these situations, more than 16 hours of private duty nursing services may be provided for a limited period until other arrangements are made for the safety and care of the beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 6 - HOME AND COMMUNITY-BASED SERVICES WAIVERS FOR BLIND OR DISABLED CHILDREN AND ADULTS COMMUNITY RESOURCES FOR PEOPLE WITH DISABILITIES (CRPD) WAIVER PROGRAMAM › Section 10:60-6.1 - Managed long-term services and supports (MLTSS)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Managed long-term services and supports (MLTSS) under the New Jersey 1115 Comprehensive Medicaid Waiver expands existing managed care programs to include managed long-term care services and supports and expands home and community-based services. The purpose of MLTSS is to increase the availability and utilization of home and community-based services for seniors and individuals with disabilities, allowing them to remain at home in the community instead of living in a nursing facility.
(b) The beneficiary's annual long-term services and support cost cannot exceed the annual cost threshold, unless he or she is granted an exception due to temporary higher care needs or long-term complex medical needs, as identified in the interdisciplinary team process.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 6 - HOME AND COMMUNITY-BASED SERVICES WAIVERS FOR BLIND OR DISABLED CHILDREN AND ADULTS COMMUNITY RESOURCES FOR PEOPLE WITH DISABILITIES (CRPD) WAIVER PROGRAMAM › Section 10:60-6.2 - Eligibility for MLTSS

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Individuals qualify for MLTSS by meeting established Medicaid financial requirements and Medicaid clinical and age and/or disability requirements for nursing facility services contained in N.J.A.C. 10:69, 70, 71, or 72.
1. For children who meet the nursing home level of care, and who are applying for MLTSS, there is no deeming of parental income or resources in the determination of eligibility.
2. Once qualified to receive MLTSS, the individual must be enrolled with a managed care organization (MCO) in order to receive MLTSS services. Limited MLTSS services may be authorized by DMAHS after the individual has been determined clinically eligible for MLTSS and prior to enrollment into the MCO.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 6 - HOME AND COMMUNITY-BASED SERVICES WAIVERS FOR BLIND OR DISABLED CHILDREN AND ADULTS COMMUNITY RESOURCES FOR PEOPLE WITH DISABILITIES (CRPD) WAIVER PROGRAMAM › Section 10:60-6.3 - Services available under Community Resources for People with Disabilities (CRPD) Waiver programs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except for nursing facility services, all approved services under the New Jersey Medicaid program as described in N.J.A.C. 10:49, Administration, are available under the Community Resources for People with Disabilities (CRPD) Waiver program from approved Medicaid providers.
(b) Waiver services are as follows:
1. Case management: A process in which a professional nurse or social worker is responsible for planning, locating, coordinating, and monitoring a group of services designed to meet the individual health needs of the beneficiary being served. The case manager shall be the pivotal person in establishing a service package.
i. Special Child Health Services (SCHS) units under contract to the New Jersey State Department of Health and Senior Services shall provide case management to children up to the age of 21.
ii. Beneficiaries 21 years of age or older shall be referred for case management services to those sites approved by the Division, in accordance with this Chapter.
iii. Case management shall not be provided when a beneficiary is in an inpatient hospital setting and the stay extends a full calendar month.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 6 - HOME AND COMMUNITY-BASED SERVICES WAIVERS FOR BLIND OR DISABLED CHILDREN AND ADULTS COMMUNITY RESOURCES FOR PEOPLE WITH DISABILITIES (CRPD) WAIVER PROGRAMAM › Section 10:60-6.4 - Basis for reimbursement for Model Waiver services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A provider of case management or private duty nursing services shall be reimbursed by the New Jersey Medicaid program on a fee-for-service basis for services provided. Providers shall be precluded from receiving additional reimbursement for the cost of these services above the fee established by the Medicaid program.
1. All costs associated with the provision of private duty nursing services by home health agencies shall be included in the routine Medicare/Medicaid cost-reporting mechanism.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 6 - HOME AND COMMUNITY-BASED SERVICES WAIVERS FOR BLIND OR DISABLED CHILDREN AND ADULTS COMMUNITY RESOURCES FOR PEOPLE WITH DISABILITIES (CRPD) WAIVER PROGRAMAM › Section 10:60-6.5 - Procedures used as financial controls for Model Waiver programs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Total program costs shall be restricted by limits placed on the maximum number of beneficiaries served Statewide in each of the three programs.
(b) A case manager shall be responsible for the development of the service plan with each beneficiary/family and with input from the provider agencies and the Medicaid professional staff. The case manager shall be responsible for monitoring the cost of the service package.
(c) The cost of Medicaid services provided shall not exceed the cost of institutionalization for the beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 11 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:60-11.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare programs adopted the Federal Centers for Medicare & Medicaid Services' (CMS) Healthcare Common Procedure Coding System codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. §§
										1320d et seq., and incorporated herein by reference, as amended and supplemented, and published by PMIC, 4727 Wilshire Blvd., Suite 300, Los Angeles, CA 90010. Revisions to the Healthcare Common Procedure Coding System made by CMS (code additions, code deletions, and replacement codes) will be reflected in this chapter through publication of a notice of administrative change in the New Jersey Register. Revisions to existing reimbursement amounts specified by the Department and specification of new reimbursement amounts for new codes will be made by rulemaking in accordance with the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq., and 52:14F-1 et seq. The HCPCS codes as listed in this subchapter are relevant to certain Medicaid/NJ FamilyCare Home Care services.
(b) These codes are used when requesting reimbursement for certain Home Care services and when a CMS 1500 Claim Form is required.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 11 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:60-11.2 - HCPCS codes and maximum reimbursement rates

Current through Register Vol. 56, No. 14, July 15, 2024
(a) PERSONAL CARE ASSISTANT SERVICES
HCPCS Code
Mod
Description
Maximum Rate
S9122
Personal Care Assistant Service (Individual/hourly/weekday)
$20.00
S9122
TV
Personal Care Assistant Service (Individual/hourly/weekend/holiday)
$20.00
(b) HCPCS CODES FOR EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT/PRIVATE DUTY NURSING:
HCPCS Code
Mod
Description
Maximum Rate
S9123
EP
PDN-RN, EPSDT, Per Hour
$60.00
S9124
EP
PDN-LPN, EPSDT, Per Hour
$48.00
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
FISCAL AGENT BILLING SUPPLEMENT
AGENCY NOTE: The Fiscal Agent Billing Supplement is appended as a part of this chapter/manual but is not reproduced in the New Jersey Administrative Code. When revisions are made to the Fiscal Agent Billing Supplement, replacement pages will be distributed to providers and copies will be filed with the Office of Administrative Law.
The Fiscal Agent Billing Supplement is available on the website of the New Jersey Medicaid/NJ FamilyCare fiscal agent:
www.njmmis.com
If you do not have internet access and would like to request a copy of the Fiscal Agent Billing Supplement, write to:
Gainwell Technologies
PO Box 4801
Trenton, New Jersey 08650-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, New Jersey 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
RANCHO SCALE
Level
Response
Patient Function
I
No response
Patient is completely unresponsive to any
stimulus.
II
Generalized response
Patient reacts to the environment, but not as a
specific response to the stimulus--responses
are often the same despite change of stimuli.
The earliest response is often gross movement
to deep pain.
III
Localized response
Patient reacts in a specific manner to the
stimulus, but may inconsistently turn head to
sound, withdraw an extremity to pain, squeeze
fingers placed in the hand, or respond to
family members more than others.
IV
Confused, agitated
Patient is in a heightened state of activity,
but is still severely detached from the
surroundings. Internal confusion and very
limited ability to learn is combined with short
attention span and easy fatigue. The patient
is unable to cooperate and may be aggressive,
combative, or incoherent.
V
Confused, inappropriate/
Patient appears alert and is able to respond to
nonagitated
simple commands. Responses are best with
familiar routines, people, and structured
situations. Distractibility and short
attention span lead to difficulty learning new
tasks and agitation in response to
frustrations. If physically mobile, there may
be wandering. Much external structure is
needed. Initiation and memory are limited.
VI
Confused, appropriate
Patient shows goal-directed behavior, but still
is dependent on external structure and
direction. Simple directions are followed
consistently and there is carry-over of
relearned skills (like dressing), yet new
learning progresses very slowly with little
carry-over. Orientation is better and there is
no longer inappropriate wandering.
VII
Automatic, appropriate
Patient appears appropriate and oriented with
familiar settings such as home and hospital,
but is confused and often helpless in
unfamiliar surroundings. The daily routine can
be managed with minimal confusion as long as
there are no changes. There is little recall
of what has just been done. There is only a
superficial understanding of the disability,
with lack of insight into the significance of
the remaining deficits. Judgment is impaired
with inability to plan ahead. New learning is
slow and minimal supervision is needed.
Driving is unsafe; supervision is needed for
safety in the community or in school and
workshop settings.
VIII
Purposeful, appropriate
Patient may not function as well as before the
injury, but is able to function independently
in home and community skills, including
driving. Alert, oriented, and able to
integrate past and present events. Vocational
rehabilitation is indicated. Difficulties
dealing with stressful or unexpected situations
can arise, as there may be a decrease in
abstract reasoning, judgment, intellectual
ability, and tolerance of stress relative to
premorbid capabilities.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 1 - GENERAL PROVISIONS › Section 10:60A-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this chapter is to provide standards for Medicaid/NJ FamilyCare reimbursement and Medicaid/NJ FamilyCare clinical eligibility for pediatric medical day care (PMDC) services.
1. PMDC is a program that provides medically necessary services in an ambulatory care setting to children who reside in the community and who, because they are technology-dependent and/or medically complex, require continuous rather than part-time or intermittent care of a registered professional nurse in a developmentally appropriate environment and whose needs cannot be met in a regular day care or pre-school handicapped program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 2 - PROVIDER PARTICIPATION IN MEDICAID/NJ FAMILYCARE AND PROVIDER SANCTIONS AND REMEDIES › Section 10:60A-2.1 - Standards for provider participation in Medicaid/NJ FamilyCare

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A PMDC facility shall meet the following requirements for Medicaid/NJ FamilyCare provider participation:
1. Licensure and approval by the Department in accordance with the Standards for Licensure of Pediatric Medical Day Care Facilities , N.J.A.C. 8:43J.
i. Participation as a provider is contingent upon continued licensure of the PMDC facility pursuant to, and in compliance with, N.J.A.C. 8:43J and in compliance with any applicable Federal or State laws of the Medicaid/NJ FamilyCare program respecting provider participation in Medicaid/NJ FamilyCare;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 2 - PROVIDER PARTICIPATION IN MEDICAID/NJ FAMILYCARE AND PROVIDER SANCTIONS AND REMEDIES › Section 10:60A-2.2 - Evaluation of provider and quality assurance

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall conduct an evaluation of the quality and effectiveness of the services a PMDC facility provides to a PMDC beneficiary at the time professional staff designated by the Department conduct a review for reauthorization of service on-site at the PMDC facility pursuant to N.J.A.C. 10:60A-3.4(c).
(b) As part of the process of reauthorization of service for a PMDC beneficiary, professional staff designated by the Department shall review:
1. The PMDC beneficiary's most current interdisciplinary plan of care for conformance with N.J.A.C. 8:43J-5;
2. The services being provided to the PMDC beneficiary and their conformity with a PMDC beneficiary's interdisciplinary plan of care and N.J.A.C. 10:60A-5;
3. The most current interdisciplinary team's assessment of the PMDC beneficiary's progress or lack of progress in meeting the objectives prescribed by the PMDC beneficiary's interdisciplinary plan of care and any documentation by the PMDC facility staff of reasons, if any, for the PMDC beneficiary's lack of progress; and
4. The PMDC beneficiary's attendance record and reasons for absences, if any, with particular attention to an intervening hospitalization or illness.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 2 - PROVIDER PARTICIPATION IN MEDICAID/NJ FAMILYCARE AND PROVIDER SANCTIONS AND REMEDIES › Section 10:60A-2.3 - Sanctions and remedies

Current through Register Vol. 56, No. 14, July 15, 2024
Non-compliance with N.J.A.C. 8:43J or 10:60A may result in sanctions and remedies being imposed as provided in the Medicaid Administration Manual, N.J.A.C. 10:49, 8:43E, and/or any other applicable law or regulation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 2 - PROVIDER PARTICIPATION IN MEDICAID/NJ FAMILYCARE AND PROVIDER SANCTIONS AND REMEDIES › Section 10:60A-2.4 - PMDC facility fair hearings and informed dispute resolution

Current through Register Vol. 56, No. 14, July 15, 2024
A PMDC facility wishing to contest decisions made by the Department pursuant to this subchapter or N.J.A.C. 10:60A-5 may request a fair hearing by submitting a request therefor, pursuant to the Medicaid Administration Manual, N.J.A.C. 10:49, and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 3 - PROCEDURES FOR DETERMINING CLINICAL ELIGIBILITY FOR PMDC SERVICES › Section 10:60A-3.2 - PMDC clinical eligibility for Medicaid/NJ FamilyCare beneficiaries receiving private-duty nursing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Medicaid/NJ FamilyCare beneficiary who receives private-duty nursing authorized by the New Jersey Department of Human Services pursuant to N.J.A.C. 10:60 may elect to receive PMDC services instead of, but not in addition to, the authorized daytime hours of private-duty nursing, if professional staff designated by the Department determine that the Medicaid/NJ FamilyCare beneficiary is a medically complex child and/or a technology-dependent child pursuant to N.J.A.C. 10:60A-3.1.
1. PMDC hours shall supplant, not supplement, authorized private-duty nursing hours, on an hour-for-hour basis.
2. A Medicaid/NJ FamilyCare beneficiary may elect to replace some or all of the authorized private-duty nursing hours for PMDC hours, but not concurrently; that is, a Medicaid/NJ FamilyCare beneficiary shall not receive authorized private-duty nursing during the same hours the beneficiary receives replacement PMDC.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 3 - PROCEDURES FOR DETERMINING CLINICAL ELIGIBILITY FOR PMDC SERVICES › Section 10:60A-3.3 - PMDC clinical eligibility for Medicaid/NJ FamilyCare beneficiaries being discharged from a neonatal intensive care unit

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall waive the requirement at N.J.A.C. 10:60A-3.4(a)  that professional staff designated by the Department perform a functional assessment prior to admission to a PMDC facility for a Medicaid/NJ FamilyCare beneficiary being discharged from a NICU if:
1. The PMDC facility nursing director, with input from the nursing director of the NICU, performs an assessment and determines that the child is medically complex and/or technology-dependent and documents, in writing, the results of the assessment, which writing shall contain, at a minimum, a summary of findings supporting that determination;
2. Based on the PMDC nursing director's determination, the PMDC facility administrator notifies the Division, in writing, of the facility's intention to admit the Medicaid/NJ FamilyCare beneficiary by following the requirements for notification contained in, and submitting, the documentation required at N.J.A.C. 10:60A-3.4(b)1 i and provides a copy of the PMDC nursing director's written assessment; and
3. Within 20 business days following the Medicaid/NJ FamilyCare beneficiary's admission to the PMDC facility, the facility administrator transmits, by regular mail, a copy of the Medicaid/NJ FamilyCare beneficiary's discharge summary from the NICU to the Division.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 3 - PROCEDURES FOR DETERMINING CLINICAL ELIGIBILITY FOR PMDC SERVICES › Section 10:60A-3.4 - Procedure for referral to and authorization of PMDC

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medicaid/NJ FamilyCare reimbursement for PMDC is contingent upon the Department's issuance of authorization of PMDC to a Medicaid/NJ FamilyCare beneficiary.
(b) To request initial authorization, a PMDC administrator shall submit the following to the Division by regular mail:
1. A completed prior authorization request form, which requires provision of information identifying the Medicaid/NJ FamilyCare beneficiary, the primary health care provider' s report on the Medicaid/NJ FamilyCare beneficiary, and a statement of the PMDC facility's reasons for requesting approval, which form may be obtained by telephoning the fiscal agent at (800) 776-6334; and
2. A completed report of the Medicaid/NJ FamilyCare beneficiary's primary health care provider in the form at chapter Appendix A, incorporated herein by reference.