reglab/statecodes huggingface dataset:
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 10:53-2.3 - Facility setting

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In addition to the requirements at N.J.A.C. 8:36, assisted living residences and comprehensive personal care homes must meet the following criteria for HCBS Medicaid/NJ Family Care reimbursement:
1. The unit or dwelling must be a specific physical place that can be rented or occupied pursuant to a legally enforceable lease agreement by the beneficiary that, at a minimum, must provide protections that address eviction processes and appeals comparable to those provided pursuant to applicable landlord/tenant law. If a residential lease is not utilized, the facility must enter into a residency agreement or other written agreement with the beneficiary and such agreement must have the same responsibilities and protections from eviction that tenants have pursuant to State, county, and municipal landlord/tenant laws.
2. The beneficiary must have privacy in his or her sleeping or living unit.
i. The unit must have entrance door(s) lockable by the beneficiary, with only appropriate staff having keys to doors;
ii. Beneficiaries sharing units must have a choice of roommates in that residence;
iii. The beneficiary must have the freedom to furnish and decorate his or her sleeping or living unit within the lease or other agreement;
3. The beneficiary must have the freedom and support to control his or her own schedules and activities;
4. The beneficiary must have access to food at any time;
5. The beneficiary must be able to have visitors of his or her choosing at any time;
6. The residence must be physically accessible to the beneficiary; and
7. The residential setting must not have the qualities of an institution and must have the qualities of a home and community-based setting.
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 3 - REQUIRED NOTICES › Section 10:53-3.1 - Licenses

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In addition to the notice requirements at N.J.A.C. 8:36, the assisted living residence or comprehensive personal care home must post its license from the Department of Health in a conspicuous location near the main entrance or office of the facility.
(b) The assisted living program must conspicuously post a notice that its license is available to beneficiaries and the public at the program site and at the assisted living program provider's main office, in accordance with N.J.A.C. 8:36-23.6.
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 3 - REQUIRED NOTICES › Section 10:53-3.2 - Inspection and survey reports

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The assisted living residence or comprehensive personal care home must conspicuously post the most recent inspection report from the Department of Health in the entry or another equally prominent location in the building and, upon request, shall provide a copy of the report to each beneficiary or their legal guardian.
(b) The assisted living residence or comprehensive personal care home shall inform each beneficiary that he or she may review a copy of the survey report and a list of deficiencies, if applicable, from the last annual licensure inspection from the Department of Health and from any valid complaint investigation during the past 12 months.
(c) The assisted living program provider and each program site must conspicuously post notice that a copy of the last annual licensure inspection survey report and the list of deficiencies from any valid complaint investigation during the past 12 months is available for review.
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 3 - REQUIRED NOTICES › Section 10:53-3.3 - Required contact information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Assisted living residences and comprehensive personal care homes must post the following contact information in a conspicuous location in the facility:
1. "911" for the police department and the fire department that serve the municipality in which the facility is located;
2. The complaint hotline of the New Jersey Department of Health (1-800-792-9770); and
3. The toll-free number for the office of the New Jersey Long-Term Care Ombudsman (1-877-5826995).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:53A-1.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursement for hospice services provided by Medicaid was authorized pursuant to § 1905(o) of the Social Security Act, codified as 42 U.S.C. §
										1396d(o). N.J.S.A. 30:4D-6b(20) authorizes the New Jersey Division of Medical Assistance and Health Services to develop a program of hospice services. This chapter, N.J.A.C. 10:53A, Hospice Services, sets forth the rules for the provision of hospice services to the terminally ill who are eligible for Medicaid/NJ FamilyCare fee-for-service (FFS) program. Room and board services are also available for those Medicaid /NJ FamilyCare FFS beneficiaries residing in a nursing facility who are also eligible for hospice services. The Home Care Services Manual (N.J.A.C. 10:60), is applicable to hospice care as a waiver service provided under the AIDS Community Care Alternatives Program (ACCAP).
(b) This chapter provides the rules for hospice services for Medicaid/NJ FamilyCare FFS beneficiaries who are not enrolled in, and receiving services through, a health maintenance organization (HMO). Hospice services provided to a beneficiary who is enrolled with an HMO are governed by the policies of the HMO and are not within the purview of these rules.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:53A-1.3 - Contracting with physicians

Current through Register Vol. 56, No. 14, July 15, 2024
Effective August 5, 1997, hospice providers are no longer required to routinely provide all physician services directly. Medical directors and physician members of the interdisciplinary group (IDG) are no longer required to be employed by the hospice. These physicians can now be under contract with the hospice.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 2 - PROVIDER REQUIREMENTS › Section 10:53A-2.1 - Hospice enrollment requirements and billing processes

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To be approved by the Division as a hospice provider, a hospice must:
1. Be licensed by the Department of Health and Senior Services as a provider of hospice services in accordance with N.J.A.C. 8:42C. A copy of the license must be submitted to the Division of Medical Assistance and Health Services;
2. Be enrolled as a Medicare (Title XVIII) hospice provider. A copy of the Medicare provider enrollment agreement must be submitted to the Division of Medical Assistance and Health Services;
i. As stated in the Social Security Act, Section 1861(d)(d)(2)(A)(ii) ( 42 U.S.C. §
												1395x(dd) ) on Medicare certification, the term "hospice program" means a public or private organization which provides for such care in individuals' homes, on an outpatient basis, and on a short-term inpatient basis. Thus, a Medicare certified hospice shall not limit or market hospice services exclusively to a long term care facility population; and
3. Complete and submit the Medicaid "Provider Application" (FD-20); "Ownership and Controlling Interest Statement" (CMS-1513); and the "Medicaid Provider Agreement" (FD-62).
i. Documents specific to provider enrollment, referenced in (a)3 above, are located as Forms #8, #9, and #10 in the Appendix of the Administration chapter (N.J.A.C. 10:49--Appendix), and may be obtained from and submitted to:
Molina Medicaid Solutions
Provider Enrollment
PO Box 4804
Trenton, New Jersey 08650-4804
ii. Hospice provider agreements are approved by:
Molina Medicaid Solutions
Provider Enrollment
PO Box 4804
Trenton, New Jersey 08650-4804
iii. A change in the ownership of a hospice is not considered a change in the individual's designation of a hospice and requires no action on the Medicaid/NJ FamilyCare FFS hospice beneficiary's part. The hospice shall notify the Division in writing of a change in ownership and shall submit a new application package.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 2 - PROVIDER REQUIREMENTS › Section 10:53A-2.2 - Changing from one hospice to another

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order for a hospice beneficiary to change hospices, the hospice policies and procedures listed below shall be followed:
1. An individual may change hospices once in each benefit period. The change of the hospice is not considered a revocation of the election of hospice services.
2. In order to change the designation of the hospice, an individual shall file a signed statement, the Change of Hospice, FD-384 form incorporated herein by reference as Form #7 in the Appendix, with the hospice where the individual was initially enrolled and also with the newly designated hospice. The statement shall include the following information:
i. The name of the hospice from which the individual received hospice services; and
ii. The name of the hospice from which the individual will receive hospice services and the date the change is effective.
3. The original hospice of enrollment and the new hospice must send the Hospice Eligibility Form, FD-383 to the medical assistance customer center (MACC), county welfare agency (CWA), or , as applicable, Division of Child Protection and Permanency (DCP&P) in order to change providers. (See Form #6, the Hospice Eligibility Form, FD-383, in the Appendix in this chapter, incorporated herein by reference and 10:53A-3.2 for the policy for medical and financial eligibility for Medicaid/NJ FamilyCare FFS).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 2 - PROVIDER REQUIREMENTS › Section 10:53A-2.4 - Standards for staffing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Medical Director of the hospice shall assume overall responsibility for the medical component of the hospice services.
(b) The hospice shall designate an interdisciplinary group or groups composed of, at a minimum, the following individuals who are employed by or under contract with the hospice and who provide and/or supervise the services offered by the hospice:
1. A physician (doctor of medicine or osteopathy);
2. A registered professional nurse;
3. A medical social worker (see 10:53A-3.4 for qualifications); and
4. A pastoral or other counselor.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 2 - PROVIDER REQUIREMENTS › Section 10:53A-2.5 - Administrative policy for admission and discharge from room and board services in a nursing facility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If a beneficiary of hospice services is admitted to a nursing facility (NF) from any location, or is changed from nursing facility status to hospice status (while residing in a nursing facility), or is discharged from the hospice or dies, the NF shall submit to the CWA and the DOH field office, a completed Notification from Long-Term Care Facility of Admission or Termination of a Medicaid Patient LTC-2 (Form #9 in the Appendix, incorporated herein by reference) to prompt a change in the beneficiary's status. For SSI beneficiaries, the hospice shall be responsible for notifying the MACC of the beneficiary's death or discharge from the NF by completing FD-383 (Appendix Form #6). The MACC will be responsible for notifying the Social Security Administration of the beneficiary's change in status.
(b) If the beneficiary residing in an NF chooses hospice benefits, the NF shall submit to the fiscal agent, a completed Long Term Care Turnaround Document (TAD) (MCNH-117) (Form #11 in the Appendix herein incorporated by reference) to remove the beneficiary from the Long-Term Care Facility billing system. The following information shall be placed on the MCNH-117 in the REMARKS column (Field #38 on the bottom):
"DISCHARGED FROM NURSING FACILITY TO HOSPICE"
1. The hospice beneficiary is removed from the Long Term Care Facility billing system effective on the date the Election of Hospice Benefits Statement, FD-378 (Appendix Form #1) is signed. On that date and thereafter, the Medicaid/NJ FamilyCare fiscal agent will directly reimburse the hospice for services rendered to the hospice beneficiary and the NF will no longer be reimbursed for care beginning this date. The hospice shall be responsible for reimbursing the NF for room and board services provided under contract with the hospice.
2. If the beneficiary revokes hospice and returns to NF care, the NF shall complete and submit the Long Term Care Turnaround Document (TAD) (MCNH-117) form to the fiscal agent. The following information shall be placed on the MCNH-117 in the REMARKS column (Field #38 on the bottom):
"ADMITTED TO NURSING FACILITY AND DISCHARGED FROM HOSPICE"
3. The effective date of the change from hospice care to NF care is the date the Revocation of Hospice Benefits, FD-381 (Form #4 in the Appendix incorporated herein by reference) is signed. The NF will be reimbursed for care provided on this date and thereafter, and the hospice will no longer be reimbursed for care beginning on this date.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 2 - PROVIDER REQUIREMENTS › Section 10:53A-2.6 - Recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The medical record of the hospice beneficiary maintained by the hospice shall be complete and accurate and reflect the services provided. The medical record shall include, at a minimum, the following information:
1. Identification information;
2. Certification/recertification documents;
3. Informed consent documents;
4. Election forms;
5. Hospice eligibility forms;
6. Pertinent medical history and physical examination data;
7. Test results;
8. Initial and subsequent assessments;
9. Plan of care and updates; and
10. Complete documentation of all services and events (including evaluations, treatments, progress notes, etc.).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 2 - PROVIDER REQUIREMENTS › Section 10:53A-2.7 - Monitoring

Current through Register Vol. 56, No. 14, July 15, 2024
(a) On a random selection basis, the Division shall conduct post-payment quality assurance reviews based on Surveillance and Utilization Review System (SURS) reports and other sources to assure compliance with program, personnel, recordkeeping and service delivery requirements. Provisions shall be made to recover funds, when reviews by the Division reveal that overpayments to the hospice have been made. At the specific request of the Division, the hospice shall submit a plan of care and other documentation for those Medicaid/NJ FamilyCare FFS beneficiaries selected for a quality assurance review.
1. The review shall involve contact with the hospice and the beneficiary and will focus on the following areas:
i. Number of beneficiaries;
ii. Cost per beneficiary including the "cap" requirements;
iii. Number of days of service per beneficiary and the quality of services;
iv. Comparative analysis between claim payments and the plan of care; and
v. Completion of forms necessary for eligibility for hospice services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 2 - PROVIDER REQUIREMENTS › Section 10:53A-2.8 - Provision for provider fair hearings

Current through Register Vol. 56, No. 14, July 15, 2024
Pursuant to the N.J.A.C. 10:49-10, Notices, Appeals and Fair Hearings, providers with the New Jersey Medicaid/NJ FamilyCare FFS program have the right to file for fair hearings.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 2 - PROVIDER REQUIREMENTS › Section 10:53A-2.9 - Advance directives

Current through Register Vol. 56, No. 14, July 15, 2024
All hospices participating in the New Jersey Medicaid/NJ FamilyCare FFS program are subject to the provisions of State and Federal statutes regarding advance directives, including, but not limited to, appropriate notification to patients of their rights, development of policies and practices, and communication to and education of staff, community and interested parties. Detailed information may be located at 10:49-9.15, and sections 1902(a)(58), and 1902(w)(1) of the Social Security Act ( 42 U.S.C. §§
										1396a(a)(58) and 1396a(w) ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 3 - BENEFICIARY REQUIREMENTS › Section 10:53A-3.1 - Eligibility for covered hospice services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For the purposes of this subchapter only, the term "applicant" refers to an individual applying for hospice eligibility who may or may not be Medicaid/NJ FamilyCare FFS eligible at the time of application.
(b) In order to receive hospice services, an applicant must be eligible for Medicaid/NJ FamilyCare FFS either in the community or in an institution. Additionally, an applicant is eligible for hospice services in the community if he or she would be eligible for Medicaid if he or she were institutionalized. Eligibility rules are found at N.J.A.C. 10:71, 10:72, and 10:78, incorporated herein by reference. Applicants eligible only for the Medically Needy component of the New Jersey Medicaid program are not eligible for hospice services under the Medicaid State Plan benefit.
1. The transfer of resource provisions of N.J.A.C. 10:71-4.7 apply to applicants seeking hospice services while residing in a nursing facility as well as to applicants seeking eligibility for hospice services in the community but whose income disqualifies them from New Jersey Care. . . Special Medicaid Programs.
2. Applicants not already eligible for Medicaid/NJ FamilyCare FFS but who express interest in hospice services should be referred to the county welfare agency for a determination of eligibility. Applicants already residing in a nursing facility should be referred to the county welfare agency in which the facility is located. Applicants in the community or waiting for placement in a nursing home should be referred to the county welfare agency in their county of residence.
3. The providers of hospice services to Medicaid/NJ FamilyCare beneficiaries enrolled in a managed care organization or HMO shall comply with the procedures of that managed care organization or HMO, including, but not limited to, any prior authorization or other utilization control procedure required.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 3 - BENEFICIARY REQUIREMENTS › Section 10:53A-3.3 - Benefit periods

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There are two 90-day benefit periods and an unlimited number of subsequent 60-day periods. The benefit periods shall be recorded on a Hospice Benefits Statement, FD-379 (Form #2 in the Appendix, incorporated herein by reference) and filed in the beneficiary's medical record.
(b) Contents of the Election of Hospice Benefits Statement, FD-378 (Appendix Form #1) shall include the following:
1. The identification of the particular hospice that will provide the care to the applicant;
2. The applicant's or his or her representative's acknowledgment, that he or she has been given a full understanding of hospice services;
3. The applicant's or his or her representative's acknowledgment that he or she understands that the regular Medicaid/NJ FamilyCare FFS services other than hospice services are waived by the signing of the Election of Hospice Benefits Statement, FD-378 and/or the Representative Statement for the Election of Hospice Benefits, FD-380 (Form #3 in the Appendix, incorporated herein by reference), unless the services are prior authorized;
4. The effective date of the election statement; and
5. The signature of the applicant or the applicant's representative.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 3 - BENEFICIARY REQUIREMENTS › Section 10:53A-3.4 - Covered hospice services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The amount, character, and scope of New Jersey Medicaid/NJ FamilyCare FFS hospice services shall be the same for all hospice beneficiaries and shall not be less than the hospice services provided under Medicare (Title XVIII) (Section 1861(dd) et seq. of the Social Security Act, codified as 42 U.S.C. Section 1395x(dd)1 ).
(b) The Division reimburses for covered hospice services that are reasonable and necessary for the palliation and management of the terminal illness, and which are provided to a hospice beneficiary consistent with the beneficiary's individualized plan of care.
1. Required hospice services which shall be available to the hospice beneficiary include nursing care, medical social services, supervisory physician services, counseling services, durable medical equipment and supplies including drugs and biologicals, homemaker/home health aide services, physical therapy, occupational therapy and speech-language pathology services.
i. The following services are considered "core" hospice services: nursing care, medical social services, physician services and counseling services.
(1) A hospice provider shall ensure that substantially all core services are routinely provided directly by hospice employees.
(2) A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of hospice beneficiaries during periods of peak patient loads or under extraordinary circumstances or to obtain physician specialty services.
(3) If contracted staff is used, the hospice shall maintain professional, financial and administrative responsibility for the services and shall assure the qualifications of the staff and that services meet all requirements under each level of care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 3 - BENEFICIARY REQUIREMENTS › Section 10:53A-3.5 - Services unrelated to the terminal illness

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospice beneficiary, by signing the Election of Hospice Benefits Statement, FD-378 (6/92) agrees to waive most regular Medicaid/NJ FamilyCare FFS services. However, Medicaid/NJ FamilyCare FFS covered services unrelated to the terminal illness, included in the plan of care, may be provided by approved Medicaid/NJ FamilyCare FFS providers upon approval of the interdisciplinary team of the hospice.
1. The reasons for providing unrelated services and the verification that the unrelated services are not, in any way, related to the terminal illness shall be documented in the plan of care by a member of the interdisciplinary team.
i. Documentation shall clearly specify those services that are related to and those services that are unrelated to the terminal illness.
ii. Services unrelated to the terminal illness are subject to the same coverage provisions, limitations, prior authorization requirements, and conditions applied to services available to other general non-hospice Medicaid/NJ FamilyCare FFS beneficiaries.
iii. All payments for services (except for physician's services) that are unrelated to the terminal illness may be denied if not approved by the interdisciplinary team, documented in the plan of care and on file in the patient's medical record.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 3 - BENEFICIARY REQUIREMENTS › Section 10:53A-3.6 - Plan of care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Requirements for the initial plan of care for beneficiaries of hospice services are listed below:
1. At least one of the persons involved in developing the initial plan of care shall be a registered professional nurse or physician.
2. In establishing the initial plan of care, the member of the basic interdisciplinary group (a physician, a registered professional nurse, a medical social worker, or a counselor) who assesses the beneficiary's needs shall contact at least one other group member before writing the initial plan of care.
3. The initial plan of care shall be established on the same day as the assessment if the day of assessment is to be considered a covered day for hospice services.
4. At a minimum, the other two members of the basic interdisciplinary group shall review the initial plan of care and provide their input to the plan of care within two calendar days of the day of assessment.
5. The initial plan of care shall be approved by the Medical Director of the hospice by his or her signature on the plan of care in the medical record, thereby assuming professional medical responsibility for the hospice care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 3 - BENEFICIARY REQUIREMENTS › Section 10:53A-3.7 - Provision for beneficiary fair hearings

Current through Register Vol. 56, No. 14, July 15, 2024
Pursuant to N.J.A.C. 10:49-10, Notices, Appeals and Fair Hearings, Medicaid/NJ FamilyCare FFS beneficiaries have the right to file for fair hearings.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT › Section 10:53A-4.2 - Basis of payment-hospice providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division reimburses an approved hospice provider for those hospice services related to the terminal illness and included in the beneficiary's plan of care according to the methodology and indices in section 1814(i)(1)(C)(ii), 1814(i)(2)(B), and 1814(i)(2)(D) of the Social Security Act.
1. One of the four predetermined, cost-related prospective payment rates subject to the "cap" amounts (see 10:53A-1.2 for definition of "cap") is reimbursed for each day the beneficiary is receiving hospice services (see 10:53A-4.4 for calculations). The rates vary depending on the level of care which is based on the type and intensity of services furnished on that day and are consistent with the plan of care. The levels of care are, as follows:
i. Routine home care;
ii. Continuous home care;
iii. Inpatient respite care; and
iv. General inpatient care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT › Section 10:53A-4.3 - Basis of payment-physician services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The method of calculation of the basic per diem rates for hospice services listed in 10:53A-4.1 includes the costs of the administrative and general supervisory activities performed by physicians who are employees of the hospice provider or those working under financial arrangements with the hospice provider.
1. The administrative and supervisory activities are generally performed by the physician serving as the Medical Director and/or the physician member of the hospice interdisciplinary group.
i. Interdisciplinary group activities include participation in the establishment of plans of care, supervision of care and services, periodic review and updating of plans of care, and the establishment of governing policies.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT › Section 10:53A-4.4 - Limitations on reimbursement for hospice services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division limits aggregate payments to a hospice during a hospice "cap" period to the same degree, amount, and methodology as Medicare except the room and board per diem amounts reimbursed to hospice providers for services provided in a nursing facility are not subject to the "cap limitations" on the overall reimbursement to hospice providers.
1. Any payments in excess of the "cap" must be refunded by the hospice to the Division.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT › Section 10:53A-4.5 - Submitting claims for payment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospice shall submit claims in accordance with policies and procedures set forth in 10:49-7.1, 7.2 and 7.3, incorporated herein by reference, regarding the timely filing of claims and the timeliness of claims submission and inquiry.
(b) Documents needed specifically for the administration of the Hospice Care Program are Forms #1 through #10 located in the Appendix at the end of this chapter and may be obtained by writing to the following address:
Molina Medicaid Solutions
Provider Enrollment
PO Box 4804
Trenton, New Jersey 08650-4804
or forms can be downloaded from Molina's website at:
http://www.njmmis.com
.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 5 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:53A-5.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid/NJ FamilyCare program adopted the Centers for Medicare & Medicaid Services' Healthcare Common Procedure Coding System (HCPCS). The HCPCS procedure codes as listed in this subchapter are relevant to certain Medicaid/NJ FamilyCare fee-for-service hospice services.
(b) For a complete description of the basis of payment for the HCPCS codes listed below, refer to 10:53A-4.2, Basis of payment-hospice providers in this chapter. Section 1814(i)(1)(C)(ii) of the Social Security Act authorizes the rates and provides for annual increases in payment rates for hospice services. The Federally predetermined prospective annual rates are calculated based on the annual hospice rates established by Medicare. Section 1814(i)(2)(B) of the Act provides for an annual increase in the hospice cap amounts. Hospice payment rates for care and services are in effect from October 1 of one year to September 30 of the following year. For the "cap" amounts, the fiscal year ends on October 31 of the calendar year. In addition, Section 1814(i)(2)(D) of the Act requires that providers submit their claim for hospice services provided at an individual's home only on the basis of the geographic location at which the services are furnished.
(c) States have the flexibility to establish hospice rates at amounts no lower than the Medicare allowable hospice rate. The New Jersey Medicaid/NJ FamilyCare program is setting hospice rates for the four "levels of care" at the prospective predetermined levels which are determined by CMS.
(d) The rates marked with an asterisk are adjusted for regional differences in wages, in accordance with 42 CFR 418.306, using indices based on regions listed initially in the Federal statute as referenced in (b) above. Specific directions for calculating individual hospice rates for the four levels of hospice care (routine, continuous, inpatient respite and general inpatient care); for the co-payment for inpatient respite care; and for the annual update of the rates and the wage indices, can be found in the Federal Register, published annually, in accordance with 42 CFR 418.306, or by contacting the United States Department of Health and Human Services, Centers for Medicare and Medicaid Administration.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 5 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:53A-5.2 - HCPCS procedure codes for hospice services

Current through Register Vol. 56, No. 14, July 15, 2024
Note: The rates of the procedure codes marked with an asterisk (*) are subject to an adjustment based on regional differences in wages as set by Federal statute and current annual Federal Register updates as referenced in 10:53A-5.1(b) and (d).
*T2042
ROUTINE HOME CARE RATE
Per diem rate, calculated as referenced in
10:53A-5.1(d)  and 4.2(b)1 and (d)1.
*T2043
CONTINUOUS HOME CARE RATE
Per diem rate, calculated as referenced in
10:53A-5.1(d)  and 4.2(b)2 and (d)1.
*T2044
INPATIENT RESPITE CARE RATE
Per diem rate, calculated and adjusted annually
in 10:53A-4.2(d)  and 4.4.
*T2045
GENERAL INPATIENT CARE RATE
Per diem rate, calculated and adjusted annually
and limited according to 10:53A-4.2(b)3
and (d).
T2046
ROOM AND BOARD RATE
Per diem rate, calculated and adjusted annually
as referenced in 10:53A-4.2(c) and (d).
Y6337
THERAPEUTIC LEAVE DAYS
Per diem rate, calculated, and annually adjusted,
as referenced in 10:53A-4.2(c)1  ii and
(d).
Y6338
BED RESERVATION DAYS RATE
Per diem rate, calculated and adjusted annually
as referenced in 10:53A-4.2(c)1  ii and
(d).
Y6339
HOSPICE RESPITE CO-PAYMENT
Per diem rate, as referenced in N.J.A.C.
10:53A-4.2(g).
Y6343
DRUG AND BIOLOGICALS CO-PAYMENT
Reimbursed as referenced in N.J.A.C.
10:53A-4.2(f).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
FISCAL AGENT BILLING SUPPLEMENT
AGENCY NOTE: The Fiscal Agent Billing Supplement is appended as a part of this chapter but is not reproduced in the New Jersey Administrative Code. The Fiscal Agent Billing Supplement can be downloaded free of charge from:
www.njmmis.com
. When revisions are made to the Fiscal Agent Billing Supplement, a revised version will be posted on
www.njmmis.com
and copies will be filed with the Office of Administrative Law. If you do not have access to the internet and require a copy of the Fiscal Agent Billing Supplement, write to:
Molina Medicaid Solutions
PO Box 4801
Trenton, New Jersey
08650-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, New Jersey
08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:54-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a)The Physician Services chapter outlines the policies and procedures of the New Jersey Medicaid/NJ FamilyCare program for a physician who prescribes, provides directly, or personally directs medically necessary health services to Medicaid/NJ FamilyCare beneficiaries. The policies and procedures in this chapter foster the delivery of services in the most efficient and cost effective manner consistent with good medical practice.
(b) As a Medicaid/NJ FamilyCare provider, the physician may also participate in special programs, such as the HealthStart (Maternity and Pediatric Services), and managed health care, which is provided to designated beneficiaries in selected counties, in accordance with the provisions of N.J.A.C. 10:49-20 and 10:74, respectively.
(c) Medicaid/NJ FamilyCare rules regarding physicians who have a collaborative arrangement with advanced practice nurses (APNs) may be found in the New Jersey Administrative Code at N.J.A.C. 10:58A. Medicaid/NJ FamilyCare rules regarding physicians who employ APNs may be found in N.J.A.C. 10:54 (this chapter).
(d) Medicaid/NJ FamilyCare rules covering independent certified nurse midwives (CNM) may be found in the New Jersey Administrative Code at N.J.A.C. 10:58. Medicaid/NJ FamilyCare rules regarding physicians who employ CNMs may be found in N.J.A.C. 10:54 (this chapter).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:54-1.3 - Provider participation criteria

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All physicians, licensed doctors of medicine or surgery (M.D.) or doctors of osteopathy (D.O.) or podiatric medicine pursuant to N.J.A.C. 13:35 (incorporated herein by reference), authorized to provide medical and surgical services by the State of New Jersey, who are an approved Medicaid/NJ FamilyCare program participating provider in accordance with (b) below, and who comply with all the rules of the New Jersey Medicaid/NJ FamilyCare program, are eligible to provide medical and surgical services for Medicaid/NJ FamilyCare program beneficiaries.
1. Any out-of-State physician may provide medical and surgical services under this Program if he or she meets the comparable documentation and licensing requirements in the State in which he or she is practicing, and is a New Jersey Medicaid/NJ FamilyCare participating provider.
2. An applicant shall provide the Division with a photocopy of the current license and current certification at the time of the application for enrollment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:54-1.4 - Reimbursement based on specialist designation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursement rates for physician services are differentiated as specialist or non-specialist according to the criteria for specialist designation listed in (b) below.
(b) An applicant for specialist designation by the New Jersey Medicaid/NJ FamilyCare program, except as noted in (c) below, shall be a licensed physician who:
1. Is a diplomate of a specialty board approved by the American Board of Medical Specialties or the Advisory Board of the American Osteopathic Association; or
2. Is currently admissible to the examination administered by a specialty board approved by the American Board of Medical Specialties or the Advisory Board of the American Osteopathic Association, and/or has evidence of completion of an appropriate qualifying residency approved by the American Medical Association or American Osteopathic Association.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:54-1.5 - Certification of physician services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All physician providers shall be required to certify that the services billed on any claim were personally rendered by the physician or under his or her personal direction, except under the circumstances listed in (b) below.
(b) Physician services furnished by another physician who is not the primary physician during a period not exceeding 14 continuous days, in the case of an informal reciprocal arrangement, or for 90 continuous days, in the case of an arrangement involving per diem or other fee-for-service compensation, shall be permitted as exceptions to (a) above, in accordance with the following:
1. The primary physician may bill for physician services provided by the covering physician if the name of the covering physician is identified on the claim form and/or EPSDT form, as applicable; or
2. If the covering physician is a Medicaid/NJ FamilyCare physician provider in his or her own right, then the covering physician may bill under his or her own Medicaid/NJ FamilyCare Provider Service Number (MPSN) for services rendered during the "covering period," in accordance with 10:49-3.4.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:54-1.6 - Provider signature requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All claim forms for covered services shall be personally signed by the physician or by an authorized representative of the physician. (See Fiscal Agent Billing Supplement.) The following signature types shall not be accepted:
1. Initials instead of signature;
2. Stamped signature; and
3. Automated (machine-generated) signature.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.1 - Patient choice of physician

Current through Register Vol. 56, No. 14, July 15, 2024
The patient shall be allowed free choice of physicians, except for individuals enrolled as Medicaid/NJ FamilyCare program beneficiaries in Managed Care organizations (such as HMOs), in which case, the provisions of N.J.A.C. 10:74 shall apply.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.2 - Direction of physician or other permitted and qualified health care professional services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Personal direction of physicians or other permitted and qualified health care professionals means that the services listed in this section shall be rendered in the participating physician's physical presence during part or all of the procedure or service, as specified in this section. It is not the intent of the program to reimburse a participating physician for medical care, and/or history and/or physical examinations performed by residents or other permitted and qualified health care professionals, without the participating physician's physical presence.
1. The Medicaid/NJ FamilyCare participating physician who bills the program for his or her service shall be physically present and shall perform or personally direct the key portion of the service billed, as follows:
i. If the participating physician cannot identify a key portion of the service, then he or she shall be present for the entire service.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.3 - Physician personal direction of an Advanced Practice Nurse specializing in anesthesia

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Anesthesia services provided by an Advanced Practice Nurse specializing in anesthesia (APN/Anesthesia), according to the conditions for practice in N.J.A.C. 13:37-13.1 and 13.2, shall be eligible for reimbursement provided:
1. The APN/Anesthesia is employed by a physician who is a specialist in anesthesia;
2. The physician specialist is an approved provider in the New Jersey Medicaid/NJ FamilyCare program; and
3. The physician specialist submits the claim for services rendered under his or her Medicaid/NJ FamilyCare Provider Billing Number.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.4 - Physician collaboration with Certified Nurse Midwives

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Certified Nurse Midwife shall work with a physician under the collaborative arrangement specified by the Board of Medical Examiners in N.J.A.C. 13:35-2A, incorporated herein by reference.
(b) Under the New Jersey Medicaid/NJ FamilyCare program, the Certified Nurse Midwife may be either a direct provider of midwifery services or an employee of a physician, physician group, physician/practitioner group, another certified nurse midwife, hospital or independent clinic (see as appropriate, N.J.A.C. 10:54, 10:52, 10:58 or 10:66).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.5 - Physician collaboration with an advanced practice nurse (APN)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An advanced practice nurse (APN) shall collaborate with a physician, or physician/practitioner group in accordance with N.J.A.C. 10:58A, Advanced Practice Nurse Services, and N.J.A.C. 13:37-6.3 and 7.6, incorporated herein by reference.
1. Under the New Jersey Medicaid/NJ FamilyCare program, the advanced practice nurse may be either a direct provider of services, (see N.J.A.C. 10:58A, Advanced Practice Nurse Services Chapter) or an employee of a physician, physician group, physician/practitioner group, another advanced practice nurse, hospital, or independent clinic (see the appropriate requirements of N.J.A.C. 10:54, N.J.A.C. 10:52 or N.J.A.C. 10:66).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.6 - Recordkeeping; general

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All physicians shall keep such legible individual records as are necessary to fully disclose the kind and extent of services provided, as well as the medical necessity for those services.
(b) The minimum recordkeeping requirements for services performed in the office, home, residential health care facility, nursing facility (NF), and the hospital setting shall include a progress note in the clinical record for each visit, which supports the procedure code(s) claimed.
(c) The progress note shall be placed in the clinical record and retained in the appropriate setting for the service performed.
(d) Records of Residential Health Care Facility patients shall be maintained in the physician's office.
(e) The required medical records including progress notes, shall be made available, upon their request, to the New Jersey Medicaid/NJ FamilyCare program or its agents.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.7 - Minimum documentation; initial visit; new patient

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following minimum documentation shall be entered on the medical record, regardless of the setting where the examination is performed, for the service claimed by use of the procedure codes for Initial visit--New patient:
1. Chief complaint(s);
2. Complete history of the present illness and related systemic review, including recordings of pertinent negative findings;
3. Pertinent past medical history;
4. Pertinent family and social history;
5. A record of a full physical examination pertaining to, but not limited to, the history of the present illness and including recordings of pertinent negative findings;
6. Diagnosis(es) and the treatment plan, including ancillary services and medications ordered;
7. Laboratory, X-Rays, electrocardiograms (ECGs), and any other diagnostic tests ordered, with the results; and
8. The specific services rendered and/or modality used (for example, biopsies, injections, individual and/or group psychotherapy, and family therapy).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 2 - PHYSICIAN SERVICES-GENERAL › Section 10:54-2.8 - Minimum documentation; established patient

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following minimum documentation shall be entered in the progress notes of the medical record for the service designated by the procedure codes for ESTABLISHED PATIENT:
1. In an office or Residential Health Care Facility:
i. The purpose of the visit;
ii. The pertinent physical, family and social history obtained;
iii. A record of pertinent physical findings, including pertinent negative findings based upon i and ii above;
iv. Procedures performed, if any, with results;
v. Laboratory, X-Ray, electrocardiogram (ECG), or any other diagnostic tests ordered, with the results of the tests; and
vi. Prognosis and diagnosis.