reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.2 - Notices

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey
				Medicaid or NJ FamilyCare program may print a notice of prospective policy
				changes affecting Medicaid or NJ FamilyCare beneficiaries or providers
				generally in one or more newspapers in New Jersey.
1. This public notice will be accompanied by
				a proposed rulemaking on the subject of the notice in the New Jersey
				Register.
2. The public notice may
				precede or be subsequent to the Register publication.
3. The Department of Human Services, or the
				Department of Health and Senior Services where authorized by Reorganization
				Plan No. 001-1996, may proceed to adopt the regulatory changes pursuant to
				52:14B-4 without providing further
				notice.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.3 - Opportunity for fair hearing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An opportunity
				for a fair hearing may be granted to any provider requesting a hearing on any
				valid complaint or issue arising out of the Medicaid or NJ FamilyCare claims
				payment process, exclusive of HMO claims processing or HMO-provider contract
				issues:
1. Such issues shall include, but not
				be limited to, denials of prior authorization and denial of claims submitted
				for payment.
2. Such requests for
				hearing shall be made in writing within 20 days from the date of the notice of
				the agency action giving rise to said complaint or issue.
3. For claim denial or payment adjustment,
				the 20 days' notice starts from the date in the right hand corner of the
				Remittance Advice Claims Status returned to providers with the Remittance
				Advice cover page (see the Fiscal Agent Billing Supplement following the second
				chapter of each Providers Services Manual regarding the Remittance Advice cover
				page and Claims Status explanations and examples). Providers should include a
				photocopy of the applicable Claims Status page, highlighting the beneficiary
				and applicable edit code(s) when submitting a hearing request.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.4 - Advance notice of intent to terminate, reduce, or suspend assistance for Medicaid and NJ FamilyCare-Plan A beneficiaries

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In cases of any
				proposed action to terminate, reduce or suspend assistance, the Medicaid Agent
				or DMAHS shall give the claimant timely and adequate notice detailing the
				reasons for the proposed action. Under these requirements:
1. "Timely" means that the notice is dated at
				least 10 days before the action is to be taken; and
2. "Adequate advance notice" means a written
				notice that includes a statement of the action the Medicaid Agent or DMAHS
				intends to take, reasons for the proposed departmental action, the specific
				regulations that support, or the change in Federal or State law that requires
				the action, the claimant's right to request a fair hearing, or in cases of a
				departmental action based on a change in law, the circumstances under which a
				hearing shall be granted, and the circumstances under which assistance shall be
				continued if a fair hearing is requested.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.5 - Location of hearing

Current through Register Vol. 56, No. 14, July 15, 2024
The hearing shall be conducted at a reasonable time, date
				  and place after adequate written notice of the hearing is given.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.6 - Impartiality of official conducting the hearing

Current through Register Vol. 56, No. 14, July 15, 2024
The hearing shall be conducted by an Administrative Law
				  Judge from the Office of Administrative Law or by other persons eligible to
				  conduct hearings pursuant to the New Jersey Administrative Procedure Act, set
				  forth in 52:14B-1 et seq. and 52:14F-1 et
				  seq.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.7 - Beneficiary's right to different medical assessment

Current through Register Vol. 56, No. 14, July 15, 2024
When the hearing involves medical issues, such as those
				  concerning a diagnosis or an examining physician's report or the medical review
				  team's decision, and if the hearing officer considers it necessary to have a
				  medical assessment other than that of the person or persons involved in making
				  the original decision, such medical assessment shall be obtained at
				  Departmental expense from a source satisfactory to the claimant and shall be
				  made part of the record.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.8 - Hearing procedures

Current through Register Vol. 56, No. 14, July 15, 2024
The hearing shall be conducted pursuant to the procedures
				  set forth in the Administrative Procedure Act and the Uniform Administrative
				  Procedure Rules (N.J.A.C. 1:1). The Special Hearing Rules set forth in N.J.A.C.
				  1:10B apply to claimant (beneficiary) hearings. (See
				  42 C.F.R.
				  431.200, Subpart E).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.9 - Prompt, definitive and final action

Current through Register Vol. 56, No. 14, July 15, 2024
Prompt, definitive and final administrative action shall be
				  taken within 90 days from the date of the request for a fair hearing, except
				  where claimant requests an adjournment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.10 - Notification to claimants

Current through Register Vol. 56, No. 14, July 15, 2024
Claimants shall receive a written final decision, in the
				  name of the Department and shall be notified of their right to judicial review.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.11 - Action upon favorable decision to claimants

Current through Register Vol. 56, No. 14, July 15, 2024
When the final hearing decision is favorable to claimants or
				  when the Department decides in favor of claimants prior to the hearing, the
				  Department shall make corrective payments retroactively to the date the
				  incorrect action was taken or such earlier date as may be provided under State
				  policy.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.12 - Hearing decision

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A final
				decision by the Medicaid Agent's or DMAHS' head shall specify the reasons for
				the decision and identify the supporting evidence or may incorporate by
				reference the findings, conclusions, and recommendations, contained in the
				initial decision.
(b) Final
				decisions shall be binding on the Medicaid Agent or DMAHS.
(c) Under this rule, no person who
				participated in the local decision being appealed shall participate in a final
				administrative decision on such a case; the Medicaid Agent or DMAHS shall be
				responsible for seeing that the decision is carried out promptly.
(d) The final decision shall be promptly
				implemented.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 10 - NOTICES, APPEALS AND FAIR HEARINGS › Section 10:49-10.13 - Accessibility of hearing decisions to local agencies and the public

Current through Register Vol. 56, No. 14, July 15, 2024
The Medicaid Agent or DMAHS shall establish and maintain a
				  method for informing, at least in summary form, all local agencies of all fair
				  hearing decisions by the hearing authority and the decisions shall be
				  accessible to the public (subject to the provisions of safeguarding public
				  assistance information).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 11 - EXCLUSION FROM PARTICIPATION IN THE NEW JERSEY MEDICAID AND NJ FAMILYCARE PROGRAMS SUSPENSION, DEBARMENT, AND DISQUALIFICATION › Section 10:49-11.2 - Periodic notice to client

Current through Register Vol. 56, No. 14, July 15, 2024
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 12 - PROVIDER REINSTATEMENT › Section 10:49-12.1 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter,
				  shall have the following meanings, unless the context clearly indicates
				  otherwise:
"Committee" means the Provider Reinstatement
				  Committee.
"Person" means any natural person, company, firm,
				  corporation, professional association, partnership, or other entity, who has
				  been excluded from participation in the New Jersey Medicaid or the NJ
				  FamilyCare program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 12 - PROVIDER REINSTATEMENT › Section 10:49-12.2 - Requests for reinstatement

Current through Register Vol. 56, No. 14, July 15, 2024
Persons who have been debarred, disqualified or suspended
				  from participating in the New Jersey Medicaid or the NJ FamilyCare program
				  shall petition the Director for reinstatement in writing.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 12 - PROVIDER REINSTATEMENT › Section 10:49-12.3 - Petition by debarred, disqualified or suspended person

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Persons
				debarred or disqualified for a definitely stated period of time may petition
				the Director for reinstatement 90 days prior to the expiration of the period of
				debarment or disqualification.
(b)
				Persons disqualified for an indefinitely stated period of time may petition the
				Director for reinstatement after a disqualification period of eight
				years.
(c) Persons who have been
				suspended, debarred or disqualified as the result of an indictment, conviction
				or license revocation may immediately petition the Director for reinstatement
				upon acquittal, reversal of the conviction upon appeal or restoration of the
				license, whichever is applicable.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 12 - PROVIDER REINSTATEMENT › Section 10:49-12.4 - Director's powers

Current through Register Vol. 56, No. 14, July 15, 2024
The Director may on his or her own motion order the
				  reinstatement of debarred, disqualified or suspended persons or may refer the
				  matter to the Provider Reinstatement Committee.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 12 - PROVIDER REINSTATEMENT › Section 10:49-12.5 - Provider Reinstatement Committee

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Provider
				Reinstatement Committee shall be a non-standing committee that is convened for
				the purpose of evaluating requests for reinstatement.
1. The Committee shall be composed of three
				impartial officials of the New Jersey Medicaid or the NJ FamilyCare program
				appointed by the Director.
i. The Committee
				members shall not have been directly involved in the debarment,
				disqualification or suspension of persons requesting reinstatement.
ii. The Chairperson of the Committee shall be
				an attorney from the Office of Legal and Regulatory Liaison/Division of Medical
				Assistance and Health Services.
iii. Whenever possible, the associate members
				of the Committee shall be one member of the Medicaid Agent or the NJ FamilyCare
				staff from the same discipline as the debarred, disqualified or suspended
				persons and one member from the general administrative staff of the
				Division.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 12 - PROVIDER REINSTATEMENT › Section 10:49-12.6 - Criteria for reinstatement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reinstatement
				will not be granted unless it is reasonably certain that the causes which led
				to the debarment, disqualification or suspension shall not be repeated. In
				determining a person's fitness for reinstatement, the Committee and the
				Director may consider, among other factors:
1. Statements from debarred, disqualified or
				suspended persons setting forth the reasons why they should be
				reinstated;
2. Statements from
				private health insurers, indicating whether there have been any questionable
				claims submitted during the period of exclusion from Program
				participation;
3. Statements from
				peer review bodies, probation or parole officers or professional associates,
				attesting to their belief, supported by facts, that the causes which led to the
				debarment, disqualification or suspension shall not be repeated;
4. The absence of any pending criminal,
				licensing, or professional disciplinary proceedings;
5. Full restitution and the payment of any
				criminal fines imposed;
6. Full
				satisfaction of any civil penalties imposed;
7. Full satisfaction of interest
				payments;
8. Compliance with the
				terms and conditions of Consent Orders or Court Orders; and
9. Satisfaction of any conditions or
				requirements previously imposed by the Medicaid or the NJ FamilyCare
				program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 12 - PROVIDER REINSTATEMENT › Section 10:49-12.7 - Committee procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Committee
				shall meet at the Division's central offices.
(b) Persons requesting reinstatement and/or
				their representative shall be notified, in writing, as to the time, date and
				place of the meeting.
(c) All
				correspondence concerning the meeting shall be directed to the Chairperson of
				the Committee.
(d) Persons
				requesting reinstatement may appear on their own behalf or be represented by
				counsel.
(e) The Committee shall be
				governed by the New Jersey Administrative Procedure Act concerning
				admissibility of evidence at the meeting.
(f) The Chairperson of the Committee shall
				rule on all procedural questions and objections that may be raised at the
				meeting.
(g) Persons requesting
				reinstatement shall have the burden of providing their fitness for
				reinstatement by a preponderance of the evidence.
(h) Persons may present evidence of their
				fitness for reinstatement by the testimony of witnesses under oath or by
				documentary evidence, or both.
(i)
				After reviewing the testimony and documentation presented, the Committee shall
				prepare a written report which discusses the testimony, contains findings of
				facts and recommended disposition.
(j) At least two members of the Committee
				shall concur in the recommended disposition.
(k) Copies of the Committee's report shall be
				sent to all parties at the meeting. Upon receipt of the Committee's report, the
				parties shall have the opportunity to submit written objections or exceptions
				to said report within the time period specified by the committee.
(l) After the expiration of the time period
				prescribed for the filing of the exceptions, the Committee's report, exceptions
				or objections thereto, evidence and any transcripts shall be forwarded to the
				Director.
(m) The Director in
				consultation with the Commissioner of Health and Senior Services, where
				appropriate, shall have final decisional authority and may adopt, reverse or
				modify the Committee's recommended determination. The Director may also, for
				cause, remand the matter back to the Committee for further testimony.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 13 - PROGRAM CONTROLS › Section 10:49-13.1 - Medical review and evaluation

Current through Register Vol. 56, No. 14, July 15, 2024
Under the provisions of Federal and State law, the Medicaid
				  Agent or DMAHS shall provide continuing review and evaluation of the care and
				  services provided under the Medicaid and NJ FamilyCare programs. This includes
				  review of utilization of services of practitioners and other providers.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 13 - PROGRAM CONTROLS › Section 10:49-13.2 - Audits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A field audit
				shall be subject to the following:
1.
				"Completion of the field audit" for nursing facility providers for purposes of
				30:4D-17(f) 
				shall be defined in the following manner:
i.
				For all such audits and audit recovery cases pending on March 1, 1983, it shall
				mean the date that field work is completed, or the date information requested
				from the provider during the course of that field work is received, whichever
				is later.
ii. For all such audits
				and audit recovery cases pending on March 1, 1983, which are, have been or will
				be referred either to the Legal Action Committee, or to the Division of
				Criminal Justice or other agency for criminal investigation, it means the date
				the Office of Program Integrity Administration (OPIA) receives authorization to
				take administrative action.
iii.
				For all such audits initiated on or after March 1, 1983, it means the date the
				exit conference is completed or the date information requested from the
				provider during the course of the exit conference is received, whichever is
				later.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 13 - PROGRAM CONTROLS › Section 10:49-13.3 - Applicability to DMAHS programs of 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 that are
				  contained in the following sections of
				  30:4D-1 et seq. and this chapter
				  are fully applicable to all of the programs administered in whole or in part by
				  the Division, including, but not limited to, Plans B, C and D of the NJ
				  FamilyCare program:
				  30:4D-6.c., 6.f., 7.h., 7.i.,
				  7.k., 7.l., 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, 8.2(a)1ii, 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 49 - ADMINISTRATION MANUAL › Subchapter 13 - PROGRAM CONTROLS › Section 10:49-13.4 - Rewards for information relating to fraud and abuse

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division of
				Medical Assistance and Health Services may pay a monetary reward for
				information that leads to the recovery of at least $ 100.00 from individuals or
				entities that have engaged in health care-related fraud or abuse including
				ineligible receipt of benefits involving the programs administered by DMAHS
				(including, but not limited to, the New Jersey Medicaid and NJ FamilyCare
				programs), the Pharmaceutical Assistance to the Aged and Disabled (PAAD)
				program administered by Department of Health and Senior Services, and/or the
				Work First New Jersey General Assistance (GA) program administered by the
				Division of Family Development. The determination of whether an individual or
				entity meets the criteria for an award, and the amount of the award, is at the
				discretion of DMAHS. DMAHS shall pay a reward only if a reward is not otherwise
				provided for by law. When DMAHS applies the criteria specified in (b), (c) and
				(e) below to determine the eligibility and the amount of the reward, DMAHS
				shall notify the beneficiary of the reward as specified in (d) below.
(b) The following pertain to information
				eligible for reward.
1. In order for an
				individual or entity to be eligible to receive a reward, the information
				supplied shall relate to the activities of a specific individual or entity, and
				shall specify the time period of the alleged activities.
2. DMAHS shall not give a reward for
				information relating to an individual or entity that, at the time the
				information is provided, is already the subject of a review or investigation by
				DMAHS or its contractors; the New Jersey Department of Human Services (DHS);
				the New Jersey Department of Health and Senior Services; the New Jersey
				Department of Law and Public Safety; the Health Care Financing Administration
				and the Office of the Inspector General of the U.S. Department of Health and
				Human Services or their contractors; the U.S. Department of Justice; the
				Federal Bureau of Investigation; or any other Federal, State, county or
				municipal law enforcement agency.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 14 - RECOVERY OF PAYMENTS AND SANCTIONS › Section 10:49-14.1 - Recovery of payments correctly made

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Correctly paid
				benefits shall only be recoverable from the estate of an individual who was 65
				years of age or older when the individual received medical assistance if:
1. The individual leaves no surviving
				spouse;
2. For estates of
				individuals who died between February 1, 1984 and October 20, 1992, the
				individual left no surviving child;
3. For estates of individuals who died on or
				after October 21, 1992, the individual leaves no surviving child who is under
				the age of 21 or any surviving blind or permanently and totally disabled
				children;
4. The amount to be
				recovered is in excess of $ 500.00; and
5. The gross estate is in excess of $
				3,000.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 14 - RECOVERY OF PAYMENTS AND SANCTIONS › Section 10:49-14.2 - Sanctions-Special Status Program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The "Special
				Status Program" either restricts the Medicaid or NJ FamilyCare beneficiary(s)
				listed on the HBID Card to a single provider, except in a medical emergency, or
				warns providers that the beneficiary's card has been used by an unauthorized
				person or persons, or for an unauthorized purpose. If a warning letter is
				issued to a beneficiary, a message will be included in the eligibility message
				on the REVS/MEVS/eMEVS system alerting the provider to ask the Medicaid or NJ
				FamilyCare beneficiary for additional identification or to take other
				appropriate action.
1. The restriction is
				issued to Medicaid or NJ FamilyCare beneficiaries determined to have misused,
				abused or overutilized their Medicaid or NJ FamilyCare benefits.
				Overutilization occurs when a beneficiary has utilized Medicaid or NJ
				FamilyCare services or items at a frequency or amount that is not medically
				necessary. Examples of misuse or abuse include, but are not limited to,
				medically harmful or inappropriate use of different drugs or provider services,
				obtaining or attempting to obtain early refills of prescriptions in violation
				of 10:51-1.19(a)5,
				at more than one pharmacy, and forgery or alteration of prescriptions. A
				determination that there has been misuse, abuse or overutilization of benefits
				obtained by use of an HBID Card shall create a presumption that the beneficiary
				listed on the HBID Card, or a person responsible for a minor listed on the HBID
				Card, was responsible for such actions. If this presumption is successfully
				rebutted by or on behalf of the Medicaid or NJ FamilyCare beneficiary, he or
				she shall not be enrolled in the Special Status Program.
i. A beneficiary shall be permitted to change
				the designated provider upon demonstration of good cause and the Division may
				grant the request.
ii. The Division
				may change the provider to which the beneficiary is restricted if a pattern of
				continued misuse, abuse or overutilization by the beneficiary is evident, or if
				it is determined that the provider has engaged in fraud or abuse, or if the
				Division determines that such a change is in the best interest of the
				beneficiary and/or the programs it administers in whole or part.
iii. The beneficiary may request a contested
				case hearing in the following situations:
(1)
				If the beneficiary objects to being included in the special status
				program;
(2) If the beneficiary
				requests a change and the request is denied;
(3) If the agency causes undue delay in
				responding to the beneficiary's request for change.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 14 - RECOVERY OF PAYMENTS AND SANCTIONS › Section 10:49-14.3 - Authority to adjust, compromise, settle or waive claims, liens, and certificates of debt

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				Commissioner, Department of Human Services; Director, Division of Medical
				Assistance and Health Services; Assistant Director, Office of Program Integrity
				Administration; and the Commissioner or Deputy Commissioner, Department of
				Health and Senior Services, or anyone serving in an acting capacity in any of
				those positions shall have the authority to adjust, compromise, settle or waive
				any claim, lien or certificate of debt arising under this Act (30:4D-1 et seq.), and to execute
				an appropriate release or document of discharge with respect to that claim,
				lien or certificate of debt.
(b)
				Such authority may be exercised by other officials only in the following
				limited circumstances:
1. The Administrator,
				Bureau of Administrative Control may compromise, settle or waive any claim or
				lien not arising under
				30:4D-7(h) 
				within the dollar limits specified by the Director, Division of Medical
				Assistance and Health Services; and
2. The Fiscal Agent may compromise, settle or
				waive claims arising under
				30:4D-7(h) 
				within the dollar limits specified by the Director, Division of Medical
				Assistance and Health Services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 14 - RECOVERY OF PAYMENTS AND SANCTIONS › Section 10:49-14.4 - Recoveries involving a county welfare agency (CWA)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of
				this section is to define areas of responsibility and establish basic
				principles and procedures in those collection activities in which the Division
				of Medical Assistance and Health Services (DMAHS), the Division of Family
				Development (DFD) and/or a county welfare agency (CWA) may be involved. It is
				intended that maximum conservation of public funds be effected without
				duplication of effort. It is recognized that certain situations may fall into
				more than one of the following categories. Any such matter will be processed in
				accordance with the provisions of the first occurring applicable
				category.
(b) The following pertain
				to incorrectly granted assistance (cash and/or medical assistance):
1. In instances involving incorrect
				eligibility for medical assistance, whether or not in combination with cash
				assistance, the CWA shall determine the period(s) of ineligibility and
				ascertain from DMAHS the amount of medical assistance incorrectly granted. The
				CWA shall then attempt recovery of medical assistance incorrectly granted
				either by administrative collection, or by way of restitution in a criminal or
				disorderly persons proceeding.
i. Recoveries
				or attempts at recoveries can be made from those persons specified in
				30:4D-7i.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 14 - RECOVERY OF PAYMENTS AND SANCTIONS › Section 10:49-14.5 - Administrative charges/service fees

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A provider
				shall not pay nor require payment of an administrative charge or service fee
				for the privilege of doing business with another provider or for services for
				which reimbursement is included as part of the Medicaid or NJ FamilyCare fee.
1. An example of a prohibited practice is
				that a nursing facility may not require a pharmacy to pay an administrative
				charge or service fee to the facility for handling of the nursing facility
				resident's medications, drugs and/or related pharmaceutical records.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 14 - RECOVERY OF PAYMENTS AND SANCTIONS › Section 10:49-14.6 - Contracts with county welfare agencies

Current through Register Vol. 56, No. 14, July 15, 2024
Payment shall be made by the Department of Human
				  Services/Division of Medical Assistance and Health Services to the CWA for
				  conducting investigations and for determining whether applicants qualify for
				  benefits under the New Jersey Medicaid or NJ FamilyCare program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 15 - AVAILABILITY AND MAINTENANCE OF PROGRAM POLICY ISSUANCES › Section 10:49-15.1 - Maintenance of public policy issuances

Current through Register Vol. 56, No. 14, July 15, 2024
Program manuals and other policy issuances, which affect the
				  public, including the Medicaid Agent's rules and regulations governing
				  eligibility, need and amount of assistance, beneficiary's rights and
				  responsibilities, and services offered by the Medicaid Agent, shall be
				  maintained in the State or Division Central Office and in each Medical
				  Assistance Customer Center for examination during regular workdays and regular
				  office hours by individuals, and upon request, for study or reproduction by
				  such individuals. These manuals and other policy issuances are also distributed
				  to entities which serve as custodians such as the State Library, county welfare
				  agencies (CWA), and regional legal services offices.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 15 - AVAILABILITY AND MAINTENANCE OF PROGRAM POLICY ISSUANCES › Section 10:49-15.2 - Availability of material

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to
				facilitate public access, a current copy of material described in
				10:49-15.1 shall be made available
				without charge to custodians who request the material for this
				purpose.
(b) Custodians shall meet
				the following requirements:
1. They shall be
				centrally located and publicly accessible to a substantial number of the
				beneficiary population they serve; and
2. They shall agree to accept responsibility
				for filing all amendments forwarded by the Medicaid Agent.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 15 - AVAILABILITY AND MAINTENANCE OF PROGRAM POLICY ISSUANCES › Section 10:49-15.3 - Reproduction of policy material

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The specific
				policy materials necessary for an applicant or beneficiary (or his or her
				representative) to determine whether a fair hearing should be requested, or to
				prepare for a fair hearing, shall be reproduced without charge upon
				request.
(b) The Medicaid Agent may
				impose a charge for copying or reproducing materials. If a charge is imposed,
				it shall be computed pursuant to
				47:1A-1.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 16 - DEMONSTRATION PROJECTS › Section 10:49-16.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter sets forth the basic parameters for
				  demonstration projects established pursuant to
				  30:4D-1 et seq., as amended, and
				  Section 1115 of the Social Security Act. Any time a demonstration project is
				  implemented, New Jersey Medicaid providers will receive information and
				  instructions if the project is relevant to the services they provide.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 16 - DEMONSTRATION PROJECTS › Section 10:49-16.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter,
				  shall have the following meanings, unless the context clearly indicates
				  otherwise.
"Principal" means all Division management personnel.
"Project" means any demonstration project authorized through
				  a waiver by the Secretary of Health and Human Services of certain requirements
				  under Title XIX of the Social Security Act as provided under Section 1115 of
				  the Social Security Act.
"Provider" means providers of medical and health services
				  under a project.
"Recipient" means any beneficiary who receives services from
				  the project.
"Services" means medical or health services rendered as an
				  integral part of the project.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 16 - DEMONSTRATION PROJECTS › Section 10:49-16.3 - Implementation of projects

Current through Register Vol. 56, No. 14, July 15, 2024
The Medicaid Agent may implement projects directly or
				  through contractual arrangements with any legal entity, including, but not
				  limited to, corporations organized pursuant to Title 14A, New Jersey statutes
				  (14A:1-1 et seq.) and Title 15
				  revised statutes (R.S. 15:1-1 et seq.), as well as boards, groups, agencies,
				  persons and other public or private entities.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 16 - DEMONSTRATION PROJECTS › Section 10:49-16.5 - Sanctions related to demonstration projects

Current through Register Vol. 56, No. 14, July 15, 2024
The Commissioner of Human Services and the Commissioner of
				  Health and Senior Services, in addition to any and all other authority, shall
				  have the authority to totally suspend or partially reduce payment in order to
				  enforce compliance with this subchapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 18 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT EPSDT › Section 10:49-18.1 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) EPSDT is a
				federally mandated comprehensive child health program for Medicaid
				beneficiaries from birth through 20 years of age. The Omnibus Budget
				Reconciliation Act of 1989 (OBRA '89) codified EPSDT. Accordingly, the term
				"EPSDT Services" means the following:
1.
				EPSDT Screening Services;
2. Vision
				Services;
3. Dental
				Services;
4. Hearing Services;
				and
5. Such necessary health care
				diagnostic services, treatment and other measures to correct or ameliorate
				defects, and physical and mental illnesses and conditions discovered by the
				screening services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 19 - HEALTHSTART › Section 10:49-19.1 - HealthStart

Current through Register Vol. 56, No. 14, July 15, 2024
HealthStart is a program which provides comprehensive
				  maternity care services for all pregnant women (including those determined to
				  be presumptively eligible) and child health care services for children (through
				  two years of age) who are eligible for Medicaid benefits. Detailed information
				  about this program is included in the Physician Services Manual or N.J.A.C.
				  10:54, Independent Clinic Services Manual or N.J.A.C. 10:66, Nurse-Midwifery
				  Services Manual or N.J.A.C. 10:58, and the Hospital Services Manual or N.J.A.C.
				  10:52.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 21 - THE MEDICAID/NJ FAMILYCARE MANAGED CARE PROGRAM › Section 10:49-21.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
The Medicaid/NJ FamilyCare Managed Care Program is a program
				  under which Health Maintenance Organizations (HMOs) contract with the
				  Department of Human Services to provide health care services to Medicaid
				  beneficiaries. Requirements governing HMO providers and services are codified
				  at N.J.A.C. 10:49-74. For more information, providers may contact the Medicaid
				  Managed Care Hotline at 1-800-356-1561.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 21 - THE MEDICAID/NJ FAMILYCARE MANAGED CARE PROGRAM › Section 10:49-21.2 - Capitation payment system

Current through Register Vol. 56, No. 14, July 15, 2024
Under the Medicaid/NJ FamilyCare Managed Care Program, HMOs
				  are reimbursed through a capitation payment system whereby DMAHS pays an HMO a
				  set amount for the services it provides to beneficiaries, as described in
				  N.J.A.C. 10:74.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 21 - THE MEDICAID/NJ FAMILYCARE MANAGED CARE PROGRAM › Section 10:49-21.3 - Medicaid beneficiaries

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Medicaid/NJ
				FamilyCare Managed Care Program is a mandatory enrollment program for AFDC and
				AFDC-related New Jersey Care pregnant women and children, Aged, Blind and
				Disabled (ABD) individuals without Medicare and NJ FamilyCare beneficiaries and
				is offered to the Medicare-Medicaid dual eligible beneficiary as an alternative
				to the existing Medicaid fee-for-service program.
(b) Medicaid/NJ FamilyCare beneficiaries
				enrolled in HMOs receive two identification cards.
1. One card is issued by the HMO and
				appropriate toll-free telephone numbers are indicated on the card. These
				telephone numbers allow the provider to inquire whether a service the provider
				intends to perform will be covered or if the provider needs a prior
				approval.
2. The second card issued
				is the same Health Benefits Identification (HBID) card issued to all
				beneficiaries. Questions about covered services should be referred to the HMO's
				toll-free number. Providers can also utilize the REVS/MEVS/eMEVS program to
				identify managed care organization eligibility and/or inquire about the HMO
				enrollment status.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 21 - THE MEDICAID/NJ FAMILYCARE MANAGED CARE PROGRAM › Section 10:49-21.4 - Medicaid/NJ FamilyCare Managed Care Program services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				services are provided under the Medicaid/NJ FamilyCare Managed Care Program:
1. Primary and specialist care;
2. Preventive health care and
				counseling;
3. Early and Periodic
				Screening, Diagnostic and Treatment (EPSDT);
4. Audiology Services;
5. Organ transplants, donor and recipient
				costs;
6. Inpatient and outpatient
				hospital services;
7. Emergency
				medical care;
8. Laboratory and
				radiology services;
9. Prescription
				drugs (Legend and non-legend drugs);
10. Family planning services
11. Podiatrist services;
12. Chiropractor services;
13. Optometrist services;
14. Optical and hearing appliances;
15. Home health agency services;
16. Medical supplies and durable medical
				equipment;
17. Dental
				services;
18. Ambulance, Mobile
				Intensive Care Unit (MICU) and invalid coach transportation services;
19. Prosthetic and orthotic
				services;
20. Hospice services;
				and
21. Private duty nursing agency
				services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 22 - HOME AND COMMUNITY-BASED SERVICES WAIVER PROGRAMS › Section 10:49-22.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Home and
				Community-Based Services Waivers are five-year, renewable Federal waiver
				programs, prepared by the Division of Medical Assistance and Health Services in
				response to the Omnibus Budget Reconciliation Act of 1981 ( Section 2176,
				Public Law 97-35 and amendments under P.L. 99-509 ). These Home and
				Community-Based Services Waivers are submitted to the CMS of the United States
				Department of Health and Human Services. The purpose of these programs is to
				help eligible individuals remain in the community, or return to the community,
				rather than be cared for in a nursing facility or hospital setting.
(b) Retroactive eligibility is not available
				to waiver program beneficiaries; no waiver service received prior to the date
				of enrollment shall be considered for reimbursement.
(c) Total program costs are restricted by
				limits on the number of community care slots and on per-person costs. The case
				manager is responsible for the development of the service plan with the
				client/family, with input from provider agencies, and for monitoring the cost
				of the service package.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 22 - HOME AND COMMUNITY-BASED SERVICES WAIVER PROGRAMS › Section 10:49-22.2 - Approved Waivers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey
				Medicaid program has received waivers for the following programs:
1. Community Care Program for the Elderly and
				Disabled (CCPED);
2. Community
				Resources for Persons with Disability (CRPD);
3. AIDS Community Care Alternatives Program
				(ACCAP);
4. Traumatic Brain Injury
				Program;
5. Home and
				Community-Based Services Waiver Program for Developmentally Disabled
				Individuals; and
6. Assisted
				Living/Alternative Family Care (AL/AFC) Waivers.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 22 - HOME AND COMMUNITY-BASED SERVICES WAIVER PROGRAMS › Section 10:49-22.3 - Administration of waivered programs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division of
				Medical Assistance and Health Services provides oversight to the following Home
				and Community-Based Services Waivers, which are administered by the Division of
				Disability Services (DDS): Community Resources for Persons with Disability
				(CRPD); AIDS Community Care Alternatives Program (ACCAP) and Traumatic Brain
				Injury Waiver.
(b) The Division
				provides oversight to the Division of Developmental Disabilities in its
				administration of its Home and Community-Based Services Waiver for
				developmentally disabled individuals.
(c) The Division provides oversight to the
				Department of Health and Senior Services, which administers the Community Care
				program for the Elderly and Disabled (CCPED) waiver, and the Assisted
				Living/Alternate Family Care (AL/AFC) waiver.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 22 - HOME AND COMMUNITY-BASED SERVICES WAIVER PROGRAMS › Section 10:49-22.4 - Home and Community-Based Services Waivers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any questions
				regarding the Community Resources for Persons with Disability (CRPD), AIDS
				Community Care Alternatives Program (ACCAP) or Traumatic Brain Injury (TBI)
				Program waivers may be directed to the Division of Disability Services, by
				calling 1-888-285-3036 or 1-609-292-1210 (TTY system for the deaf) or by
				accessing its website:
http://www.state.nj.us/humanservices/dds/
.
(b) Any questions regarding the Community
				Care Program for the Elderly and Disabled (CCPED) or Assisted
				Living/Alternative FamilyCare (AL/AFC) waivers may be directed to DHSS,
				Division of Consumer Support Services, by calling (609) 588-2611 or by
				accessing its website:
http://www.state.nj.us/health/
.
(c) Any questions regarding the Home and
				Community-Based Services Waiver Program for Developmentally Disabled
				Individuals may be directed to the Division of Developmental Disabilities by
				calling 1-800-832-9173 or by accessing its website:
http://www.state.nj.us/humanservices/ddd/
.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 23 - LIFELINE PROGRAMS › Section 10:49-23.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
Lifeline Programs provide an annual benefit to eligible
				  persons toward the cost of electricity and natural gas. The Lifeline Credit
				  Program (LCP) and the Tenants Lifeline Assistance Program (TLAP) are
				  administered by the Department of Health and Senior Services. The rules for
				  these programs are promulgated by the Department of Health and Senior Services.
				  Although the Department of Health and Senior Services also administers the
				  Lifeline benefit, because Supplemental Security Income (SSI) beneficiaries
				  receive the benefit as a Special Utility Supplement (SUS) in their monthly SSI
				  checks, DMAHS is responsible for establishing the policies and procedures for
				  eligibility for this benefit as part of their SSI income eligibility for the
				  Medicaid program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 23 - LIFELINE PROGRAMS › Section 10:49-23.2 - Applications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Applications
				for the Lifeline Programs are sent automatically to persons benefiting from the
				following Medicaid programs:
1. Medical
				Assistance to the Aged (MAA);
2.
				Medical Assistance Only (MAO); and
3. New Jersey Care ... Special Medicaid
				Programs.