New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 5 - SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-5.10 - Services available to beneficiaries eligible for NJ FamilyCare-Plan I

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The services
				listed below are available to beneficiaries eligible for NJ FamilyCare-Plan I,
				on a fee-for-service basis, when medically necessary:
1. Advanced practice nurse
				services;
2. Clinic services
				(services in an independent outpatient health care facility, other than a
				hospital, that provides covered ambulatory care services);
3. Emergency room services;
4. Family planning services including medical
				history and physical examination (including pelvic and breast), diagnostic and
				laboratory tests, drugs and biologicals, medical supplies and devices,
				counseling, continuing medical supervision, continuity of care and genetic
				counseling.
i. Services provided primarily for
				the diagnosis and treatment of infertility, including sterilization reversals,
				and related office (medical and clinic) visits, drugs, laboratory services,
				radiological and diagnostic services and surgical procedures shall not be
				covered by the NJ FamilyCare program;
5. Federally qualified health center primary
				care services;
6. Home health care
				services, limited to skilled nursing for a home bound beneficiary which is
				provided or supervised by a registered nurse, and home health aid services when
				the purpose of the treatment is skilled care; medical social services which are
				necessary for the treatment of the beneficiary's medical condition; and
				short-term physical, speech or occupation therapy with the same limitations
				described in (a)21 below;
i. Personal care
				assistant services are not covered;
7. Hospice services;
8. Hospital services--inpatient;
9. Hospital services--outpatient;
10. Laboratory (clinical);
11. Nurse-midwifery services;
12. Optometric services, including one
				routine eye examination per year;
13. Optical appliances, limited to one pair
				of glasses or contact lenses per 24 month period;
14. Organ transplant services which are
				non-experimental or non-investigational;
15. Prescription drug services, except that
				over-the-counter drugs are not covered;
16. Physician services;
17. Podiatric services, except that routine
				foot care is not covered;
18.
				Prosthetic appliances, limited to initial provision of prosthetic device that
				temporarily or permanently replaces all or part of an external body part lost
				or impaired as a result of disease or injury or congenital defect;
i. Coverage includes repair and replacement
				when due to congenital growth;
19. Private duty nursing only when authorized
				by DMAHS;
20. Radiological
				services;
21. Outpatient
				rehabilitative services, including physical, occupational and speech therapy
				for non-chronic conditions and acute illnesses and injuries. Outpatient
				rehabilitation benefits are limited to treatment over a period of 60
				consecutive business days per incident of illness or injury beginning with the
				first day of treatment, except that:
i.
				Speech therapy services rendered for treatment of delays in speech development,
				unless resulting from disease, injury or congenital defects are not
				covered;
22. Inpatient
				rehabilitation services, including physical, occupational and speech therapy
				for non-chronic conditions and acute illnesses and injuries;
23. Transportation services, limited to
				ambulance for medical emergency only;
24. Maternity and related newborn
				care;
25. Diabetic supplies and
				equipment;
26. Services for mental
				health or behavioral conditions;
i. Inpatient
				hospital services, including psychiatric hospitals, limited to 35 days per
				year;
ii. Outpatient benefits for
				short-term, outpatient evaluative and crisis intervention or home health mental
				health services, limited to 20 visits per year. When authorized by the Division
				of Medical Assistance and Health Services, inpatient benefit exchanges are
				allowed, as follows:
(1) One mental health
				inpatient day may be exchanged for up to four home health visits or four
				outpatient services, including partial care. This is limited to an exchange of
				up to a maximum of 10 inpatient days for a maximum of 40 additional outpatient
				visits.
(2) One mental health
				inpatient day may be exchanged for two days of treatment in partial
				hospitalization up to the maximum number of covered inpatient days.
iii. Inpatient and outpatient
				services for substance abuse are limited to detoxification;
iv. Adult mental health rehabilitation
				services provided in/by community residence programs (see N.J.A.C. 10:77A) are
				not eligible for payment under NJ FamilyCare-Plan I; and
v. NJ FamilyCare-Plan I beneficiaries under
				age 21 who are receiving services under the Division of Child Behavior Health
				Services, may be eligible for additional mental health and mental health
				rehabilitation services as authorized by the Contracted Systems Administrator.
				(See 10:49-5.10(c);
				and
27. Elective/induced
				abortion services.