New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 142 - PERSONAL PREFERENCE PROGRAM › Subchapter 1 - GENERAL PROVISIONS › Section 10:142-1.4 - 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 indicates
				  otherwise:
"Activities of daily living (ADLs)" are tasks that determine
				  a participant's ability to self-care. Examples include, but are not limited
				  to:* eating, bathing, dressing, toileting, transferring (walking), and
				  continence, which can be provided by a personal care assistant.
"Adverse agency action" is defined as an administrative
				  action performed resulting in either a denial, reduction, or disenrollment of
				  services, a denial of a request for an exception, a denial of a request for
				  increase in service benefits, or a failure to act upon a request for services
				  within prescribed time frames. Such actions may be performed by either: a
				  managed care organization (MCO) or by the Division.
"Authorized representative" is defined as a surrogate
				  decision maker, who is at least 18 years of age, serves in an unpaid capacity,
				  and is present and available to meet in person with the participant on a
				  regular basis, to provide assistance with choices and decision making, and
				  ensuring that services are being performed in accordance with the cash
				  management plan. Types of authorized representatives include the
				  following:
1. "Pre-determined representative" is used in circumstances
				  where a representative has been court appointed;
2. "Voluntary representative" is used in circumstances where
				  the participant chooses to use someone of his or her choosing to assist with
				  managing the program;
3. "Mandated representative" is a term and condition for
				  continued participation in the program, which is used in circumstances, such as
				  misspending of cash allocation, or when the nature of one's disability involves
				  diminished cognitive functioning, resulting in the inability to self-direct
				  services; or
4. "Surrogate representative" is used in circumstances in
				  which the pre-determined representative (under paragraph 1 above) selects
				  another individual to act in his or her place.
"Budget" means the value of a cash management plan
				  (CMP).
"Budget authority" means the participant, or authorized
				  representative, where appropriate, has the responsibility to manage his/her
				  budget, determine the types of goods and services to be purchased, and
				  establish their worker's wage rates.
"Care manager (CM)" means an individual employed by a managed
				  care organization (MCO), or by a State-contracted care management agency, who
				  provides enrollee-centered, goal-oriented, culturally relevant assistance to
				  assure that an enrollee receives needed services in a supportive, effective,
				  efficient, timely, and cost-effective manner.
"Cash and counseling" is defined as a system for delivery of
				  personal care services using the concept of consumer direction, which is the
				  foundation of the Personal Preference Program. A monthly allowance is issued to
				  the participant in place of traditional personal care assistance (PCA)
				  services, who, with the guidance of a consultant, purchases, goods, and
				  services to meet personal care needs.
"Cash management plan (CMP)" means a document used by the
				  Personal Preference Program participant to define the services the participant
				  needs and to budget the monthly cash allowance accordingly. The CMP is a
				  mandatory document prepared by the participant, and made effective following
				  approval by the State Program Manager or designated State staff. The CMP serves
				  as the participant's budget document for the program and must be adhered to for
				  the length of enrollment in the program. The CMP shall be amended as necessary
				  to reflect changes in the awarded and approved services.
"Centers for Medicare and Medicaid Services" (CMS) means the
				  Federal agency within the U.S. Department of Health and Human Services that
				  works with the State to administer Medicaid.
"Consultant" is defined as an individual employed by the
				  counseling agency, or counseling entity, that is under contract with the
				  Division. The consultant provides counseling services related to consumer
				  direction to participants and their representatives, and provides front line
				  support to guide individuals in effectively managing their roles as a
				  participant in a participant directed program. The consultant provides
				  programmatic counseling and assists in the development of the participant's
				  budget, as well as updates, as necessary.
"Counseling agency" also referred to as "counseling entity"
				  means an agency that is under contract directly with either the State of New
				  Jersey or the Vendor Fiscal Employer Agent to serve as a source of consultant
				  services and provide financial counseling for Personal Preference Program
				  participants.
"Department" means the New Jersey Department of Human
				  Services (DHS).
"Division" means the Division of Disability Services (DDS)
				  within the New Jersey Department of Human Services, which is responsible for
				  the administration of the Personal Preference Program (PPP). The DDS may
				  alternately be referred to as the "State Program Office."
"Division of Medical Assistance and Health Services (DMAHS)"
				  means the agency within the New Jersey Department of Human Services, that
				  administers the New Jersey managed care organization (MCO) contract on behalf
				  of the Department. DHS is the single State Medicaid agency in New Jersey, and
				  DMAHS is designated as the Medicaid administrative authority.
"Domestic household employee" means a person who is an
				  employee of the participant and provides personal care services and supports to
				  a participant, who is enrolled in the Personal Preference Program as defined in
I.R.C. §§ 31
.3306(c)(2)-1(a)(2).
"Employer authority" means the participant, or their
				  authorized representative, where appropriate, has the responsibility for
				  hiring, supervising, managing, and firing workers. If combined with budget
				  authority, the participant, or authorized representative, sets the rate of pay
				  for workers.
"Fair hearing" means a hearing held by the Office of
				  Administrative Law (OAL) under
N.J.S.A.
				  52:14B-1
et seq., and
52:14F-1
et seq., and N.J.A.C. 1:1-1 and 10:6.
"Fee for service (FFS)" means the method used for Medicaid
				  reimbursement based on its payment for specific services covered by the DMAHS,
				  but not covered by the MCO, which are rendered to an eligible participant, in
				  accordance with
N.J.A.C. 10:49
.
"Home visit" means a face to face visit with a program
				  consultant that is performed routinely, in the participant's home, with the
				  presence of the participant and representative, where appropriate, for the
				  purpose of evaluating how well service needs are being met through the cash
				  management plan. Completion of the visit by telephone, "skyping," or other
				  communications technology are not acceptable under the program.
"Managed care organization (MCO)" refers to a health
				  maintenance organization (HMO) that is under contract with the State of New
				  Jersey, Division of Medical Assistance and Health Services (DMAHS), for the
				  provision of health care services for consumers that are eligible for Medicaid
				  benefits, as defined by Article 1, page 15 of the MCO contract.
"Medicaid fiscal agent" means an entity under contract with
				  the State of New Jersey that processes and adjudicates provider claims on
				  behalf of the New Jersey Medicaid Program.
"Medicaid provider" means any agency meeting applicable
				  requirements and standards for participation in the New Jersey Medicaid
				  Program, meeting the requirements at
N.J.A.C.
				  10:49-3.1
.
"Medical facility" means a nursing home, residential, or
				  rehabilitation facility, assisted living facility, or hospital that provides
				  medical and personal care for individuals with chronic illness or
				  disability(ies).
"Participant" means an individual who is receiving services
				  under the Personal Preference Program in New Jersey.
"Participant directed goods and services" means equipment or
				  supplies in lieu of hands on personal care provided by an assistant employed by
				  the participant not otherwise afforded through Medicaid or the Medicaid State
				  Plan.
"Participant directed services" means an approach to service
				  delivery that affords participants choice and control over the services they
				  receive and the individuals who provide them. The participant requiring
				  services makes the choices about what, when, where, and from whom he or she
				  receives services, based upon the underlying assumption that the participant
				  knows best about his/her wants and needs.
"Personal care assistance services" also known as PCA
				  services, means a Medicaid service pursuant to
N.J.A.C.
				  10:60-3.1
, which provides for
				  assistance with personal care, household duties, and health-related tasks
				  performed by a qualified individual in a beneficiary's place of residence,
				  under the supervision of a registered professional nurse, as certified by a
				  physician in accordance with a written plan of care. PCA services are
				  alternatively known as traditional agency services, or traditional
				  model.
"Personal care assistant" means a person who is employed by a
				  Medicaid provider agency to provide personal care assistance services, and who
				  meets the qualifications set forth at
N.J.A.C.
				  10:60-1.2
.
"Reassessment" is a face-to-face home visit defined as
N.J.A.C.
				  10:60-3.5(a)
3.
				  Completion of the reassessment visit by telephone, "skyping," or other
				  communications technology are not acceptable under the program.
"Risk assessment profile" means a tool used to evaluate
				  individual risk, safety, and planning for mitigation of risk for the
				  participant. The tool addresses cognitive, hearing/communication, ambulation,
				  nutritional, functional, and structural limitation factors, and evaluates a
				  participant's need of an emergency back-up plan for incorporation into the cash
				  management plan.
"Self-direction" also known as "consumer direction" or
				  "participant direction," means a service delivery model that emphasizes
				  autonomy and empowerment by expanding the participant's degree of choice and
				  control over his or her long-term services and supports. Under this model,
				  participants and their authorized representatives or family members serve as
				  the common law employer, and with training and guidance, are responsible for
				  directly hiring, training, supervising, firing their paid caregivers, and
				  making informed decisions about their own care.
"State program office" is also known as the Division of
				  Disability Services, under the New Jersey Department of Human Services, and is
				  the agency responsible for the administration of the Personal Preference
				  Program.
"Vendor fiscal employment agent (VF/EA)" means an entity,
				  under contract with the State of New Jersey, which provides a range of fiscal
				  and business services to participants enrolled in the Personal Preference
				  Program.
"Worker" means a domestic household employee hired by, and
				  who performs duties in and around the home, for a Personal Preference Program
				  participant. A worker shall be employed for no more than 40 hours per calendar
				  week across all programs and shall be exempt from overtime pay. Individuals who
				  reside in the same residence as the participant they serve, and who qualify for
				  the Live In Exception pursuant to
IRS Notice 2014-7, 2014-4 I.R.B.
				  445,
may work over 40 hours a week for their standard pay rate, and
				  shall remain exempt from overtime pay.