reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 5 - ADMINISTRATION › Section 10:79-5.7 - Case records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of
				the case record is to provide a complete documentary record of eligibility
				determination agency actions and the reasons therefore.
(b) The case record shall include:
1. A record of all eligibility determination
				agency actions and decisions relating to the case, as well as documentary
				evidence relating to such actions and decisions, including application
				forms;
2. All forms relating to
				financial eligibility; and
3. All
				case-related correspondence, memorandum, and documents except those required by
				law or regulation to be maintained elsewhere.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 6 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:79-6.1 - Notice of the eligibility determination agency decision-Plan A

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				eligibility determination agency shall promptly notify any applicant for, or
				beneficiary of, the NJ FamilyCare-Children's Program-Plan A in writing of any
				agency decision affecting the applicant or beneficiary. When a decision relates
				to any adverse action which may entitle a beneficiary to a fair hearing, the
				action may not be implemented until at least 10 days after the mailing of the
				notice.
1. For notices of action adverse to a
				beneficiary, the date of mailing of the notice must appear on the
				notice.
2. Notices of any
				eligibility determination agency action must contain the name, address, and
				telephone number of the legal services agency serving that county.
3. In the case of an applicant or beneficiary
				who cannot be located, the notice shall be mailed to his or her last known
				address.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 6 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:79-6.2 - Fair hearings

Current through Register Vol. 56, No. 14, July 15, 2024
(a) It is the right
				of every applicant for or beneficiary of the NJ FamilyCare-Children's
				Program-Plan A program to be afforded the opportunity for a fair hearing in the
				manner set forth in N.J.A.C. 10:49-10, including, when applicable, continuation
				NJ FamilyCare-Children's Program-Plan A benefits pending the results of the
				fair hearing.
(b) Any request for a
				fair hearing for a NJ FamilyCare-Children's Program-Plan A beneficiary shall be
				forwarded to the Division of Medical Assistance and Health Services, Office of
				the Legal and Regulatory Liaison, PO Box 712, Trenton, New Jersey
				08625-0712.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 6 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:79-6.3 - Notice of the Statewide determination agency decision-Plans B, C, and D

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Statewide eligibility determination
				agency shall promptly notify any applicant for, or beneficiary of, the NJ
				FamilyCare-Children's Program-Plan B, C and D program in writing of any agency
				decision affecting the applicant or beneficiary. When a decision relates to any
				adverse action which may entitle a beneficiary to an appeal, the action may not
				be implemented until at least 10 days after the mailing of the notice (see (e)
				below for exceptions to the 10-day notice requirement).
1. For notices of action adverse to a
				beneficiary, the date of mailing of the notice shall appear on the
				notice.
2. In the case of an
				applicant or beneficiary who cannot be located, the notice shall be mailed to
				his or her last known address.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 6 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:79-6.4 - Post-application client responsibilities

Current through Register Vol. 56, No. 14, July 15, 2024
Upon a determination of eligibility for the NJ
				  FamilyCare-Children's Program, the authorized agent or applicant has the
				  on-going responsibility for the reporting of changes in family circumstances
				  and for the provision of information as delineated at
				  10:79-2.1(c).
				  Further, as requested by the eligibility determination agency, additional
				  information must be provided. At any time that the eligibility determination
				  agency lacks sufficient information to confirm continuing program eligibility
				  because of the unwillingness of the authorized agent or agents to provide
				  necessary information, the agency shall commence action to terminate the case
				  and pursue recovery when warranted.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 6 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:79-6.5 - Grievances and appeals for NJ FamilyCare-Children's Program-Plan B, C, and D

Current through Register Vol. 56, No. 14, July 15, 2024
(a) It is the right of every applicant for,
				or beneficiary of, NJ FamilyCare-Children's Program-Plan B, C, or D, to be
				afforded the opportunity for a grievance review in the manner established in
				the policies and procedures set forth below. The notification of the right to a
				grievance review shall be incorporated in or attached to each adverse action
				notice and shall include explanation on how to request a grievance. Appropriate
				complaints and grievances regarding NJ FamilyCare-Children's Program should be
				referred to:
NJ FamilyCare-Children's Program
PO Box 8367
Trenton, NJ 08650-9802
(b) In situations where a beneficiary is
				denied medical services to which he or she feels that he or she is entitled,
				and those services are considered fee-for-service under the NJ
				FamilyCare-Children's Program-Plan B, C and D, a request for a hearing and a
				brief explanation of the situation should likewise be sent to the above
				address.
(c) In a situation where a
				beneficiary is denied services through the MCO provider, the beneficiary should
				be referred to the MCO's complaint and/or grievance system.
(d) For those cases involving termination for
				program fraud and abuse, the applicant shall have the right to an
				administrative law hearing as indicated at N.J.A.C. 10:79-7.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 6 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:79-6.6 - Right to a grievance review-Plans B, C and D

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Those agency
				actions which adversely affect an applicant or beneficiary and may be grieved
				include, but are not limited to: determination of household composition, earned
				and unearned income calculations, and interpretation of residency, citizenship
				and age requirements.
(b) A
				grievance will not be considered for those cases in which eligibility is
				precluded by Federal or State statute. They include, but are not limited to:
				income standard, age requirement, and citizenship requirement. A grievance
				shall not be considered for non-payment of premiums.
(c) An applicant must submit a description of
				the grievance to the agency in writing within 20 days of the date of the
				adverse action notice. The agency shall notify the applicant or beneficiary of
				its decision, on the matter, specifying the reasons for the decision, within 60
				days of the receipt of the complete documentation of the grievance.
(d) This grievance shall be heard by a panel
				comprised of State staff, who will make recommendations to the DMAHS Director.
				Within 60 days of receipt of the appeal, the DMAHS Director shall issue a final
				agency decision, which is subject to judicial review in the Appellate
				Division.
(e) As a first step in
				the grievance process, the Division shall initiate an informal dispute
				resolution process upon receipt of the grievance request and prior to the
				grievance board hearing the case. This process shall include reviewing the
				grievance, researching the issue involved, and may include contact with the
				individual filing the grievance. The intent of this process is to try and
				resolve the grievance prior to the grievance board hearing.
(f) The agency shall retain all
				correspondence and documentation relating to the grievance in the applicant's
				or beneficiary's file.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 6 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:79-6.7 - Premiums

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Effective July 1, 2015, families with
				income above 150 percent and at or below 200 percent of the Federal poverty
				level eligible for NJ FamilyCare-Children's Program-Plan C do not have to pay a
				monthly premium.
(b) Effective July
				1, 2015, for children in families with gross income above 200 percent and at or
				below 250 percent of the Federal poverty level eligible for NJ
				FamilyCare-Children's Program-Plan D, a monthly premium shall be required.
				There shall be a single dollar premium of $ 43.00 per month per family that
				applies to all families, regardless of income and regardless of the number of
				children in the family.
(c)
				Effective July 1, 2015, for children in families with gross income above 250
				percent and at or below 300 percent of the Federal poverty level eligible for
				NJ FamilyCare-Children's Program-Plan D, a monthly premium shall be required.
				There shall be a single dollar premium of $ 86.00 per month per family that
				applies to all families, regardless of income and regardless of the number of
				children in the family.
(d)
				Effective July 1, 2014, for children in families with gross income above 300
				percent and at or below 350 percent of the Federal poverty level eligible for
				NJ FamilyCare Children's Program-Plan D, a monthly premium shall be required.
				There shall be a single dollar premium of $ 144.50 per month per family that
				applies to all families, regardless of income and regardless of the number of
				children in the family.
(e)
				Families shall be billed in advance of the coverage month. Failure to submit
				the full contribution shall result in termination of coverage for the month
				following the coverage month that the premium has not been received by the NJ
				FamilyCare-Children's Program.
1. All past
				due premiums must be paid in full prior to a beneficiary being reenrolled in
				the NJ FamilyCare-Children's Program-Plans B, C or D.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 6 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:79-6.8 - Limitation on cost sharing-Plans C and D

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be
				a family limit on the level of cost-sharing equal to five percent of gross
				household income for Plan C and D beneficiaries. Cost-sharing shall include the
				premium payments and the personal contribution to care.
(b) The cost-sharing limit shall be
				calculated annually starting with the date of initial enrollment of any
				children in the family or the annual reenrollment date. For ease of
				administration, the annual premium shall be calculated by the Statewide
				eligibility determination agency and used to reduce the family cost from the
				first day of enrollment.
(c) Once
				the limits have been met, the Statewide eligibility determination agency shall
				issue a certification indicating that the Plan C or D member has met their cost
				share limit, and the provider shall not collect a personal contribution until
				further notice.
(d) No cost sharing
				shall be imposed on children who are American Indians/Alaska Natives. Proof of
				Federally recognized AI/AN tribal status shall be in the form of a tribal card
				or letter, in accordance with 42 C.F.R. 36a.16.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 6 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:79-6.9 - Copayments-Plans C and D

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For children in
				families with gross income above 150 percent of the Federal poverty level who
				are eligible for NJ FamilyCare-Children's Program-Plans C and D, copayments
				shall be required.
(b) Copayments
				shall be effective upon date of enrollment.
(c) Copayments shall be charged in an amount
				in accordance with
				10:49-9.1(a) and
				(c).
(d) No cost sharing shall be imposed on
				children who are American Indians/Alaska Natives. Proof of Federally recognized
				AI/AN tribal status shall be provided in the form of a tribal card or letter,
				in accordance with 42 C.F.R. 36a.16.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 7 - NJ FAMILYCARE-CHILDREN'S PROGRAM BENEFICIARY FRAUD AND ABUSE POLICIES › Section 10:79-7.1 - Termination of eligibility for good cause for fraud and abuse

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any violation
				of (b) below by an applicant, beneficiary, caretaker adult or authorized agent
				may result in the termination of the applicant's or beneficiary's eligibility
				from NJ FamilyCare-Children's Program-Plan B, C and D. An individual receiving
				a Notice of Proposed Termination issued by the Director of the Division may
				request, within 20 days of the date of the Notice, an administrative law
				hearing before the Office of Administrative Law. The Notice shall be dated at
				least 20 days prior to the end of the month in which the termination is
				effective. Failure to request a hearing within this time limit shall result in
				automatic termination of benefits. Until such time as a final agency decision
				is issued by the Director as a result of such a hearing which terminates an
				individual from NJ FamilyCare-Children's Program-Plan B, C and D, the
				individual shall remain eligible for such benefits, unless the Director
				determines and states in the Notice of Proposed Termination that temporary
				suspension of benefits prior to a hearing is necessary to protect the integrity
				of the NJ FamilyCare-Children's Program-Plan B, C and D program and/or the
				health, safety or welfare of other NJ FamilyCare-Children's Program-Plan B, C
				and D beneficiaries.
(b) The
				following grounds shall constitute good cause for termination:
1. Knowingly or intentionally making or
				causing to be made false statements or misrepresentations of material fact in
				any application or reapplication for benefits under NJ FamilyCare-Children's
				Program-Plan B, C or D;
2.
				Knowingly or intentionally making or causing to be made false statements,
				misrepresentation of material fact, or alterations on any NJ
				FamilyCare-Children's Program-Plan B, C and D program claim form, eligibility
				card, or other document issued by or on behalf of the Division;
3. Intentionally misusing or abusing NJ
				FamilyCare-Children's Program-Plan B, C or D program benefits;
4. Knowingly or intentionally converting all
				or part of NJ FamilyCare-Children's Program-Plan B, C or D program benefits to
				a use other than the individual's own legitimate use and benefit;
5. Giving, loaning, or selling an eligibility
				card to anyone for use by an individual or individuals other than the eligible
				person or persons for whom the card was issued;
6. Forgery or attempted forgery involving
				eligible services and/or claim forms for such services;
7. Engaging in a course of conduct or
				performing an act deemed improper or abusive of the NJ FamilyCare-Children's
				Program following notification that this conduct should cease; or
8. Failure to cooperate in a NJ
				FamilyCare-Children's Program investigation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 7 - NJ FAMILYCARE-CHILDREN'S PROGRAM BENEFICIARY FRAUD AND ABUSE POLICIES › Section 10:79-7.2 - Application for readmission subsequent to termination of eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
After at least one year has elapsed from the date of the
				  final agency decision terminating the eligibility of an applicant or
				  beneficiary of NJ FamilyCare-Children's Program-Plan B, C, or D for good cause
				  under N.J.A.C. 10:79-7.1, the terminated
				  individual, or anyone with authority to act on his or her behalf, may apply to
				  the Director for readmission to the NJ FamilyCare-Children's Program-Plan B, C,
				  or D. The Director has full discretion to approve or deny such an application.
				  Any individual whose application for readmission has been denied may request an
				  administrative law hearing on the denial, and/or may submit another application
				  to the Director when at least two years have elapsed from the date of the final
				  agency decision denying readmission.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 7 - NJ FAMILYCARE-CHILDREN'S PROGRAM BENEFICIARY FRAUD AND ABUSE POLICIES › Section 10:79-7.3 - Applicability

Current through Register Vol. 56, No. 14, July 15, 2024
10:79-7.1 and 7.2 shall apply only
				  to applicants for and beneficiaries of NJ FamilyCare-Children's Program-Plan B,
				  C and D benefits, and shall not be applicable to termination due to
				  ineligibility initiated under N.J.A.C. 10:79-2 through 4.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 7 - NJ FAMILYCARE-CHILDREN'S PROGRAM BENEFICIARY FRAUD AND ABUSE POLICIES › Section 10:79-7.4 - Applicability to this chapter of Medicaid provisions relating to fraud and abuse, third-party liability and administrative and judicial remedies

Current through Register Vol. 56, No. 14, July 15, 2024
All of the relevant provisions pertaining to fraud and
				  abuse, third-party liability, and administrative and judicial remedies, which
				  are contained in the following sections of
				  30:4D-1 et seq. and N.J.A.C. 10:49
				  shall be fully applicable to the NJ FamilyCare-Children's Program:
				  30:4D-6c, 6f, 7h, 7i, 7k, 7l, 7.1,
				  12, 17(e), 17(f), 17(g), 17(i), 17.1 and 17.2, as well as
				  10:49-3.2, 4.1 through 4.5, 5.5,
				  6.1(a)3, 7.3, 7.4, 7.5, 9.6 through 9.12, 11.1, 12.1 through 12.7, 13.1, 13.4,
				  14.2 through 14.6 and 16.5.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 8 - PRESUMPTIVE ELIGIBILITY FOR NJ FAMILYCARE-CHILDREN'S PROGRAM › Section 10:79-8.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter describes presumptive eligibility for
				  children up to the age of 19 whose family's income is no greater than 350
				  percent of the Federal Poverty Level and who otherwise meet the eligibility
				  requirements for NJ FamilyCare-Children's Program. The presumptive eligibility
				  determination makes it possible for a child or the children in a family to
				  receive NJ FamilyCare-Children's Program medical services on a fee-for-services
				  basis from any NJ FamilyCare-Children's Program fee-for-service participating
				  provider for a temporary period prior to application for NJ
				  FamilyCare-Children's Program benefits and while the application for these
				  benefits is being processed by the county welfare agency or the Statewide
				  eligibility determination agency.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 8 - PRESUMPTIVE ELIGIBILITY FOR NJ FAMILYCARE-CHILDREN'S PROGRAM › Section 10:79-8.2 - Period of presumptive eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The period of
				presumptive eligibility shall begin on the date an approved presumptive
				eligibility entity determines that, based on information provided by the family
				of the presumptively eligible beneficiary, the child meets the requirements and
				standards of this chapter.
(b) The
				period of presumptive eligibility shall terminate:
1. On the last day of the month in which a
				determination of eligibility or ineligibility for NJ FamilyCare-Children's
				Program is made; or
2. If the
				child, or the child's parent, guardian, caretaker, or authorized agent fails to
				cooperate in the application process with the eligibility determination agency,
				on the last day of the month subsequent to the month in which the child was
				determined presumptively eligible.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 8 - PRESUMPTIVE ELIGIBILITY FOR NJ FAMILYCARE-CHILDREN'S PROGRAM › Section 10:79-8.3 - Presumptive eligibility determination entities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A qualified
				presumptive eligibility entity shall be a New Jersey Medicaid provider and:
1. An acute care hospital;
2. A local health department that provides
				primary care services; or
3. A
				Federally Qualified Health Center (FQHC).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 8 - PRESUMPTIVE ELIGIBILITY FOR NJ FAMILYCARE-CHILDREN'S PROGRAM › Section 10:79-8.4 - Presumptive eligibility processing performed by the presumptive eligibility determination entity

Current through Register Vol. 56, No. 14, July 15, 2024
(a) From preliminary information provided by
				a child (if appropriate), parent, guardian, caretaker adult, or authorized
				agent, the approved presumptive eligibility entity shall determine if the child
				meets the eligibility criteria of this chapter. The approved presumptive
				eligibility entity shall obtain sufficient information from the child (if
				appropriate), parent, guardian, caretaker adult, or authorized agent to
				complete the one-page Presumptive Eligibility (PE) application. For purposes of
				the presumptive eligibility determination, the qualified presumptive
				eligibility determination entity shall request from the child (if appropriate),
				parent, guardian, caretaker adult, or authorized agent only that information
				necessary to determine the child's presumptive eligibility or ineligibility.
				The qualified presumptive eligibility determination entity shall make the
				determination of eligibility based solely on information obtained in the
				interview and shall not require any verification or documentation of the
				presumptively eligible beneficiary's statements. A one-page PE application
				shall be used to apply for presumptive eligibility for NJ FamilyCare
				services.
(b) For any child
				determined presumptively eligible, the approved presumptive eligibility
				determination entity shall:
1. Complete and
				sign the one-page Presumptive Eligibility (PE) application and forward the
				original to the appropriate eligibility determination agency within two working
				days of the date the presumptive eligibility determination was made.
i. An application that appears to meet the
				eligibility criteria for NJ FamilyCare-Children's Program-Plan A shall be sent
				to the county welfare agency for the child's county of residence; and
ii. An application that appears to meet the
				eligibility criteria for NJ FamilyCare-Children's Program-Plan B, C, or D shall
				be sent to the Statewide eligibility determination agency;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 8 - PRESUMPTIVE ELIGIBILITY FOR NJ FAMILYCARE-CHILDREN'S PROGRAM › Section 10:79-8.5 - Responsibilities of the Division of Medical Assistance and Health Services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon receipt of
				a properly completed application from the approved presumptive eligibility
				determination entity, Division staff shall:
1. Assign a presumptive eligibility number.
i. If the income level of the family
				indicates eligibility for NJ FamilyCare-Children's Program-Plans B, C or D and
				the beneficiary was previously terminated for non-payment of premiums, a
				presumptive eligibility number shall not be assigned until past due premiums
				are paid in full;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 8 - PRESUMPTIVE ELIGIBILITY FOR NJ FAMILYCARE-CHILDREN'S PROGRAM › Section 10:79-8.6 - Responsibilities of the eligibility determination agency

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon receipt
				of the one-page PE application from the approved presumptive eligibility
				determination entity, the eligibility determination agency shall check for
				existing Medicaid, Medically Needy, or NJ FamilyCare-Children's Program
				eligibility. If the child is receiving Medicaid benefits, Medically Needy
				benefits, or NJ FamilyCare-Children's Program benefits, no further action shall
				be required by the county welfare agency or the Statewide eligibility
				determination agency.
(b) If the
				child is not currently receiving Medicaid, Medically Needy, or NJ
				FamilyCare-Children's Program benefits, the eligibility determination agency
				shall, notwithstanding the application disposition standards in
				N.J.A.C.
				10:79-2.3(f), arrive at a
				case disposition within the presumptive eligibility period.
1. If the time period specified in
				10:79-8.2(b)2  is
				exceeded, the presumptive eligibility determination agency shall notify the
				Division of Medical Assistance and Health Services of any such delay. The
				Division shall continue the child's presumptive eligibility until a final
				determination is made.
2. The
				eligibility determination agency shall also provide the individual applying on
				the child's behalf with written notification, prior to the expiration of the
				presumptive eligibility period, of the specific reasons for the delay.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 8 - PRESUMPTIVE ELIGIBILITY FOR NJ FAMILYCARE-CHILDREN'S PROGRAM › Section 10:79-8.7 - Responsibility of the applicant

Current through Register Vol. 56, No. 14, July 15, 2024
The parent, guardian, caretaker or authorized agent of a
				  presumptively eligible child shall be contacted by the county welfare agency or
				  Statewide eligibility determination agency, as appropriate, during the
				  presumptive eligibility period to provide any additional information required
				  to complete the application process. As part of the eligibility determination
				  process for NJ FamilyCare-Children's Program, the parent, guardian, caretaker
				  or authorized agent of a presumptively eligible child shall complete any forms
				  required as a part of the application process, and shall assist the eligibility
				  determination agency in securing evidence that verifies eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 8 - PRESUMPTIVE ELIGIBILITY FOR NJ FAMILYCARE-CHILDREN'S PROGRAM › Section 10:79-8.8 - Notification and fair hearing rights

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For a
				presumptively eligible child who is subsequently determined ineligible for NJ
				FamilyCare-Children's Program benefits:
1.
				The eligibility determination agency shall not be required to provide either
				timely or adequate notice for the end of the presumptive eligibility. The
				presumptively eligible beneficiary shall not have any right to a fair hearing
				based on the termination of presumptive eligibility; and
2. The eligibility determination agency shall
				provide the child (if appropriate), child's parent, guardian, caretaker or
				authorized agent a notice of denial of the child's NJ FamilyCare-Children's
				Program application in accordance with N.J.A.C. 10:79-6. The applicant's rights
				to a fair hearing or a grievance hearing are also outlined in N.J.A.C.
				10:79-6.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 8 - PRESUMPTIVE ELIGIBILITY FOR NJ FAMILYCARE-CHILDREN'S PROGRAM › Section 10:79-8.9 - Scope of services during the presumptive eligibility period

Current through Register Vol. 56, No. 14, July 15, 2024
All presumptively eligible NJ FamilyCare-Children's Program
				  beneficiaries shall be eligible to receive all applicable NJ
				  FamilyCare-Children's Program services listed in
				  10:49-5.2 (for Plan A),
				  10:49-5.6(a) and
				  (b) (for Plans B and C services), and
				  10:49-5.7(a) and
				  (b) (for Plan D) on a fee-for-service basis
				  during the presumptive eligibility period, including the services that are
				  otherwise only available through a managed care organization, except for those
				  services that a managed care organization may provide as additional services
				  beyond the NJ FamilyCare-Children's Program required services. The provision of
				  the managed care services fee-for-service shall be limited to the presumptive
				  eligibility period.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 8 - PRESUMPTIVE ELIGIBILITY FOR NJ FAMILYCARE-CHILDREN'S PROGRAM › Section 10:79-8.10 - Limitation on number of presumptive eligibility periods

Current through Register Vol. 56, No. 14, July 15, 2024
A child shall be limited to one continuous presumptive
				  eligibility period within a 12-month cycle beginning from the month in which
				  the child initially received presumptive eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79A - ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION PROJECT › Subchapter 1 - GENERAL PROVISIONS › Section 10:79A-1.2 - Statement of purpose and goals

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				This chapter implements
				P.L.
				2011, c. 114, by
				establishing, and thereby allowing the Department to implement, rules for such
				a demonstration project in a manner that addresses issues including, but not
				limited to, project standards, antitrust laws (including the active supervision
				prong of the State Action Immunity Doctrine ( California Retail Liquor Dealers
				Association v. Midcal Aluminum, Inc., 445 US 97 (1980))), and the Departments
				exercise of independent judgment and control in its oversight and regulation of
				the conduct of the Medicaid ACOs in the Demonstration Project.
(b) The Demonstration Project encourages
				additional appropriate care, not reduced care, for the most vulnerable
				beneficiaries; and the Demonstration Project does not contain mechanisms to
				control access, such as pre-certification activities or processes for denying
				care.
(c) The Department, in
				consultation with the Office of the Attorney General, will exercise ongoing
				oversight and regulation of the conduct of the Medicaid ACOs in the
				Demonstration Project to safeguard against violations of Federal
				laws.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79A - ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION PROJECT › Subchapter 1 - GENERAL PROVISIONS › Section 10:79A-1.3 - General requirements and provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Under the Demonstration Project, Medicaid
				ACOs shall refrain from, and implement appropriate safeguards against, conduct
				that may facilitate collusion among Medicaid ACO participants affecting the
				commercial health care marketplace, including, but not limited to, discussions
				among ACO participants about rates negotiated with commercial payers.
(b) Medicaid ACOs participating in the
				Demonstration Project shall include sufficient clinical integration. Any
				agreement reached by the Medicaid ACO, with the Division or a Medicaid managed
				care organization for sharing of savings within the ACO, must be necessary to
				improve care for Medicaid beneficiaries by incentivizing the integration of
				care between multiple distinct entities. Since the Demonstration Project does
				not impact the negotiated fee schedules between payers, hospitals, and
				providers, it is considered pro-competitive.
(c) All approvals, exceptions, or
				authorizations of any kind issued under this chapter or as part of the
				Demonstration Project established under the Act are for purposes of
				implementing the Act only and shall not extend beyond the Demonstration Project
				or beyond the timeframes for the Demonstration Project that are established
				under the Act. This specifically includes, but is not limited to, any exception
				to a requirement to obtain a certificate of need.
(d) Under no circumstances shall a Medicaid
				ACO negotiate reimbursement rates for clinical services provided by its
				participating providers. A gainsharing plan may be negotiated and
				administered.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79A - ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION PROJECT › Subchapter 1 - GENERAL PROVISIONS › Section 10:79A-1.4 - Review and oversight

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In
				accordance with the Act, this chapter, and the Departments ongoing authority to
				oversee and regulate the Medicaid ACOs, the Department, in consultation with
				the Office of the Attorney General, shall:
1.
				Review each submitted ACO certification application and issue a written
				decision on the determination to approve or deny the application, specifying
				the reason(s) for approval or denial;
2. Review each gainsharing plan submitted by
				a certified Medicaid ACO or by a Medicaid ACO applicant and issue a written
				decision on the determination to approve or deny the gainsharing
				plan;
3. Review each Medicaid ACOs
				annual report and issue a written acceptance or rejection of the annual
				report;
4. Evaluate the
				Demonstration Project annually to assess whether cost savings are achieved and
				whether there is an improvement in outcomes including health screenings,
				emergency room visits, hospitalization, and inpatient recidivism
				rates;
5. In consultation with the
				Department of Banking and Insurance, evaluate the Demonstration Project
				annually to assess potential anticompetitive effects on commercial rates for
				clinical services in the ACOs designated area. The evaluation should take the
				form of a written report and should recommend terminating the ACO if
				information available on commercial rates in the designated area supports a
				conclusion that the ACO is causing rates to rise more quickly than they do in
				comparable markets that do not have an ACO; and
6. Provide a mechanism whereby payors,
				non-ACO providers, or other potentially affected parties in the designated area
				can lodge complaints about any anticompetitive activity by ACOs and their
				participants.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79A - ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION PROJECT › Subchapter 1 - GENERAL PROVISIONS › Section 10:79A-1.5 - Application process for approval of Medicaid ACOs in the Demonstration Project

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Certification is required in order to demonstrate that an entity seeking
				participation in the Demonstration Project meets the minimum governance and
				operational standards set forth in the Act and this chapter to carry out the
				Demonstration Project objectives.
(b) An entity seeking participation in the
				Demonstration Project must submit an application to the Department to become
				certified as a Medicaid ACO. In addition, a certified Medicaid ACO must obtain
				approval by the Department of a gainsharing plan in accordance with this
				chapter prior to the commencement of its second Demonstration Project year. ACO
				certification and gainsharing plan applications may be submitted to the
				Department simultaneously, or the applicant may apply for certification prior
				to submitting its gainsharing plan for approval. However, in no event shall a
				gainsharing plan be submitted more than one year following certification
				approval.
1. An ACOs certification
				application, including exhibits, is a government record subject to the Open
				Public Records Act,
				47:1A-1 et seq., upon submission
				of such application to the Department for certification and approval.
2. The certification application shall be a
				maximum of 10 double-spaced, typed pages, 12-point font minimum.
3. The certification application must include
				the application checklist provided by the Department. The checklist must be
				signed by an individual with legal authority to bind the ACO to affirm that the
				applicant will function in accordance with all applicable State and Federal
				laws, rules, and regulations, and that the information contained in the
				application is complete and accurate.
4. The certification application must be
				submitted to the Department by July 7, 2014.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79A - ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION PROJECT › Subchapter 1 - GENERAL PROVISIONS › Section 10:79A-1.6 - Gainsharing plan submission and review

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The gainsharing plan shall set forth the
				ACOs comprehensive plans and processes for accomplishing the Medicaid ACO
				Demonstration Project objectives.The gainsharing plan shall outline the ACOs
				vision for improving health outcomes and the quality of care, as measured by
				objective benchmarks, as well as patient experience of care, for vulnerable
				populations by increasing access to primary and behavioral health care services
				and utilization of preventive care and reducing use of emergency rooms and
				in-patient care settings for routine care.
1.
				Criteria to be considered by the Department and the Department of Health in
				approving a gainsharing plan shall include, but are not limited to whether the
				gainsharing plan:
i. Promotes the following:
(1) Care coordination through
				multi-disciplinary teams, including care coordination of patients with chronic
				diseases and the elderly;
(2)
				Expansion of the medical home and chronic care models;
(3) Increased patient medication adherence
				and use of medication therapy management services;
(4) Use of health information technology and
				sharing of health information; and
(5) Use of open access scheduling in clinical
				and behavioral health care settings;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79A - ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION PROJECT › Subchapter 1 - GENERAL PROVISIONS › Section 10:79A-1.7 - Annual ACO reporting requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An ACO shall provide information to the
				Department to document its activities and the Department shall review and
				evaluate information provided by the ACO to ensure the Demonstration Project is
				being administered in a way that achieves the Demonstration Project objectives
				while protecting patient safety and safeguarding the use of public
				funds.
(b) With the exception of
				any commercial rate data provided pursuant to (c)8 below, the ACOs annual
				report will be considered a government record subject to the Open Public
				Records Act,
				47:1A-1 et seq., upon submission
				to the Department.
(c) To enable
				the Department to carry out its monitoring, oversight, and evaluation
				responsibilities, the ACO shall report annually to the Department as follows:
1. The total savings achieved pursuant to the
				savings calculation methodology in this chapter. The annual savings achieved
				report must provide the benchmark payment calculation and the expenditures made
				during that year of the Demonstration Project and must be reported within 30
				days of savings distribution;
2.
				The amount of savings distributed to each participating ACO member pursuant to
				the distribution of savings methodology contained in the ACOs gainsharing
				plan;
3. How each participating ACO
				member spent its savings distribution;
4. Quality performance at the practice level
				and for the ACO as a whole;
5.
				Patient experience findings at the practice level and for the ACO as a
				whole;
6. The cumulative and
				categorical number of complaints received at a practice level, the types of
				complaints received, and the resolutions implemented.
i. The ACO must collect and respond in a
				timely manner to patients and consumers comments and complaints and ensure
				compliance with all State and Federal laws affecting patient access to
				appropriate care and services. If the ACO learns of a material concern
				regarding patient safety and/or satisfaction, the ACO shall promptly report
				such concern to the Department within three business days independent of the
				annual reporting requirements so that such concern can be properly
				addressed;
7. The ACO
				must renew its certification that it will not negotiate rates for participants
				services with any public or private payer and attest that it has not done so in
				the previous year. Failure to comply with this requirement is grounds for
				decertification of the ACO; and
8.
				The ACO shall certify that it and its participants have complied with any
				request to provide the Department and the Department of Banking and Insurance
				with all data necessary for the State to monitor the ACOs impact on commercial
				rates in its designated area.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79A - ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION PROJECT › Subchapter 1 - GENERAL PROVISIONS › Section 10:79A-1.8 - Data analyses and annual project evaluation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pursuant to the Act, the Rutgers Center
				for State Health Policy (the Center) shall make HIPAA-compliant data requests
				to the Department and the Department of Health to support the Demonstration
				Project.
(b) The Department, in
				consultation with the Department of Health, shall review the Centers assessment
				of the gainsharing plans in accordance with the Act.
(c) Certified ACOs shall execute a
				HIPAA-required business associate agreement between the ACO and its
				participating hospitals, primary care offices, and other members, as needed, to
				permit sharing of protected health information. Certified ACOs shall perform
				data analyses of patient utilization of local hospitals to improve care
				coordination and monitor program performance. All such agreements shall require
				that beneficiaries are to be notified by all such members or providers that the
				ACO will obtain beneficiary-identifiable data, and that beneficiaries shall be
				given the opportunity to decline such data sharing, in which case no such data
				sharing shall occur.
(d) Certified
				ACOs shall, upon direction from the Department, execute HIPAA-compliant data
				use agreements for sharing of protected health information with the Rutgers
				Center for State Health Policy, for use in the annual evaluation of the
				Demonstration Project. The protected health information shall enable an
				evaluation of patient care utilization over time without providing direct
				patient identifiers.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79A - ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION PROJECT › Subchapter 1 - GENERAL PROVISIONS › Section 10:79A-1.9 - Use of savings by a managed care organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A managed care organization that
				participates in the Demonstration Project and expects to earn savings pursuant
				to a contract with an ACO shall report to the Department and make available to
				the public how savings earned by the managed care organization will be used.
1. Possible uses for shared savings include:
i. Program administration costs;
ii. Retained earnings;
iii. Increased care coordination activities;
				and
iv. Increased payments to
				providers for medical home activities.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79B - COMMUNITY SUPPORT SERVICES FOR ADULTS WITH MENTAL ILLNESS › Subchapter 1 - GENERAL PROVISIONS › Section 10:79B-1.1 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter,
				  shall have the following meanings, unless the context clearly indicates
				  otherwise.
"Community support services (CSS)" shall have the same
				  definition as that provided at
N.J.A.C. 10:37B
.
"Comprehensive rehabilitative needs assessment (CRNA)" shall
				  have the same definition as that provided at
N.J.A.C.
				  10:37B
.
" Individualized rehabilitation plan (IRP)" shall have the
				  same definition as that provided at
N.J.A.C. 10:37B
.
"Serious mental illness" shall have the same definition as
				  that provided at
N.J.A.C. 10:37B
.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79B - COMMUNITY SUPPORT SERVICES FOR ADULTS WITH MENTAL ILLNESS › Subchapter 1 - GENERAL PROVISIONS › Section 10:79B-1.2 - Purpose, scope, and eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this chapter is to set
				forth the rules governing the provision of CSS to New Jersey
				Medicaid/FamilyCare Plan A and Alternative Benefit Plan
				beneficiaries.
(b) Community
				support services are community-based, intensive, comprehensive, integrated
				mental health rehabilitation services provided by a professional,
				multi-disciplinary team to adults who have a serious mental illness, with the
				intent to assist the beneficiary to achieve and maintain valued life roles in
				employment, education, housing, and social environments.
(c) To participate in the Medicaid/NJ
				FamilyCare program, all providers shall be under contract with the Division of
				Mental Health and Addiction Services (DMHAS) as a licensed provider of CSS and
				shall meet the requirements set forth by Division of Medical Assistance and
				Health Services (DMAHS) and by the DMHAS related to CSS in accordance with
N.J.A.C. 10:37B
.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79B - COMMUNITY SUPPORT SERVICES FOR ADULTS WITH MENTAL ILLNESS › Subchapter 2 - PROGRAM STANDARDS › Section 10:79B-2.1 - Beneficiary eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Adult
				Medicaid/NJ FamilyCare Plan A and Alternative Benefit Plan beneficiaries (18
				years or older) shall be eligible for adult CSS provided in/by community
				support service providers, if the client has a serious mental illness and such
				services have been determined by the Division of Mental Health and Addiction
				Services (DMHAS) or an authorized agent contracted with the Department of Human
				Services to be clinically necessary using the criteria established by DMHAS
				(see
N.J.A.C. 10:37B
). Other diagnoses not listed in
N.J.A.C. 10:37B
may be approved by DMHAS or their authorized
				agent if determined appropriate. The diagnoses shall be made by the referring
				agency or provider.
(b) NJ
				FamilyCare-Plans B, C, and D beneficiaries are not eligible for CSS.
(c) Beneficiaries eligible as "medically
				needy" in accordance with
N.J.A.C. 10:70
shall not be eligible
				for CSS provided in/by community support service providers.
(d) DMHAS or a designated entity acting on
				behalf of DMHAS shall offer to eligible beneficiaries the opportunity to choose
				a CSS provider.