New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 59 - MEDICAL SUPPLIER MANUAL › Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT › Section 10:59-1.3 - Requirements for program participation as a medical supplier

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Effective July 1, 2006, P.L. 2006, c. 45 and P.L. 2007, c. 111, as amended by P.L. 2007, c. 336, require the Division to institute a moratorium on, among other services, medical supply services.
1. Any provider that was not an approved Medicaid or NJ FamilyCare fee-for-service provider of medical supply services prior to July 1, 2006 is ineligible to become an approved fee-for-service provider of such services for Medicaid or NJ FamilyCare, unless the Division determines that the provider meets the special needs of the Division.
2. Special needs criteria for medical supplier provider applicants are as follows:
i. Sufficient access analysis: Using geo-accessing, the Division will determine whether the beneficiaries living in an area in which the provider is located, or intends to locate, have sufficient access to the Medicaid or NJ FamilyCare-covered service that the provider intends to offer. For example, if a mileage standard for a service is one provider in six miles or two providers in 12 miles, sufficient access exists under the moratorium for that service when a beneficiary has access to a minimum of one participating provider within six miles or two participating providers within 12 miles of the beneficiary's residence. Mileage standards are set forth below:
Miles per One
Miles per Two
Miles per One
Miles per Two
Provider-Urban
Providers-Urban
Provider-Non urban
Providers-Non
urban
six Miles
12 Miles
15 Miles
25 Miles
ii. Special needs analysis: After the Division performs a sufficient access analysis, the Division will perform a special needs analysis utilizing the following criteria:
(1) The number of beneficiaries in the area in question who may have special needs;
(2) Capacity limits and service offerings of existing providers and the provider applicant;
(3) The provider applicant's availability, as revealed in its proposed minimum and maximum hours of service, including whether the provider will offer a level of service not currently available, such as a 24-hour access system, emergency services and home delivery of services;
(4) Whether the provider applicant is a specialty medical services provider deemed by DMAHS to fill a need for specific medical supply that would not otherwise be filled; and
(5) A provider that is selected to provide institutional pharmaceutical services to a facility that is a newly licensed institution, or a replacement provider that shall provide identical services to an existing licensed institution, may also be approved for participation as a provider of medical supply services under the moratorium if the provider provides a level of services acceptable to the Department of Health and Senior Services and meets all applicable State and Federal rules and regulations. Additionally, institutional providers of pharmaceutical services may be approved as providers of medical supply services for the purpose of billing Medicare Part B for covered medical supply services and Medicare Part D services.
3. Situations not subject to the moratorium for fee-for-service providers of medical supply services are as follows:
i. A change of ownership only;
ii. A change of location only: A provider that has not changed ownership on or after July 1, 2006, which changes location on or after July 1, 2006 and prior to November 7, 2011, or which changes location to a location within the State of New Jersey on or after November 7, 2011, and continues to operate as a Medicaid or NJ FamilyCare provider at the new location, continues to provide the same level of services and delivery and meets all applicable State and Federal rules and regulations;
iii. Medicare is the primary payer. Situations where Medicare is the primary payer and the provider bills for cross-over claims and wraparound Medicare Part D payments; and
iv. A pharmacy that sells medical supplies.
4. A pharmacy provider is not approved to be a provider of medical supply services based on licensure as a pharmacy. Licensed pharmacies shall file a separate provider application to request participation as a provider of medical supply services.