New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 16 - DEMONSTRATION PROJECTS › Section 10:49-16.4 - Necessary criteria for a demonstration project

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				shall apply to all projects implemented under this subchapter:
1. All projects shall have approval from the
				United States Department of Health and Human Services;
2. All projects entered into under this
				subchapter shall be subject to all relevant State and Federal statutes and
				regulations, except to the extent that appropriate waivers shall have been
				granted;
3. The Commissioner of
				Human Services or the Commissioner of Health and Senior Services shall have the
				authority to review and approve in writing arrangements and agreements, whether
				formal or otherwise, between all projects and third parties prior to the
				execution thereof;
4. All projects
				in their hiring policies shall not discriminate against any individual on the
				basis of race, sex, religion, ethnicity or age, and shall comply with all the
				requirements of Title VI of the Civil Rights Act of 1964, as amended, and other
				applicable Federal and State laws or regulations pertaining to the civil rights
				of individuals;
5. No project shall
				deny services to any eligible person on the basis of race, sex, religion,
				ethnicity or age, and all projects shall comply with all the requirements of
				Title VI of the Civil Rights Act of 1964, as amended, pertaining to the civil
				rights of individuals;
6. All
				projects shall institute procedures for safeguarding of information in
				compliance with applicable Federal and State regulations and shall strictly
				adhere to same;
7. All projects
				shall collect and report data relevant to the project on a periodic basis, in a
				manner and fashion prescribed by the Medicaid Agent, including but not limited
				to, the following:
i. Financial data, such as
				line item expenditure statements and audit reports;
ii. Data necessary to the project regarding
				the characteristics of the population involved in the project and the control
				population, if any; and
iii.
				Program data, such as number and type of service rendered;
8. All projects shall furnish to the Medicaid
				Agent, in a manner and fashion prescribed by the Medicaid Agent, periodic
				progress reports;
9. The Medicaid
				Agent at its option may require receipt of copies of all project
				reports;
10. Any project entered
				into under this subchapter may include components fundable from sources other
				than that authorized by Section 1115 of the Social Security Act. These funds
				cannot be matched under the provisions of Section 1115 if they are Federal
				funds or if these funds are not otherwise matchable;
11. Nothing herein shall abridge the
				Commissioner's statutory authority to implement and administer demonstration
				programs under Section 1115 of Title XIX of the Social Security Act and
				30:4D-7, as amended;
12. Each project shall have the
				organizational and administrative capabilities to carry out its duties and
				responsibilities under the contract. This shall include as a minimum the
				following:
i. A full-time administrator to
				manage the day-to-day business activities of the project;
ii. Data reporting capabilities sufficient to
				provide necessary and timely reports to the Medicaid Agent;
iii. Financial reports and books of accounts
				maintained in accordance with generally accepted accounting principles, which
				are sufficient to fully disclose the disposition of all program funds received;
				and
iv. An annual independent audit
				arranged for by the project;
13. Each project director shall advise the
				Medicaid Agent of the project's administrative organization and changes
				thereto. This includes the functions and responsibilities of each principal, an
				organizational chart and a list of all personnel and providers used either
				directly by the project or through contractual arrangements. For each principal
				and each provider not previously reported, the following information shall be
				included:
i. Full name;
ii. Business address;
iii. Date and place of birth;
iv. Social Security Account Number;
v. IRS employer number;
vi. Professional license number (when
				applicable); and
vii. Medical
				specialty (when applicable);
14. Each project director shall submit to the
				Commissioner of Human Services or the Commissioner of Health and Senior
				Services for written approval a manual of administrative procedures which shall
				include personnel, purchasing and internal fiscal procedures. This manual shall
				be in conformance with approved management procedure; and
15. In those instances where a project
				involves the delivery of services, the following shall apply where appropriate
				and necessary:
i. The project shall
				demonstrate, to the satisfaction of the Commissioner of Human Services or the
				Commissioner of Health and Senior Services, the capability to provide for
				and/or arrange for the provision of those services which are required as
				components of the project;
ii. All
				individuals receiving services funded under Title XIX of the Social Security
				Act shall be informed in a simple, brief statement of their rights to a fair
				hearing;
iii. The project shall
				develop and establish grievance procedures for beneficiaries in addition to
				fair hearing procedures established pursuant to this paragraph;
iv. The project shall take steps to insure
				that it is rendering services that are consistent with and utilizes existing
				related Federal and State programs such as the EPSDT;
v. The project shall insure that there will
				be periodic peer review and quality of care audits;
vi. The project shall utilize eligibility
				criteria for eligibles to receive services as defined by the Department, and
				the Department shall insure, by a review process, that the project is in
				conformance with these criteria;
vii. The project shall take appropriate
				action to insure that the eligibility criteria provided per (a)15vi above is
				faithfully executed;
viii. The
				project shall obtain written approval from the Commissioner of Human Services
				and the Commissioner of Health and Senior Services prior to implementing the
				following:
(1) The methods of enrollment and
				enrollment forms to be used to enroll beneficiaries;
(2) The form and content of informational and
				instructional materials to be distributed to beneficiaries outlining the nature
				and scope of covered services provided by the project;
(3) The form and content of informational and
				instructional materials to be distributed to inform enrollees of changes in
				program scope or administration; and
(4) Provider claim forms and instructions for
				their use where such claim forms are unique to this contract;
ix. The project shall provide to
				the Medicaid Agent, for written approval prior to use, the form and content of
				all public information releases pertaining to the project; and
x. The project shall insure that all
				marketing representatives have received instruction, as appropriate, from the
				Medicaid Agent, on acceptable enrollment practices.