reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:52A-1.1 - Scope and purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The rules in this chapter shall apply to all Division of Medical Assistance and Health Services (DMAHS) funded Psychiatric Acute Partial Hospital (APH), and Partial Hospital (PH) services for adults. To the extent that the provisions of this chapter conflict with the provisions of N.J.A.C. 10:52, APH and PH services shall be regulated by this chapter.
(b) The concepts of wellness and recovery shall serve as the guiding principles in the delivery of both adult acute partial hospital and partial hospital services. As a result of their involvement with this program, beneficiaries should be able to better manage their illnesses and improve the quality of their lives. Each program shall identify and build upon each recovering beneficiary's strengths and areas of health in addressing the beneficiary's needs. The environment in which the program services are delivered shall encourage hope and emphasize individual dignity and respect. As recovery is most often a process, not an event, the provider shall address the needs of each beneficiary over time and across different levels of disability. Recovery principles shall be applied to the full range of engagement, intervention, treatment, rehabilitation and supportive services that a beneficiary may need.
1. The purpose of the APH services shall be to stabilize acute symptomatology in order to divert eligible beneficiaries from the need for inpatient psychiatric hospitalization. Treatment shall be provided at a level of intensity based upon clinical evaluation and formulation.
2. The purpose of PH services is to assist beneficiaries with severe mental illness to achieve community integration through valued living, learning, working and social roles. The role of PH is, therefore, to facilitate the beneficiary's integration into the community, not to become a permanent outcome, although it is recognized that some beneficiaries may need the support of PH for long periods of time. This balance between recovery and clinical services is accomplished through the provision of individualized, comprehensive, non-residential, structured programs which provide, but are not limited to, counseling, case management, psycho-education, pre-vocational services, community integration services and psychiatric services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 2 - ENROLLING AS A PROVIDER › Section 10:52A-2.1 - Authority to provide services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each program site location, as described in 10:52-1.3, at which APH or PH services are provided and which has been approved to be a Medicaid provider by the Division's Office of Reimbursement Services shall provide services and be reimbursed for those services pursuant to N.J.A.C. 10:49 and 10:52 and this chapter.
(b) Each program site location, as described in 10:52-1.3, at which APH or PH services are provided, shall be approved to be a Medicaid provider by the Division's Office of Reimbursement Services and, additionally, shall either be licensed by the Commissioner of the Department of Human Services as a mental health program and have a purchase of services contract with the Division of Mental Health Services, or be licensed by the Commissioner of the Department of Health and Senior Services as a health care facility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 2 - ENROLLING AS A PROVIDER › Section 10:52A-2.2 - Reporting change of address or ownership

Current through Register Vol. 56, No. 14, July 15, 2024
A participating provider shall reapply to the DMAHS Office of Reimbursement Services prior to operating if there are any changes in ownership or site location. In the case of a site relocation, the provider shall reapply prior to operating at the new location. DMAHS shall not reimburse for services provided prior to the date of the approval of the application.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 3 - BENEFICIARY ELIGIBILITY REQUIREMENTS › Section 10:52A-3.1 - Eligibility for APH services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to be eligible for APH services, an individual shall first be determined to be an eligible beneficiary in the Medicaid/NJ FamilyCare program in accordance with the Division's rules.
(b) In order to be eligible for APH services, a beneficiary shall be at least 18 years of age or older, unless prior authorized by DMAHS.
(c) In order to be eligible for APH services, a beneficiary shall:
1. At the time of referral or as a result of psychiatric evaluation provided or arranged for, have at least one of the following primary DSM-IV-TR diagnoses on Axis I:
i. Schizophrenia or Other Psychotic Disorders (298.9, 295.xx);
ii. Major Depressive Disorder (296.xx);
iii. Bipolar Disorders (296.xx, 296.89);
iv. Delusional Disorder (297);
v. Schizoaffective Disorder (295.7);
vi. Anxiety Disorders (300.xx); or
vii. A covered psychiatric disorder diagnosis consistent with codes, Axis I-V of the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR as amended and supplemented, including some 301.XX Axis II codes if the personality disorder is considered in the severe range and the beneficiary is at high risk of psychiatric hospitalization;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 3 - BENEFICIARY ELIGIBILITY REQUIREMENTS › Section 10:52A-3.2 - Eligibility for PH services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to be eligible for PH services, an individual shall first be determined to be an eligible beneficiary in the Medicaid/NJ Family Care program in accordance with the Division's eligibility rules at N.J.A.C. 10:49, 10:69, 10:71, 10:72, 10:78 and 10:79.
(b) In order to be eligible for PH services, an individual shall be at least 18 years of age or older, unless prior authorized by DMAHS.
(c) In order to be eligible for PH services, a beneficiary shall at the time of referral:
1. Have a primary diagnosis as set forth in 10:52A-3.1(c)1;
2. Have impaired functioning, which necessitates learning critical skills in order to achieve valued community roles and community integration in at least one of the following domains on a continuing, intermittent basis for at least one year or have recently decompensated to a significantly impaired status:
i. Maintenance of personal self-care;
ii. Development of interpersonal relationships;
iii. Ability to work;
iv. Ability to receive an education;
v. Ability to live in the community; or
vi. Ability to acquire or maintain safe, affordable housing when at risk of requiring a more restrictive living situation; and
3. Have a Global Assessment of Functioning (GAF) Scale scores of between 30 and 70, as set out in the DSM-IV-TR page 32.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 3 - BENEFICIARY ELIGIBILITY REQUIREMENTS › Section 10:52A-3.3 - Ineligibility for APH and PH services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An applicant or beneficiary who presents with any of the following criteria shall be excluded from participation in APH and PH services:
1. Has a primary diagnosis of substance abuse or dependence;
2. Is an imminent danger to self or others;
3. Is in need of acute medical care;
4. Is in need of detoxification;
5. Has a primary diagnosis of "developmentally disabled" as defined in the term "developmental disability" at 10:44A-1.3; or
6. Is currently participating in a PACT program, unless authorized in accordance with N.J.A.C. 10:76.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.1 - Program distinctions

Current through Register Vol. 56, No. 14, July 15, 2024
APH programs deliver intense active treatment necessary to stabilize a beneficiary's acute symptomatology and more effectively address intractable symptoms. PH programs provide services which assist beneficiaries to integrate into valued community roles.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.2 - Conditions which shall be met for APH and PH services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All of the following conditions shall be met for the provision of APH and PH services to each beneficiary:
1. Assigned staff shall complete an intake evaluation for each beneficiary within the identified timeframe established in 10:52A-4.7;
2. Assigned staff shall complete a comprehensive assessment for each beneficiary within the identified timeframe established in 10:52A-4.9;
3. The provider shall develop and maintain an Individualized Recovery Plan for each beneficiary, and shall update that Individualized Recovery Plan within the identified timeframe established in 10:52A-4.10;
4. Assigned staff shall record progress notes for each beneficiary within the identified timeframe established in 10:52A-4.11;
5. Assigned staff shall develop and maintain an applicable discharge plan for each beneficiary within the identified time frame established in 10:52A-4.12;
6. The provider shall monitor APH and PH services through a quality assurance, utilization review and outcome protocol;
7. Program hours of service:
i. APH and PH providers shall make services available to beneficiaries a minimum of five hours per day and a minimum of five days per week at the times most needed by the beneficiaries;
8. After conducting a treatment team evaluation, the treatment team shall certify that a beneficiary requires the services of APH or PH in strict accordance with the beneficiary eligibility requirements set forth in this chapter;
9. After the initial service plan required by 10:52A-4.7 has been developed, the treatment team shall examine the beneficiary to determine whether the beneficiary needs APH service. If so, the treatment team shall prepare a certification to that effect at least every 30 days to document that clinical evidence exists for continued stay. With respect to PH services, the treatment team shall examine the beneficiary and, if appropriate, prepare such a certification, every 60 days to document whether clinical evidence exists for continued stay; and
10. APH programs shall maintain affiliation agreements with local psychiatric community designated screening centers and inpatient hospital programs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.3 - Reimbursable and non-reimbursable APH and PH services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursable APH services are:
1. Psychiatric services in APH:
i. APH providers shall provide a face-to-face, individual encounter with a psychiatrist or an advanced practice nurse a minimum of every other week for at least 15 minutes in APH. More frequent encounters may be required as deemed clinically necessary during all program hours based upon the beneficiaries' symptomatology and acuity;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.4 - Length and hours of service

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Length and hours of service for APH shall be as follows:
1. Initial length of service requests for APH shall not exceed a maximum of seven business days, while awaiting prior authorization (PA) approval.
2. Prior authorization for APH is required every 90 days for up to a maximum of six months per beneficiary.
3. Beneficiaries receiving APH services shall receive no less than two hours of services per day and no more than five hours of services per day. Beneficiaries receiving APH services shall receive a maximum of 25 hours of services per week.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.5 - Prior authorization for APH services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) APH services provided to beneficiaries age 22 years or older require prior authorization for such services. Initial length of service requests for APH shall not exceed a maximum of seven business days, while awaiting prior authorization approval when the beneficiary is referred to adult acute partial hospital service by the local designated screening center or an inpatient psychiatric facility. Following the initial seven business days of service, prior authorization through a DMAHS concurrent utilization process review will be required for the remainder of the time the service is provided. Prior authorization in APH is required every 90 days for up to a maximum of six months.
(b) When requesting prior authorization, Forms FD-07 and FD-07A, "Request for Authorization of Mental Health Services and/or Mental Health Rehabilitation Services" and "Request for Prior Authorization: Supplemental Information" shall be completed and forwarded to the Medical Assistance Customer Center (MACC) that serves the county in which the services are rendered. (The forms may be obtained through the website
www.njmmis.com
or by contacting Unisys Provider Relations at 1-800-776-6334.) The "Brief Clinical History" and "Present Clinical Status" sections of the FD-07A "Request for Prior Authorization: Supplemental Information" form are particularly important and shall provide sufficient medical information to justify and support the proposed treatment request. A request for additional information may be made at the discretion of the Medicaid reviewer if the reviewer believes that insufficient medical information has been provided for the Division to make a determination. Failure to comply with such a request may result in a result in a reduction or denial of requested services.
(c) Each request for prior authorization shall reflect the criteria listed in 10:52A-3.1.
(d) The notification of the disposition (approved, modified, denied, or suspended) of a prior authorization request will be made by the Division.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.6 - Staffing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The APH and PH shall be staffed with personnel, who are licensed, when required, appropriately credentialed, culturally competent and trained to provide APH and PH services as set forth in this chapter. Staff may be engaged on a full time, part time or consulting basis, provided that services are adequate to meet the program needs of participating beneficiaries.
(b) The APH program shall maintain a qualified direct and clinical care staff-to-beneficiary ratio of 1:6 for active programming.
(c) The PH program shall maintain a qualified direct and clinical care staff-to-beneficiary ratio of 1:15 for active programming.
(d) For APH and PH each program shall have:
1. A program director who shall:
i. Have primary responsibility for program operation, development and management;
ii. Possess a professional credential such as:
(1) Licensed clinical social worker;
(2) Licensed professional counselor;
(3) Licensed rehabilitation counselor;
(4) Licensed clinical alcohol and drug counselor;
(5) Licensed psychologist;
(6) Advanced Practice Nurse; or
(7) Master of Science in Nursing with the requisite number of years of experience or possess a master's degree in a human service field and five years experience in mental health services, with two years supervisory experience; or
iii. Be available for crisis consultation and management and for coordination with outside practitioners;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.7 - Intake evaluation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The intake staff in both APH and PH shall assess an applicant's eligibility for services and develop an initial service plan with the beneficiary. All intake procedures shall be guided by a beneficiary's preferences and goals with regard to treatment and community living.
1. The initial contact shall serve to orient and engage a new beneficiary in a culturally and linguistically appropriate manner and facilitate continuity of service.
2. Intake procedures shall be designed to facilitate the beneficiary's program participation at the earliest appropriate opportunity. A lack of completion of the formal intake process shall not preclude an otherwise eligible beneficiary from receiving services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.8 - Initial service plan

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Within 24 hours of admission, staff shall develop an initial service plan as part of the intake process. The plan shall address the beneficiary's urgent presenting problems in order to meet immediate needs for food, clothing, shelter, medication and safety.
(b) The initial service plan shall be reviewed and approved by a psychiatrist within two business days after completion based upon the professional judgment of the psychiatrist that the treatment specified is clinically appropriate.
(c) Based on the information obtained from the intake interview and assessment, staff shall record the beneficiary's strengths, weaknesses and needs as part of the initial service plan. The beneficiary's urgent presenting problems, including a medication review, shall be evaluated and addressed in the initial service plan.
(d) Staff shall document the initial service plan in the beneficiary's record and staff shall revise it as needed until staff develop an Individualized Recovery Plan.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.11 - Documentation requirements for APH and PH

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The APR and PH programs shall maintain a comprehensive signature log, signed by each beneficiary, which reflects the beneficiary's daily participation in the program.
(b) Each APH program shall provide daily documentation for each beneficiary in the program. Each PH program shall provide weekly documentation for each beneficiary in the program. Documentation shall include, but not be limited to:
1. A summary of the beneficiary's participation in therapies or activities and clinical progress;
2. A description of any significant events which may have an effect on the beneficiary's achievement of his or her stated goals and objectives; and
3. Treatment plan revisions, which shall be based on the beneficiary's response to treatment plan interventions.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.12 - Discharge planning for APH and PH

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A discharge plan shall be initiated by the interdisciplinary treatment team, with beneficiary participation, at the time of admission and shall be updated with the Individualized Recovery Plan.
(b) The discharge plan shall consist of relevant, measurable goals and objectives to assist the beneficiary in accomplishing his or her discharge plan.
(c) The discharge plan shall be implemented when the beneficiary's functioning or symptomatology has improved as evidenced by scores on the Global Assessment of Functioning Scale.
(d) The discharge plan shall be implemented when the beneficiary meets the criteria for, has need for, or could benefit from, more or less intensive level of service or has achieved significant accomplishment of established goals and objectives.
(e) A discharge summary shall be written within 10 days of the beneficiary's discharge, termination or transfer from the program and shall be maintained thereafter in the beneficiary's record. The summary shall include, but need not be limited to, the following:
1. The beneficiary's presenting problem;
2. The beneficiary's admission date and date of termination from the program;
3. The course of treatment and the beneficiary's responses;
4. The reason for termination; and
5. The beneficiary's current medications.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.13 - Quality assurance and outcome review

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each APH and PH program shall maintain an established Quality Assurance Plan for the program to improve performance and treatment outcomes.
(b) Quality assurance indicators shall be based on beneficiary-identified issues and high risk factors.
(c) The Quality Assurance Plan shall be reviewed and updated annually.
(d) A copy of the Quality Assurance Plan shall be sent to the appropriate Medical Assistance Customer Center annually.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.14 - Off-site services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Off-site interventions may be provided, as long as the beneficiary is accompanied or supervised by staff.
1. The off-site interventions shall be:
i. Individualized for each beneficiary and non-stigmatizing;
ii. Integrated as a subordinate component of the beneficiary's Individualized Recovery Plan, which clearly describes each specific off-site intervention and how the intervention relates to the overall achievement of the beneficiary's specific goals and objectives in the Individualized Recovery Plan, particularly in assisting beneficiaries to apply skills learned to community settings.
iii. Properly documented in the beneficiary's record to include when the off-site activity commenced and terminated; and
iv. Limited to a defined and measurable period of time.
v. Services which are solely recreational or diversional in nature shall not be considered an APH or PH activity.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.15 - Quality assurance reviews

Current through Register Vol. 56, No. 14, July 15, 2024
(a) DMAHS shall conduct quality assurance reviews of all hospital-based mental health programs annually or more frequently, as required by DMAHS if deficiencies in the program are identified by DMAHS staff.
(b) DMAHS shall notify a program of any noncompliance findings revealed during the quality assurance review within 20 days of the review having been completed.
(c) A program shall respond in writing to any notification of findings within 30 days of notice.
(d) The program response shall include a corrective action plan to address and prevent all incidences of non-compliance.
(e) The corrective action plan shall include, but may not be limited to:
1. A timeline detailing remediation of noncompliance issues;
2. A detailed description of those steps determined necessary by the provider to ensure compliance with the corrective plan; and
3. Individuals and titles responsible for ensuring compliance with that plan.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 4 - PROGRAM REQUIREMENTS › Section 10:52A-4.16 - Termination of program

Current through Register Vol. 56, No. 14, July 15, 2024
Each hospital that discontinues an APH or PH program shall do so in an orderly fashion. Each hospital shall comply with all applicable closure and pre-closure requirements contained in State and Federal statutes, laws, rules and regulations. Additionally, the hospital shall notify the DMAHS Office of Provider Relations in writing at least 60 days in advance of the actual closing. The hospital shall develop a plan which specifies and provides referral for mental health services that are needed to provide for the present and future mental health needs of each beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52A - PSYCHIATRIC ADULT ACUTE PARTIAL HOSPITAL AND PARTIAL HOSPITAL SERVICES › Subchapter 5 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:52A-5.1 - Beneficiary rights

Current through Register Vol. 56, No. 14, July 15, 2024
(a) At the time of admission to an APH or PH program, program staff shall present and explain to each beneficiary all rights of the beneficiary under all applicable State and Federal statutes, laws, rules and regulations, as well as under all relevant hospital policies.
(b) A signed, witnessed statement shall be recorded in the beneficiary's record to the effect that the beneficiary's rights have been explained to the beneficiary.
(c) The psychiatric APH and PH program shall post, and advocate for, the beneficiary's exercise of rights.
(d) Any actions by staff to promote or assist the beneficiary in exercising his or her rights shall be clearly documented in the beneficiary's record.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52B - THE COUNTY OPTION HOSPITAL FEE PILOT PROGRAM › Subchapter 1 - GENERAL PROVISIONS › Section 10:52B-1.1 - Scope and purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter sets forth the policies and procedures for eligible counties to participate in The County Option Hospital Fee Pilot Program.
(b) The County Option Hospital Fee Pilot Program will raise funds to increase financial resources through the New Jersey Medicaid/NJ FamilyCare program to support local hospitals and to ensure that they continue to provide the necessary services to residents with low incomes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52B - THE COUNTY OPTION HOSPITAL FEE PILOT PROGRAM › Subchapter 1 - GENERAL PROVISIONS › Section 10:52B-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Act" means The County Option Hospital Fee Pilot Program Act, N.J.S.A. 30:4D-7r et seq.
"Affected hospital" means a hospital that is assessed a fee imposed by a participating county.
"Centers for Medicare and Medicaid Services (CMS)" means the agency of the Federal Department of Health and Human Services that is responsible for the administration of the Title XIX Medicaid program and the Title XXI Children's Health Insurance Program (CHIP), known in New Jersey as the Medicaid/NJ FamilyCare program.
"Commissioner" means the Commissioner of the New Jersey Department of Human Services.
"Days" mean calendar days.
"Department" means the New Jersey Department of Human Services.
"Eligible county" means a county with a population greater than 250,000, according to the 2010 Federal decennial census, that contains a municipality that:
1. Is classified, pursuant to N.J.S.A. 40A:6-4, as a First or Second Class municipality, or a Fourth Class municipality whose population exceeds 20,000; and
2. Has a Municipal Revitalization Index score, as last calculated by the New Jersey Department of Community Affairs prior to April 27, 2019, that exceeds 60.
"Fee" means the local health care-related fee authorized by the Act.
"Hospital" means a hospital that is licensed pursuant to P.L. 1971, c. 136 (N.J.S.A. 26:2H-1 et seq.) and is located within the borders of the participating county.
"Intergovernmental agreement (IGA)" means the agreement between a participating county and the Department through which a transfer of funds is made by the participating county to the Department.
"Intergovernmental transfer (IGT)" means the transfer of funds meeting the requirements of 42 U.S.C. §
										1396b(w) to the Department by a participating county pursuant to an intergovernmental transfer agreement.
"Medicaid/NJ FamilyCare program" means the New Jersey Medical Assistance and Health Services Program established pursuant to P.L. 1968, c. 413 (N.J.S.A. 30:4D-1et seq.) and P.L. 1997, c. 2 (N.J.S.A. 30:4J-8et seq.).
"Non-Federal share" means the portion of a Medicaid/NJ FamilyCare expenditure that is financed by State or local funds.
"Participating county" means an eligible county that chooses to participate in the pilot program.
"Pilot program" means The County Option Hospital Fee Pilot Program established by a participating county.
"Proposed fee and expenditure report" means a written report by a participating county that describes how the local health care-related fee authorized pursuant to the Act will be imposed in the participating county; how the funds collected from the fee will be used by the participating county; and how the plan described in the fee and expenditure report satisfies the purposes of the pilot program specified at N.J.A.C. 10:52B-1.1(b).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52B - THE COUNTY OPTION HOSPITAL FEE PILOT PROGRAM › Subchapter 2 - PARTICIPATION REQUIREMENTS › Section 10:52B-2.1 - Authorization and implementation of a county option hospital fee

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department of Human Services may authorize a county to become a participating county by approving its implementation of a pilot program imposing a fee on hospitals located within the county. Approval is subject to the following procedures:
1. The county shall submit a proposed fee and expenditure report to the Department for review and approval as specified in N.J.A.C. 10:52B-3.1;
2. The Department will make a participating county's proposed fee and expenditure report available for review and comment by affected hospitals and other interested parties for a period of 21 days and will consider the comments received in its review of the proposed report; and
3. The Department may request that a participating county amend its proposed fee and expenditure report if the Department determines that the county's proposal does not meet Federal or State requirements or address comments received during the comment period.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52B - THE COUNTY OPTION HOSPITAL FEE PILOT PROGRAM › Subchapter 2 - PARTICIPATION REQUIREMENTS › Section 10:52B-2.2 - Required elements of county ordinance or resolution

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order for an eligible county to participate in the pilot program, the county may enact a county ordinance or resolution, as appropriate to the county's form of government, that clearly defines the following:
1. The process for communicating with affected hospitals and collecting feedback and comments on the county proposal;
2. Which hospitals are subject to the fee;
3. The revenue or other metric that will be used as the basis for the fee and the rate that will be used to assess the hospital fee;
4. The notice and collection process;
5. Penalties that may be imposed for nonpayment or late payment;
6. The appeals process;
7. Use of fees for administrative costs, transfers for State administrative costs, and transfers to finance Medicaid/NJ FamilyCare payments to county providers;
8. A statement that there will be no impact on patients or payers; and
9. Affirmation that payments made under the pilot program will not supplant or otherwise offset payments made to hospitals from other sources, except that payments may be otherwise limited to the hospital's hospital-specific disproportionate share (DSH) limit as provided in Section 1923(g) of the Social Security Act ( 42 U.S.C. § 1394r-4 ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52B - THE COUNTY OPTION HOSPITAL FEE PILOT PROGRAM › Subchapter 3 - FINANCIAL REQUIREMENTS › Section 10:52B-3.2 - No impact on patients or payers

Current through Register Vol. 56, No. 14, July 15, 2024
The chief executive officer of each hospital subject to the fee shall certify that the cost of the fee shall not be assigned to any patient, insurer, self-insured employer program, or other responsible party, nor shall the fee be listed separately on any invoice or statement sent to a patient, insurer, self-insured employer program, or other responsible party.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52B - THE COUNTY OPTION HOSPITAL FEE PILOT PROGRAM › Subchapter 3 - FINANCIAL REQUIREMENTS › Section 10:52B-3.3 - Permissible use of funds

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A participating county shall use funds collected from the imposition of a fee as follows:
1. The participating county shall use at least 90 percent of the fee proceeds for the benefit of hospitals located in the county, as follows:
i. The participating county shall make an intergovernmental transfer (IGT) of the funds under an intergovernmental agreement (IGA) with the Department authorizing the Department's use of the funds as the non-Federal share of Medicaid/NJ FamilyCare payments to the local hospitals; or
ii. The participating county may retain the funds and use the funds to make payments to local hospitals as authorized in its approved fee and expenditure report. However, the Commissioner shall only approve a participating county's proposal to retain funds collected from the imposition of a fee provided that the participating county demonstrates, to the satisfaction of the Commissioner, that the county has sufficient funds to make payments to local hospitals in the amount of the fee proceeds that would otherwise have been transferred to the Department, plus an amount equal to the Federal matching funds that would have been paid to the Department had the fee proceeds been used as the non-Federal share Medicaid/NJ FamilyCare payments;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52B - THE COUNTY OPTION HOSPITAL FEE PILOT PROGRAM › Subchapter 3 - FINANCIAL REQUIREMENTS › Section 10:52B-3.4 - Notice, collection, and return of fee proceeds

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each participating county must develop a process to calculate the amount of the fee to be applied to each participating hospital in compliance with this chapter and Federal rules. The county may require submission of necessary financial data by the participating hospitals, or the county can choose to use other publicly available data sources.
(b) A participating county must specify in its ordinance or resolution, the frequency of collection of the fee (for example, quarterly, monthly, biannually, etc.).
(c) The participating county must provide written notice of the fee amount to each participating hospital postmarked at least 20 days in advance of the due date or define the due date in its ordinance or resolution.
(d) Each participating hospital will pay the fee amount indicated by the county on the specified due date.
(e) Each participating county will provide for refunding of overpayments, or amounts otherwise in error, to the participating hospitals within 15 days of identifying the overpayment or error. The participating county shall specify in its ordinance or resolution the maximum time limit by which a hospital must identify overpayments or amounts otherwise in error.
(f) In the event the Department returns to the participating county any of the transferred funds, the participating county will refund the full amount returned by the Department to the participating hospitals based on the pro rata share of the total fees paid, within 15 days after receipt by the county of the funds from the Department.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52B - THE COUNTY OPTION HOSPITAL FEE PILOT PROGRAM › Subchapter 3 - FINANCIAL REQUIREMENTS › Section 10:52B-3.5 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
A participating county may impose reasonable penalties or interest if an affected hospital fails to remit the full amount of the payment owed by the due date specified, not to exceed 1.5 percent of the outstanding payment amount per month. Any enforcement provision must be defined in the county's ordinance or resolution enacting the Department-approved fee and expenditure reports and include provisions for written notice to the participating hospitals and intended use of the funds consistent with the purpose of this chapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52B - THE COUNTY OPTION HOSPITAL FEE PILOT PROGRAM › Subchapter 3 - FINANCIAL REQUIREMENTS › Section 10:52B-3.6 - Appeal of assessment or enforcement action

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A participating county must specify a process for an appeal of the fee amount. The appeal shall be filed with the county within 15 days after the participating hospital receives notice of the fee amount due.
(b) A participating county must specify a process for an appeal of the decision to impose penalties and/or the amount of the penalties assessed pursuant to N.J.A.C. 10:52B-3.5.
(c) A hospital filing an appeal of either the amount of the fee or the penalty imposed by the county, or both, must provide any additional information requested by the county as part of the appeal process.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52B - THE COUNTY OPTION HOSPITAL FEE PILOT PROGRAM › Subchapter 3 - FINANCIAL REQUIREMENTS › Section 10:52B-3.7 - Reports and access

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Participating counties, affected hospitals, and managed care organizations are required to retain supporting documents and shall provide access to and shall furnish such reports to the Department, without charge, as the Department may specify, in order for the Department to:
1. Determine the amount of increased funding required to be paid by the managed care organizations to the hospitals;
2. Verify that the managed care organization has calculated and paid the correct amount due; or
3. Respond to inquiries from governmental entities with oversight of the pilot program, including CMS.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53 - HOME- AND COMMUNITY-BASED SERVICES PROVIDED IN ASSISTED LIVING RESIDENCES, COMPREHENSIVE PERSONAL CARE HOMES, AND ASSISTED LIVING PROGRAMS › Subchapter 1 - GENERAL PROVISIONS › Section 10:53-1.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
The rules in this chapter shall apply to assisted living residences, comprehensive personal care homes, and assisted living programs licensed by the Department of Health, in accordance with N.J.A.C. 8:36 that are also enrolled Medicaid/NJ FamilyCare providers, providing services through the Home and Community Based Services (HCBS) waiver to Medicaid/NJ FamilyCare beneficiaries.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53 - HOME- AND COMMUNITY-BASED SERVICES PROVIDED IN ASSISTED LIVING RESIDENCES, COMPREHENSIVE PERSONAL CARE HOMES, AND ASSISTED LIVING PROGRAMS › Subchapter 1 - GENERAL PROVISIONS › Section 10:53-1.2 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this chapter is to implement HCBS waiver provisions for services provided by assisted living residences, comprehensive personal care homes, and assisted living programs to Medicaid/NJ FamilyCare beneficiaries, which supplement the licensing requirements included at N.J.A.C. 8:36.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53 - HOME- AND COMMUNITY-BASED SERVICES PROVIDED IN ASSISTED LIVING RESIDENCES, COMPREHENSIVE PERSONAL CARE HOMES, AND ASSISTED LIVING PROGRAMS › Subchapter 1 - GENERAL PROVISIONS › Section 10:53-1.3 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, as used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:
"Assisted living program" means a program, licensed by the New Jersey Department of Health, in accordance with N.J.A.C. 8:36, that offers assisted living services to the tenants/residents of certain publicly subsidized housing buildings by a provider capable of providing or arranging for assistance with personal care, and of nursing, pharmaceutical, dietary, and social work services to meet the individual needs of each resident. Individuals receiving services from an assisted living program reside in their own independent apartments and are responsible for their own rent and utility payments, as defined in a lease agreement with the landlord.
"Assisted living residence" means a facility that is licensed by the Department of Health, in accordance with N.J.A.C. 8:36, to provide apartment-style housing and congregate dining and to ensure that assisted living services are available, when needed, for four or more adults unrelated to the proprietor. Apartment units offer, at a minimum, one unfurnished room, a private bathroom, a kitchenette, and a lockable door on the unit entrance.
"Comprehensive personal care home" means a facility that is licensed by the New Jersey Department of Health, in accordance with N.J.A.C. 8:36, to provide room and board and to assure that assisted living services are available, when needed, to four or more adults unrelated to the proprietor.
Residential units in comprehensive personal care homes house no more than two residents and have a lockable door on the unit entrance.
"Home and community based services (HCBS)" means the provision of services for Medicaid/NJ FamilyCare beneficiaries integrated into the community in homes and residences as an alternative to institutionalized care and services.
"Person-centered service plans" means the general service and health service plans at N.J.A.C. 8:367, Resident Assessments and Care Plans, that address an individual's long-term care needs and reflect the services and supports important to the individual to meet his or her needs, as identified through an assessment of functional need.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53 - HOME- AND COMMUNITY-BASED SERVICES PROVIDED IN ASSISTED LIVING RESIDENCES, COMPREHENSIVE PERSONAL CARE HOMES, AND ASSISTED LIVING PROGRAMS › Subchapter 2 - RESIDENTIAL SETTING REQUIREMENTS › Section 10:53-2.1 - Person-centered service plans

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order for service providers to receive Medicaid/NJ FamilyCare reimbursement for HCBS, beneficiaries in assisted living residences, comprehensive personal care homes, and assisted living programs must have person-centered service plans that meet the requirements for general service and health service plans found at N.J.A.C. 8:36-7 and follow any applicable Managed Care Organization service plan requirements.
1. The beneficiary must have a leading role in creating the service plans, whenever possible, along with the participation of their representative, as needed, and defined by the beneficiary, or, where appointed, the beneficiary's guardian.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53 - HOME- AND COMMUNITY-BASED SERVICES PROVIDED IN ASSISTED LIVING RESIDENCES, COMPREHENSIVE PERSONAL CARE HOMES, AND ASSISTED LIVING PROGRAMS › Subchapter 2 - RESIDENTIAL SETTING REQUIREMENTS › Section 10:53-2.2 - General integrated residential setting

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to be eligible to receive Medicaid/NJ FamilyCare reimbursement for the provision of HCBS to Medicaid/NJ FamilyCare beneficiaries in assisted living residences, assisted living programs, and comprehensive personal care homes, these beneficiaries must be integrated in, and have support to engage in, the greater community. This shall include, but not be limited to, providing the beneficiary with opportunities to seek employment, work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community to the same degree of access as persons not receiving Medicaid/NJ FamilyCare.
(b) The beneficiary must have the ability to select their community residence from options including, but not limited to, assisted living residences and comprehensive personal care homes. Beneficiaries in publicly subsidized housing, where the housing authority has contracted with a licensed assisted living program provider, shall have the option to consider assisted living programs. The setting options must be identified and documented in the beneficiary's person-centered service plans and based on the person's needs, preferences, and resources available for room and board.
(c) The assisted living residences, comprehensive personal care homes, and assisted living programs must ensure the beneficiary's rights of privacy, dignity, respect, as well as freedom from coercion and restraint. This shall include, at a minimum, the requirements at N.J.A.C. 8:36-4.1(a).
(d) The assisted living residences, comprehensive personal care homes, and assisted living programs must optimize, but not regiment, individual initiative, autonomy, and independence in making life choices. This includes, but is not limited to, daily activities, physical environment, and personal interactions.
(e) The assisted living residences, comprehensive personal care homes, and assisted living programs must facilitate individual choice regarding services and supports, and who provides them.