reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 48B - DECISION-MAKING FOR THE TERMINALLY ILL › Subchapter 7 - INDIVIDUALS WITHOUT CAPACITY TO MAKE MEDICAL TREATMENT DECISIONS FOR WHOM BGS IS PROVIDING GUARDIANSHIP SERVICES › Section 10:48B-7.1 - Individuals without capacity to make medical treatment decisions for whom BGS is providing guardianship services

Current through Register Vol. 56, No. 14, July 15, 2024
If the treating practitioner has determined that a terminally
				  ill individual or an individual in a permanently unconscious state for whom BGS
				  is providing guardianship lacks the capacity to make medical decisions, and the
				  treating practitioner is recommending the withholding or withdrawing of LSMT,
				  the recommendation shall be referred to an Ethics Committee recognized by the
				  Assistant Commissioner or his or her designee, pursuant to
				  N.J.A.C.
				  10:48B-3.1, for review.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 48B - DECISION-MAKING FOR THE TERMINALLY ILL › Subchapter 7 - INDIVIDUALS WITHOUT CAPACITY TO MAKE MEDICAL TREATMENT DECISIONS FOR WHOM BGS IS PROVIDING GUARDIANSHIP SERVICES › Section 10:48B-7.2 - Role and functions of Ethics Committees

Current through Register Vol. 56, No. 14, July 15, 2024
The Chief of BGS or his or her designee shall solicit
				  consultation from a recognized Ethics Committee whenever consent for
				  withholding or withdrawing LSMT is being requested by the treating
				  practitioner. The Ethics Committee shall meet as soon as possible depending
				  upon the urgency of the situation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 48B - DECISION-MAKING FOR THE TERMINALLY ILL › Subchapter 7 - INDIVIDUALS WITHOUT CAPACITY TO MAKE MEDICAL TREATMENT DECISIONS FOR WHOM BGS IS PROVIDING GUARDIANSHIP SERVICES › Section 10:48B-7.3 - Withholding or withdrawing life-sustaining medical treatment (LSMT) for individuals for whom BGS is providing guardianship services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				following procedures shall be followed:
1.
				When a recommendation to authorize the withholding or withdrawal of LSMT is
				received by staff of BGS, the recommendation shall be referred to an Ethics
				Committee recognized by the Assistant Commissioner or his or her designee,
				pursuant to
				10:48B-3.1, for review.
i. In preparation for presentation of a
				recommendation for withholding or withdrawing LSMT to an Ethics Committee
				recognized by the Assistant Commissioner or his or her designee, the Chief of
				BGS or his or her designee shall:
(1) Request
				a search of the individual's records to determine whether or not an advance
				directive or POLST exists;
(2)
				Obtain a description in writing from the treating practitioner of the diagnosis
				and prognosis of the individual, which substantiates the reasonableness of
				withholding or withdrawing potentially LSMT based upon the finding that such
				treatment would be more burdensome than beneficial, and contrary to the
				individual's best interest;
(A) The treating
				practitioner will include in the written description specific treatment
				recommendations for the individual.
(3) Obtain a second opinion that confirms the
				individual's diagnosis and prognosis; and
(4) Develop a profile detailing the relevant
				factors in a consideration to withhold or withdraw potentially LSMT including,
				but not limited to: permanently unconscious state, uncontrolled pain, severe
				and permanent physical and mental deterioration, or other similar
				criteria.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 48B - DECISION-MAKING FOR THE TERMINALLY ILL › Subchapter 7 - INDIVIDUALS WITHOUT CAPACITY TO MAKE MEDICAL TREATMENT DECISIONS FOR WHOM BGS IS PROVIDING GUARDIANSHIP SERVICES › Section 10:48B-7.4 - Procedures for rendering decision

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If the Ethics
				Committee recommends withholding or withdrawing of LSMT and DRNJ participates
				in the meeting, the Chief of BGS or his or her designee may make a decision
				immediately following the meeting. If the Chief of BGS or his or her designee
				decides to withdraw or withhold LSMT and DRNJ does not express an objection,
				consent can be given at that time. BGS shall prepare a certification pursuant
				to (b) below.
(b) If DRNJ does not
				participate in the Ethics Committee meeting and the Ethics Committee recommends
				withholding or withdrawing LSMT, and the Chief of BGS or his or her designee
				concurs with the recommendation, the Chief or his or her designee shall prepare
				a certification outlining the following:
1.
				The recommendation of the Ethics Committee;
2. The request of the treating practitioner,
				including a diagnosis and prognosis and a medical treatment plan;
3. A second opinion from another
				physician;
4. A history of
				individual's abilities and a progression of his or her illness;
5. The disposition of the family members, if
				any;
6. The BGS guardian's
				observations of the individual;
7.
				The recommended medical treatment support plan;
8. The wishes of the individual in an advance
				directive or POLST, if one exists;
9. The recommendations of BGS staff;
				and
10. Any other information
				deemed relevant to the decision.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 48B - DECISION-MAKING FOR THE TERMINALLY ILL › Subchapter 8 - PALLIATIVE CARE › Section 10:48B-8.1 - Palliative care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Palliative care
				services, including hospice services, may be provided for an individual with a
				terminal or life-threatening illness. Consideration for admission into a
				hospice program may require that a DNR Order be in place. If so, all of the
				procedures for consent to a DNR Order delineated above under N.J.A.C. 10:48B-7
				shall be followed prior to admission into a hospice program.
(b) Palliative care services, including
				hospice, may be provided in a health care facility specifically designed for
				hospice care, at a hospital, in a developmental center or in a community
				residence as defined in N.J.A.C. 10:44A or 10:44B.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:49-1.1 - Scope and purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division of
				Medical Assistance and Health Services, under the Department of Human Services,
				is designated in accordance with 42 C.F.R. 412.30, as the single State agency
				for the administration of the New Jersey Medicaid program. Under the authority
				of 30:4D-1 et seq., as amended and
				supplemented,
				30:4D-5, and pursuant to
				30:4D-4,
				30:4I-1 et seq. and 30:4J-1 et
				seq., the Division of Medical Assistance and Health Services is authorized to
				administer the Medicaid program as well as other special programs. This chapter
				provides general and specific information about the regular Medicaid program;
				special Medicaid services or programs (such as HealthStart, Prepaid Health
				Plans, and Waivered programs); the NJ FamilyCare programs and other special
				(State) funded Programs.
(b)
				Governor Whitman's Reorganization Plan No. 001-1996 gives the Department of
				Health and Senior Services (DHSS) legal authority to administer several
				components of the Medicaid program. These components include nursing facility
				services, medical day care services, PreAdmission Screening (PAS) and
				PreAdmission Screening and Annual Resident Review (PASARR), the Community Care
				program for the Elderly and Disabled (CCPED) waiver, the Assisted
				Living/Alternate Family Care (AL/AFC) waiver, and peer grouping. Rules for
				these Medicaid program components are promulgated by DHSS. Accordingly,
				providers must contact DHSS regarding requirements for these
				services.
(c) Pursuant to
				30:4D-1 et seq., as amended and
				supplemented, the Division of Medical Assistance and Health Services, under the
				Department of Human Services, is designated as the State agency responsible for
				the administration of the NJ FamilyCare program.
(d) Unless otherwise specified, or clearly
				indicated otherwise in the context of the rule, the rules of the New Jersey
				Medicaid program and the rules of the Division of Medical Assistance and Health
				Services are equally applicable to the NJ FamilyCare program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:49-1.2 - Organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Regarding the
				organization of the Division of Medical Assistance and Health Services, the
				Department of Human Services is the single State agency for receipt of Federal
				funds under Title XIX (Medicaid) and Title XXI (the State Children's Health
				Insurance Program (SCHIP)) of the Social Security Act. In New Jersey, the SCHIP
				program is known as NJ FamilyCare. The Division of Medical Assistance and
				Health Services, Department of Human Services, administers the New Jersey
				Medicaid and the NJ FamilyCare programs through its Central Office and through
				Medical Assistance Customer Centers (MACCs) located throughout the State of New
				Jersey. A listing of the MACCs is provided in the chapter Appendix. The
				Division may also designate from time to time agencies, which will assist in
				the administration of the NJ FamilyCare program.
1. The two programs are jointly financed by
				the Federal and State governments and administered by the State. The New Jersey
				Medicaid program is conducted according to the Medicaid State Plan approved by
				the Secretary, United States Department of Health and Human Services, through
				the Centers for Medicare & Medicaid Services (CMS). The NJ FamilyCare
				program is conducted according to the Title XIX and Title XXI State Plans
				approved by CMS.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.1 - Who is eligible for Medicaid?

Current through Register Vol. 56, No. 14, July 15, 2024
Medicaid beneficiaries are: those eligible for all services
				  under the regular New Jersey Medicaid program (see
				  10:49-2.2 below); those eligible
				  for a limited range of services under the Medically Needy program (see
				  10:49-2.3 below) and those
				  eligible for a limited range of services under the Home and Community-Based
				  Services Waiver Programs, in accordance with N.J.A.C. 10:49-22.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.3 - Persons eligible under the Medically Needy program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The eligibility
				rules for persons eligible under the Medically Needy program are included in
				N.J.A.C. 10:70.
(b) A Medicaid
				beneficiary under the Medically Needy program is limited to those medical
				services listed in
				10:49-5.3. Services shall be
				provided in conjunction with specific program requirements as outlined in the
				second chapter of the applicable Provider Services Manual.
(c) To be determined Medically Needy under
				the Medicaid Program, it is necessary for the person to meet categorical
				eligibility requirements, have income and/or resources in excess of the
				categorical standards, and have insufficient funds to meet his or her medical
				expenses. Medically Needy persons shall be in one of the following groups:
1. Pregnant women;
2. Needy children (under 21 years of age);
				or
3. The aged (65 years of age or
				older), the blind or the disabled.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.4 - Persons eligible under Home and Community-Based Services Programs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Individuals who
				may not be eligible for regular Medicaid benefits or Medical Needy may be
				eligible for selected services under the Home and Community-Based Services
				Waiver Programs under special eligibility rules. A brief overview of these
				programs and their rules may be found at N.J.A.C. 10:49-22.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.5 - Persons eligible under the NJ FamilyCare program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Children under
				the age of 19 whose family income does not exceed 133 percent of the Federal
				poverty level may be eligible for NJ FamilyCare-Plan A services pursuant to the
				eligibility rules at N.J.A.C. 10:78 and 10:79.
(b) Children under the age of 19 with family
				incomes above 133 percent and not in excess of 150 percent of the Federal
				poverty level may be eligible for NJ FamilyCare-Plan B services pursuant to the
				eligibility rules at N.J.A.C. 10:78 and 10:79.
(c) Children under the age of 19 with family
				incomes above 150 percent and not in excess of 200 percent of the Federal
				poverty level may be eligible for NJ FamilyCare-Plan C services pursuant to the
				eligibility rules at N.J.A.C. 10:78 and 10:79.
(d) Children under the age of 19 with gross
				family incomes above 200 percent and not in excess of 350 percent of the
				Federal poverty level may be eligible for NJ FamilyCare-Plan D services
				pursuant to the eligibility rules at N.J.A.C. 10:78 and 10:79.
(e) Former Health Access adults with incomes
				up to and including 250 percent of the Federal poverty level may be eligible
				for NJ FamilyCare-Plan D services pursuant to the eligibility rules at N.J.A.C.
				10:78 and 10:79.
(f) Specified
				parents/caretakers of children enrolled in NJ FamilyCare, in accordance with
				10:49-5.7,
				10:78-7.1 and this chapter, may be
				eligible to receive NJ FamilyCare Plan-D for Adults services.
(g) Specified parents/caretakers of children
				enrolled in NJ FamilyCare, in accordance with
				10:78-7.1 and this chapter, may be
				eligible to receive NJ FamilyCare-Plan I services on a fee-for-service
				basis.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.6 - Eligibility process (variations to routine procedure)

Current through Register Vol. 56, No. 14, July 15, 2024
There are variations to the routine procedure for
				  determining Medicaid eligibility. These variations are relevant to applying for
				  eligibility for a newborn infant or for an inpatient upon admission to a
				  hospital (see
				  10:49-2.7 ); to determining
				  presumptive eligibility for pregnant women (see
				  10:49-2.8 ); and to determining
				  retroactive eligibility (see
				  10:49-2.9 ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.7 - Applying for Medicaid eligibility for a newborn infant or for an inpatient upon admission to a hospital

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There are
				limited variations to the eligibility process for a newborn infant of a woman
				who is a Medicaid beneficiary. The policy and procedures follow:
1. Although both the mother and newborn
				infant may be Medicaid beneficiaries on the date of delivery, the newborn
				infant is not immediately assigned a Person Number (see
				10:49-2.12 ). In order to expedite
				payment to any provider before this number is assigned, the provider is
				permitted to bill for services provided to the newborn using the mother's
				Medicaid Eligibility Identification Number and Person Number on the claim
				form.
2. The period for which
				newborn services may be billed under the mother's Medicaid Eligibility
				Identification Number and Person Number shall extend from the date of birth
				until the last day of the month in which a 60 day time frame ends, or until the
				newborn is assigned his or her own Person Number, whichever happens first.
Example: If a newborn's date of birth is January 5th, the 60
				  day period ends March 6th. Claims may be submitted for dates of service through
				  March 31st using the mother's Medicaid Eligibility Identification Number and
				  Person Number, provided the newborn has not been assigned his or her own Person
				  Number in the meantime. Claims for services provided to the newborn after March
				  31st would be processed only if the required information about the newborn is
				  used (Person Number, name, age, sex, etc.).
3. The newborn's Person Number shall be used
				as soon as it is available to the provider. The practitioner or any other type
				of provider shall request the newborn's Person Number from the mother at each
				encounter.
4. Billing instructions
				for services provided a newborn infant under his or her mother's Medicaid
				Eligibility Identification Number and Person Number are provided in the Fiscal
				Agent Billing Supplement following the second chapter of each Provider Services
				Manual, as applicable.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.8 - Presumptive eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Presumptive
				eligibility" means an expedited process whereby selected certified HealthStart
				Comprehensive Maternity Care providers make preliminary Medicaid eligibility
				determinations on behalf of pregnant women (see HealthStart in applicable
				Provider Services Manuals and N.J.A.C. 10:49-19 ). This is a preliminary
				process to determine presumptive eligibility prior to the determination of
				Medicaid eligibility or ineligibility by the CWA.
1. Approved HealthStart Maternity Care
				providers (independent clinics and hospital outpatient departments) may
				determine presumptive eligibility for pregnant women who require ambulatory
				prenatal services from Medicaid participating providers.
2. A NJ FamilyCare one-page application can
				be used to apply for presumptive eligibility (PE) for Medicaid/NJ FamilyCare
				services. This is the only application that the pregnant woman will need to
				complete. The HealthStart PE provider shall send a copy of the completed
				one-page application to the CWA to determine full Medicaid/NJ FamilyCare
				eligibility using the NJ FamilyCare application instructions and documentation
				requirements.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.9 - Medicaid or NJ FamilyCare-Plan A retroactive eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any person
				applying for Medicaid or NJ FamilyCare-Plan A benefits shall be asked if he or
				she has unpaid medical bills incurred within the three-month period immediately
				prior to the month of application for Medicaid or NJ FamilyCare-Plan A.
1. Medically Needy applicants (see
				10:49-2.3(f)  )
				shall be evaluated for retroactive eligibility by the county welfare agency
				(CWA) when they apply for the Medically Needy program.
2. An applicant for NJ FamilyCare-Plan A
				whose application was processed by the Statewide eligibility determination
				agency has his or her retroactive eligibility processed by that agency. The
				applicant must indicate on his or her NJ FamilyCare-Plan A application that
				unpaid medical bills exist in the retroactive period or shall contact the
				Statewide eligibility determination agency within six months of his or her
				application date for NJ FamilyCare-Plan A.
3. Applicants who applied for Medicaid or NJ
				FamilyCare-Plan A at a CWA shall have their retroactive eligibility evaluated
				and processed at that CWA when they apply for Medicaid or NJ FamilyCare-Plan A.
				If the applicant does not indicate to the CWA that unpaid medical bills exist
				at the time of application, the applicant shall provide that information to the
				CWA within six months of the date of application. If retroactive eligibility is
				not requested from the CWA within six months from the date of application,
				retroactive eligibility will not be established.
4. Medicaid or NJ FamilyCare-Plan A
				Applicants who applied for Supplemental Security Income (SSI) may complete an
				FD-74 Form, Application for Payment of Unpaid Medical Bills (see Appendix,
				N.J.A.C. 10:49) and forward the application with required verification and all
				outstanding unpaid medical bills to the Medicaid Retroactive Eligibility Unit,
				Division of Medical Assistance and Health Services, PO Box 712, Mail Code #10,
				Trenton, New Jersey 08625-0712. An application for retroactive eligibility may
				be obtained by the applicant, or his or her authorized agent, from the CWA, the
				Medical Assistance Customer Center (MACC), the Social Security Administration
				District Office, or from the Retroactive Eligibility Unit, Division of Medical
				Assistance and Health Services. The application shall be received by the
				Retroactive Eligibility Unit within six months from the date of application for
				public assistance.
5. Applications
				for retroactive unpaid medical bills cannot be processed for services rendered
				prior to the effective date of the program. For NJ FamilyCare-Plan A, children
				eligible under
				10:79-3.4(b), the
				effective date is February 1, 1998. For NJ FamilyCare parents, the effective
				date is September 6, 2000.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.10 - Verification of eligibility for Medicaid or NJ FamilyCare; or Pharmaceutical Assistance to the Aged and Disabled (PAAD) services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each Medicaid
				or NJ FamilyCare beneficiary, except Nursing Facility beneficiaries, will be
				issued a Health Benefits Identification (HBID) Card for identification
				purposes. Each beneficiary will be issued an HBID Emergency Services Letter to
				use as identification when seeking emergency services prior to receiving the
				HBID card in the mail. (See Appendix, N.J.A.C. 10:49). This letter contains
				pertinent information, which the provider will need in order to submit claims
				for emergency services provided to the beneficiary. This letter is not valid
				proof of eligibility for Medicaid/NJ FamilyCare and should not be used by the
				provider for such purposes, except that the letter serves as proof of
				eligibility only in the event that the client is newly eligible and there is no
				record of the client when using the eligibility verification system. A request
				for reimbursement based solely upon the presentation of the Health Benefits
				Identification Card Emergency Services Letter does not guarantee payment. The
				beneficiary shall present either the HBID Emergency Services Letter or the HBID
				Card to the provider, as a proof of identification, every time a service is to
				be provided. See
				10:49-2.12 for a description and
				information about the Medicaid Eligibility Identification Number and see
				10:49-2.13 for information about
				the Medicaid and NJ FamilyCare forms or cards that are used to validate
				eligibility. The Recipient Eligibility Verification System (REVS) or Medicaid
				Eligibility Verification System (MEVS) shall be used to validate eligibility
				each time the beneficiary presents the HBID card and requests services (see
				10:49-2.11 ).
1. When extended plans of treatment have been
				approved, it is especially important to review the validation of eligibility
				form each time a service is provided.
i.
				Medical authorization or approval of a service by the Division shall not be
				construed as a guarantee that a person is eligible for the Medicaid or NJ
				FamilyCare program.
ii. There shall
				be no reimbursement for services performed after termination of eligibility,
				except as noted in
				10:49-5.5(a)9.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.11 - Recipient Eligibility Verification System (REVS)/Medicaid Eligibility Verification System (MEVS)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In the event a
				beneficiary is unable to produce an HBID card or an HBID Emergency Services
				Letter or the provider wants more current eligibility data (see N.J.A.C. 10:49)
				and the beneficiary's Medicaid or NJ FamilyCare Eligibility Identification
				Number or the Card Control Number (CCN) found on the HBID Card is known, the
				provider can verify eligibility by calling the Unisys Recipient Eligibility
				Verification System (REVS). REVS is accessed by dialing 1(800) 676-6562 or
				(609) 587-1955 in the local Trenton area). Complete instructions for using REVS
				can be found in the Fiscal Agent Billing Supplement following the second
				chapter for each Provider Services Manual. Eligibility can also be confirmed by
				inquiring online at
www.njmmis.com
.
(b) The New Jersey Medicaid/Pharmaceutical
				Assistance to the Aged and Disabled (PAAD) program offers providers an optional
				method of verifying beneficiary eligibility. The optional system is called
				Medicaid Eligibility Verification System (MEVS).
1. A provider can contract with a
				Medicaid/PAAD approved vendor that has access to the Medicaid/PAAD eligibility
				file. By contracting with a vendor, a provider through MEVS can obtain
				eligibility information by entering the Medicaid/PAAD/CCN number or, if the
				number is not available, the following data elements: the beneficiary's Social
				Security Number and date of birth.
i. For
				hospital providers only, name and date of birth may be used.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.13 - Forms that validate Medicaid eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A New Jersey
				Medicaid provider may verify a person's Medicaid eligibility by using the
				identification information on either:
1.
				Health Benefits Identification (HBID) Card (see
				10:49-2.15 );
2. HBID Emergency Services Letter (see
				10:49-2.15 ); or
3. "Validation of Eligibility" (FD-34) (see
				10:49-2.16 ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.15 - Health Benefits Identification (HBID) Card and Emergency Services Letter

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The HBID Card
				(see Appendix, N.J.A.C. 10:49) is issued to:
1. Persons (aged, blind and disabled)
				determined by the Social Security Administration to be eligible for
				Supplemental Security Income (SSI) and their spouses, if eligible as an
				essential person;
2. Persons
				determined by the CWA to be eligible for the New Jersey Care . . . Special
				Medicaid Programs and the Medically Needy program;
3. Beneficiaries in the Special Status
				program (see (e)2 below); and
4.
				Children (Medicaid recipients) under the supervision of the Division of Youth
				and Family Services (DYFS).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.16 - Validation form (FD-34) Validation of Eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The FD-34 Form,
				Validation of Eligibility (see Appendix, N.J.A.C. 10:49) identifies a Medicaid
				beneficiary who resides in a State or county institution.
1. The validation form shall be prepared and
				completed by the authorized Medicaid representative at the State or County
				institution. It is valid for the calendar month it is issued (up to a period of
				31 days) to a Medicaid beneficiary (patient/resident) in a State or county
				governmental psychiatric hospital or an intermediate care facility/mental
				retardation, and is used to obtain Medicaid covered services outside of the
				institutional setting. The form shall be returned with the Medicaid
				beneficiary.
2. Form FD-34 requires
				the signature, title, and telephone number of the authorized representative at
				the institution.
3. The Medicaid
				beneficiary or patient of a State or county institution receiving covered
				health services in the community is identified by the 12-digit Medicaid
				Eligibility Identification Number in which the first two digits identifies the
				institution. (See
				10:49-2.11(b)2 
				).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.17 - Medicaid application

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If a person has
				not applied for benefits, is unable to pay for services provided, and appears
				to meet the requirements for eligibility for the New Jersey Medicaid or NJ
				FamilyCare program, the provider shall encourage the person, or his or her
				representative, to apply for benefits:
1. To
				the CWA for programs, such as AFDC-Related Medicaid; Medicaid Only; New Jersey
				Care . . . Special Medicaid programs for pregnant women, children, and the
				aged, blind, or disabled; or for Medically Needy.
2. To the Social Security Administration for
				Supplemental Security Income benefits for the aged, blind, and disabled;
				or
3. In certain cases, to the New
				Jersey Division of Youth and Family Services, Department of Children and
				Families.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES › Section 10:49-2.19 - Medicaid or NJ FamilyCare eligibility-aliens

Current through Register Vol. 56, No. 14, July 15, 2024
For any alien who does not qualify for Medicaid or NJ
				  FamilyCare-Plan A based on his or her alien status, and thus is potentially
				  eligible for Medicaid or NJ FamilyCare-Plan A payment for emergency services
				  only (see 10:49-5.4, Medicaid or NJ
				  FamilyCare-Plan A Emergency Services for Aliens) the provider of service shall
				  complete a Form PA-1C and submit it with Certification of Treatment of
				  Emergency Medical Condition (if necessary) to the eligibility determination
				  agency in the county in which the individual lives. The provider shall inform
				  the individual that a Form PA-1C does not establish Medicaid eligibility or NJ
				  FamilyCare-Plan A eligibility but serves only to protect the date of inquiry as
				  an application date for Medicaid, or NJ FamilyCare-Plan A if an application is
				  filed within three months of the date that the Form PA-1C is signed. The
				  individual should be advised to file an application with the eligibility
				  determination agency as soon as possible.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 3 - PROVIDER PARTICIPATION › Section 10:49-3.1 - Provider types eligible to participate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Effective July
				1, 2006, P.L. 2006, c.
				45 and P.L. 2007, c. 111, as amended by
				P.L.
				2007, c. 336, require
				the Division to institute a moratorium on new Medicaid/NJ FamilyCare providers
				of chiropractic services, medical supplies except those sold in a pharmacy,
				partial care services and podiatry services.
1. Any provider that was not an approved
				Medicaid or NJ FamilyCare fee-for-service provider of chiropractic services,
				medical supplies except those sold in a pharmacy, partial care services or
				podiatry services prior to July 1, 2006 is ineligible to become an approved
				fee-for-service provider of such services for Medicaid or NJ FamilyCare, unless
				the Division affirmatively determines that the provider's services are
				necessary to meet special needs.
2.
				Situations not subject to the moratorium for fee-for-service providers of
				medical supply services are as follows:
i. A
				change of ownership only;
ii. A
				change of location only. A provider that has not changed ownership on or after
				July 1, 2006, which changes location on or after July 1, 2006, and continues to
				operate as a Medicaid or NJ FamilyCare provider at the new location, continues
				to provide the same level of services and delivery and meets all applicable
				State and Federal rules and regulations; and
iii. Medicare as the primary payer.
				Situations in which Medicare is the primary payer and the provider bills for
				cross-over claims and wraparound Medicare Part D payments.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 3 - PROVIDER PARTICIPATION › Section 10:49-3.2 - Enrollment process

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Providers shall
				complete a Provider Application and sign a Provider Agreement (see Appendix,
				N.J.A.C. 10:49) or a specialized agreement, and submit such other information
				or documentation, including, but not limited to, social security number and
				date of birth, as the program may require, depending on the nature of the
				services provided.
1. Policies and rules
				pertaining to shared health care facilities are outlined in N.J.A.C.
				10:49-4.
2. All practitioners
				participating in a group practice shall personally sign both the group
				application and the provider agreement if individual documents, or shall sign a
				single signature sheet if both documents are contained in a single
				packet.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 3 - PROVIDER PARTICIPATION › Section 10:49-3.3 - Providers with multi-locations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All providers
				participating in the Medicaid or NJ FamilyCare program shall identify all
				locations from which they are providing services to Medicaid or NJ FamilyCare
				beneficiaries.
(b) Each location
				shall comply with provider participation requirements and shall be assigned a
				separate provider number. Services rendered to Medicaid or NJ FamilyCare
				beneficiaries at a location not approved for participation are not eligible for
				Medicaid or NJ FamilyCare reimbursement.
(c) Billing through a central location for
				approved multi-location providers shall be allowed; however, providers shall
				utilize the applicable provider number for each service location. Selection of
				central or localized billing shall be left to providers, who shall state their
				preference on the application. The program reserves the right to assign unique
				provider numbers to maintain the accountability and integrity of the New Jersey
				Medicaid Management Information System (NJMMIS) and the New Jersey Medicaid or
				NJ FamilyCare program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 3 - PROVIDER PARTICIPATION › Section 10:49-3.4 - Medicaid or NJ FamilyCare provider billing number

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A seven digit
				Provider Billing Number shall be assigned by the fiscal agent to all providers
				approved for participation. The Provider Billing Number shall be entered upon
				all claims submitted in accordance with the instructions in the Fiscal Agent
				Billing Supplement. The Provider Billing Number should also be referenced in
				all written and telephone inquiries.
(b) Practitioners, as defined in (c)1 below,
				approved for participation, shall also be assigned a seven digit Provider
				Servicing Number by the Program fiscal agent. The Provider Servicing Number is
				an identification number which shall be entered upon all claim submittals in
				accordance with the instructions in the Fiscal Agent Billing
				Supplement.
(c) Providers who, for
				billing purposes, need a referring, ordering or prescribing practitioner's
				individual Provider Servicing Number, shall contact that practitioner or the
				fiscal agent, or shall access the Provider Servicing Number Directory, to
				obtain the number. A practitioner who does not participate in the Medicaid or
				NJ FamilyCare program will not have a Provider Servicing Number. In the absence
				of the referring, ordering or prescribing practitioner's individual Provider
				Servicing Number, providers must enter seven fives (5's) for non-participating
				out-of-State providers or seven sixes (6's) for non-participating in-State
				providers to indicate non-participation in the New Jersey Medicaid or NJ
				FamilyCare program. Providers may contact the Medicaid/NJ FamilyCare Fiscal
				Agent for a copy of the participating provider directory. In addition,
				providers may obtain servicing and prescribing numbers at
http://www.njmmis.com
.
1. Each participating practitioner (that is,
				physician, certified nurse midwife, advanced practice nurse, chiropractor,
				dentist, optometrist, podiatrist, or psychologist) shall supply his or her
				individual Provider Servicing Number to other providers when referring a
				Medicaid or NJ FamilyCare beneficiary for services, or ordering or prescribing
				on his behalf.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 3 - PROVIDER PARTICIPATION › Section 10:49-3.5 - One-time provider enrollment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any potential
				provider that is licensed or certified by the State of New Jersey as one of the
				provider types listed at
				10:49-3.1(a), or
				that is licensed or certified as such by a comparable state agency in the state
				in which the potential provider is located, and that is not enrolled as a New
				Jersey Medicaid or NJ FamilyCare provider, may submit an application to enroll
				as a New Jersey Medicaid or NJ FamilyCare one-time provider for the purpose of
				providing services to a specified beneficiary for a specified, limited period
				of time. The Department may approve such applications from providers if:
1. The applicant will provide, or has
				provided, covered services to a beneficiary; or
2. The applicant will provide a covered
				special or unique service to a beneficiary that is not accessible to the
				beneficiary from any other providers that are enrolled with the Division, as
				determined by the Division.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 4 - PROVIDERS' ROLE IN A SHARED HEALTH CARE FACILITY › Section 10:49-4.1 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter,
				  shall have the following meanings unless the context clearly indicates
				  otherwise.
"Discipline" means a branch of instruction or learning, such
				  as medicine, dentistry, chiropractic, and so forth.
"Patient" means anyone eligible to receive benefits from the
				  program.
"Purveyor" means any person, firm, corporation or other
				  entity other than a provider who, whether or not located in a building which
				  houses a shared health care facility, directly or indirectly, engages in the
				  business of supplying to ultimate users or providers within the shared health
				  care facility any medical supplies, equipment and/or services for which
				  reimbursement under the program is received, including, but not limited to,
				  clinical laboratory services or supplies; diagnostic radiology services; sick
				  room supplies; physical therapy services or equipment; orthopedic or surgical
				  appliances or supplies; drugs, medication or medical supplies; eyeglasses,
				  lenses or other optical supplies or equipment; hearing aids or devices; and any
				  other goods, services, supplies, equipment or procedures prescribed, ordered,
				  recommended or suggested for medical diagnosis, care or treatment, and which
				  amount to $ 10,000 per year.
"Shared health care facility" (SHCF) means four or more
				  providers, two or more of whom are practicing within different specialties
				  and/or disciplines, either independently or in association with each other,
				  within a single structure; and
1. Two or more of whom share any of the following:
i. Common waiting areas;
ii. Examining rooms;
iii. Treatment rooms;
iv. Equipment;
v. Supporting staff;
vi. Common records; and
2. One or more of whom receives payment on a fee-for-service
				  basis, and where the gross Medicaid income for the facility meets or exceeds $
				  80,000 per year.
"Specialty" means a health care practice within a discipline
				  such as pediatrics, obstetrics/gynecology, orthodontics, periodontics, and so
				  forth.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 4 - PROVIDERS' ROLE IN A SHARED HEALTH CARE FACILITY › Section 10:49-4.2 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter
				shall apply to shared health care facilities as defined herein and to providers
				located in a specific health care facility.
(b) This subchapter shall apply to purveyors,
				whether or not located in a building which houses a shared health care
				facility.
(c) Nothing in this
				subchapter shall apply to an association of health care providers delivering
				health services on other than a fee-for-service basis.
(d) This subchapter shall not apply to
				hospitals participating in the Medicaid program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 4 - PROVIDERS' ROLE IN A SHARED HEALTH CARE FACILITY › Section 10:49-4.3 - Registration of shared health care facilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No shared
				health care facility shall be operated under the program unless it has been
				registered with the Division. The Office of Quality Management and Program
				Integrity, PO Box 712, Mail Code #7, Trenton, New Jersey 08625-0712 is
				responsible for registration.
1. Providers
				within the shared health care facility shall designate one provider member who
				shall be responsible for registration:
i. Said
				responsibility and liability by the designated provider, shall be limited to
				timely filing of accurate reports required under this section.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 4 - PROVIDERS' ROLE IN A SHARED HEALTH CARE FACILITY › Section 10:49-4.4 - Prohibited practices; administrative requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division
				shall not enter into any agreement of Medicaid or NJ FamilyCare participation,
				nor shall any payment be made to any provider in a shared health care facility
				where the rental fee for the letting of space or supportive professional or
				clerical services to a provider in a shared health care facility is calculated
				in whole or in part, directly or indirectly, as a percentage of earnings or
				billings of the provider for services rendered on the premises in which the
				shared health care facility is located.
(b) No purveyor or provider, whether or not
				located in a building which houses a shared health care facility, shall
				directly or indirectly offer, pay or give, or permit or cause to be offered,
				paid or given to any provider or purveyor, and no provider or purveyor shall
				directly or indirectly solicit, request, receive or accept from any purveyor or
				provider any sum of money, credit or other valuable consideration for:
1. Recommending or procuring goods, services
				or equipment of such purveyor or provider to any other person;
2. Directing patronage or clientele to such
				purveyor or provider; or
3.
				Influencing any person to refrain from using or utilizing goods, services or
				equipment of any purveyor or provider.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 4 - PROVIDERS' ROLE IN A SHARED HEALTH CARE FACILITY › Section 10:49-4.5 - Quality of care requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To ensure
				quality, continuity and proper coordination of medical care, each shared health
				care facility shall:
1. Where feasible,
				designate an individual who, on a full-time basis, shall coordinate and manage
				the facility's activities;
2.
				Devise an appropriate means of insuring that patients shall be scheduled to
				return for appropriate follow-up care and shall be treated by a provider
				familiar with patient's medical history;
3. Post conspicuously the names and scheduled
				office hours of all providers practicing in the facility;
4. Maintain proper records. Such records
				shall contain at least the following information:
i. The full name, address and Program Number
				of the patient;
ii. The dates of
				all visits to all providers in the shared health care facility;
iii. The chief complaint for each visit to
				each provider in the shared health care facility;
iv. Pertinent history and all physical
				examinations rendered by each provider in the shared health care
				facility;
v. Diagnostic impressions
				for each visit to any provider in the shared health care facility;
vi. All medications prescribed at each visit
				by any provider in the shared health care facility who is qualified to issue
				prescriptions;
vii. The precise
				dosage and prescription regimens for each medication prescribed by a provider
				in the shared health care facility;
viii. All x-ray, laboratory work and
				electrocardiograms ordered at each visit by any provider in the shared health
				care facility;
ix. The results of
				all x-ray, laboratory work and electrocardiograms ordered as in (a)4viii
				above;
x. All referrals by
				providers in the shared health care facility to other medical providers and the
				reason for such referrals, and date of referral; and
xi. A statement as to whether or not the
				patient is expected to return for further treatment.
5. The Division shall have the right to
				inspect the business records, patient records, leases and other contracts
				executed by any provider in a shared health care facility. Such inspections may
				be by site visits to the shared health care facility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 5 - SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-5.1 - Requirements for provision of services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The services
				listed in 10:49-5.2 are available to
				beneficiaries eligible for the regular New Jersey Medicaid or the NJ
				FamilyCare-Plan A programs. Services available to Medically Needy beneficiaries
				are listed in
				10:49-5.3. The services listed in
				10:49-5.2 and 5.3 shall be
				provided in conjunction with program requirements specifically outlined in the
				second chapter of each Provider Services Manual.
1. Any service limitations imposed will be
				consistent with the medical necessity of the patient's condition as determined
				by the attending physician or other practitioner and in accordance with
				standards generally recognized by health professionals and promulgated through
				the New Jersey Medicaid program. Some services require prior authorization from
				the program before the services are provided (see N.J.A.C. 10:49-6
				--Authorization Required).