New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 24 - WORK FIRST NEW JERSEY/GENERAL ASSISTANCE CLAIMS PROCESSING › Section 10:49-24.3 - Services available under the Work First New Jersey/General Assistance (WFNJ/GA) program which shall be processed by the fiscal agent

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Medicaid/NJ
				FamilyCare fiscal agent shall reimburse only those WFNJ/GA program covered
				services listed below in this subsection when provided in an ambulatory
				setting, except as specified in
				10:49-24.4(a)14.
				These services include:
1. Advanced practice
				nurse services (for specific information, see N.J.A.C. 10:58A);
2. Abortion (elective/induced);
3. Acupuncture;
4. ADDP covered anti-retroviral
				drugs;
5. Ambulance;
6. Ambulatory surgery;
7. Blood and blood plasma;
8. Case management services for the
				chronically mentally ill (for specific information, see N.J.A.C.
				10:73);
9. Chiropractic services
				(for specific information, see N.J.A.C. 10:68);
10. Clinic services (services in an
				independent outpatient health care facility, ambulatory care facility,
				ambulatory surgical center, ambulatory care/family planning/surgical facility,
				drug treatment center, Federally qualified health center, free-standing
				end-stage renal dialysis facility), such as dental, family planning,
				laboratory, mental health, minor surgery, personal care assistance, podiatry,
				radiology, rehabilitation, or vision care (for specific information, see
				N.J.A.C. 10:66), except that:
i. Professional
				services provided by a residential alcohol or drug abuse treatment facility to
				an individual residing in the facility shall not be processed;
11. Dental services, including
				dentures (for specific information, see N.J.A.C. 10:56);
12. Durable medical equipment;
13. Family planning services, including
				medical history and physical examination (including pelvic and breast),
				diagnostic and laboratory tests, drugs and biologicals, medical supplies and
				devices, counseling, continuing medical supervision, continuity of care and
				genetic counseling, except that:
i. Services
				provided primarily for the diagnoses and treatment of infertility, including
				sterilization reversals, and related office (medical and clinic) visits, drugs,
				laboratory services, radiological and diagnostic services and surgical
				procedures shall not be processed.
14. Hearing aid services (for specific
				information, see N.J.A.C. 10:64);
15. Home care services, including home health
				care (for specific information, see N.J.A.C. 10:60);
16. Hospice services, except those provided
				in a nursing home facility (for specific information, see N.J.A.C. 10:53A).
i. The following hospice services shall be
				processed under the WFNJ/GA program:
(1)
				Routine home care rate;
(2)
				Continuous home care rate; and
(3)
				Drugs and biologicals co-payment (rendered in places other than long-term care
				facilities).
ii. The
				following hospice services shall not be processed under the WFNJ/GA program:
(1) Inpatient respite care rate;
(2) General inpatient care;
(3) Therapeutic leave days;
(4) Bed hold days;
(5) Hospice Respite Care; and
(6) Room and board;
17. Laboratory (clinical) services
				(for specific information, see N.J.A.C. 10:61);
18. Medical supplies and equipment (for
				specific information, see N.J.A.C. 10:59);
19. Mental health services (for specific
				information, see N.J.A.C. 10:66);
20. Non-maternity nurse-midwifery services,
				such as family planning (for specific information, see N.J.A.C.
				10:58);
21. Optometric services
				(for specific information, see N.J.A.C. 10:62);
22. Optical appliances (for specific
				information, see N.J.A.C. 10:62);
23. Personal care assistant;
24. Thermograms;
25. Thermography;
26. Pharmaceutical services (for specific
				information, see N.J.A.C. 10:51);
i. Prior
				authorization shall be required where patterns of medically harmful or
				inappropriate use of specific drugs, therapeutic drug classes, enteral
				nutritional supplements, needles and syringes have been identified, or for
				claims originating in certain municipalities where such patterns have been
				identified; and
ii. Effective with
				claims for dates of service on or after August 7, 2000, the Division's
				processing of claims for certain antiretroviral drugs shall be accomplished
				under the AIDS Drug Distribution Program (ADDP), administered by the Department
				of Health and Senior Services (DHSS), except for emergency supplies as
				authorized under WFNJ/GA to avert a lapse in treatment. These drugs shall
				include, but may not be limited to: thymidine nucleosides, thymidine analogs,
				protease inhibitors, nucleoside analog reverse transcriptase inhibitors,
				non-nucleoside reverse transcriptase inhibitors, carbocyclic nucleoside
				analogs, purine nucleoside analogs of deoxyadenosine, and primidine nucleoside
				analogs;
27. Physician
				services (for specific information, see N.J.A.C. 10:54);
28. Podiatric services (for specific
				information, see N.J.A.C. 10:57);
29. Prosthetic and orthotic devices (for
				specific information, see N.J.A.C. 10:55);
30. Psychological service (for specific
				information, see N.J.A.C. 10:67);
31. Radiological services (for specific
				information, see N.J.A.C. 10:54);
32. Rehabilitative services (for specific
				information, see N.J.A.C. 10:66). Payments shall be made to eligible Medicaid
				providers only. No payment shall be made to privately practicing therapists who
				are not Medicaid providers. Rehabilitative services include:
i. Physical therapy;
ii. Occupational therapy;
iii. Speech-language pathology services;
				and
iv. Audiology
				services;
33.
				Transportation services which include ambulance and mobility assistance vehicle
				(for specific information, see N.J.A.C. 10:50 and 10:66);
34. Medicare coinsurance and/or deductible
				for services specified in (a)1 through 23 above, if otherwise reimbursed by the
				New Jersey Medicaid program; and
35. Inpatient services provided by Mt. Carmel
				GuildHospital located in Newark, New Jersey.