New Jersey Administrative Code

Notes N.J. Admin. Code § 10:60-1.18 Recodified to N.J.A.C. 10:60-1.10 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a).

The following words and terms, when used in this chapter, shall have the following meaning, unless the context clearly indicates otherwise. "Accreditation organization" means an agency approved by the Department of Human Services to provide quality oversight of Medicaid/NJ Family…

(a) A home care agency or organization, as described at (a)1 through 4 below, is eligible to participate as a New Jersey Medicaid/NJ FamilyCare provider of specified home care services in accordance with N.J.A.C. 10:49-3.2: 1. A home health agency. i. Out-of-State home health age…

For services rendered on or after January 1, 1999, out-of-State home health agencies shall be reimbursed using the prospective payment rate established pursuant to N.J.A.C. 10:60-2.5. There is no cost filing required. No retroactive settlement shall be made. Notes N.J. Admin. Cod…

When the cost of home care services is equal to or in excess of the cost of institutional care over a protracted period (that is, six months or more), DDS or DMAHS retains the right to limit or deny the provision of home care services on a prospective basis. Notes N.J. Admin. Cod…

All agencies providing home health, private duty nursing, hospice, and personal care participating in the New Jersey Medicaid/NJ FamilyCare program are subject to the provisions of State and Federal statutes regarding advance directives and Practitioner Orders for Life Sustaining…

Prior authorization shall be required for all Medicaid/NJ FamilyCare-eligible individuals and non-Medicaid/NJ FamilyCare eligible individuals applying for nursing facility (NF) services. Managed long-term services and supports (MLTSS) provided under the 1115 New Jersey Comprehens…

(a) An initial visit to evaluate the need for home health services or personal care assistant (PCA) services for a fee-for-service beneficiary shall be made by the provider. For PCA services, the provider agency shall request prior authorization using form FD-365 and a State-appr…

(a) For an accredited health care service firm, home health agency, or hospice agency, on-site monitoring visits will be made periodically by DDS or DMAHS staff, or by staff of an accreditation organization, as approved by DMAHS, to the agency to review compliance with personnel,…

Notes N.J. Admin. Code § 10:60-10.1 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-10.2 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

(a) The New Jersey Medicaid/NJ FamilyCare programs adopted the Federal Centers for Medicare & Medicaid Services' (CMS) Healthcare Common Procedure Coding System codes for 2006, established and maintained by CMS in accordance with the Health Insurance Portability and Accountabilit…

(a) PERSONAL CARE ASSISTANT SERVICES HCPCS Code Mod Description Maximum Rate S9122 Personal Care Assistant Service (Individual/hourly/weekday) $20.00 S9122 TV Personal Care Assistant Service (Individual/hourly/weekend/holiday) $20.00 (b) HCPCS CODES FOR EARLY AND PERIODIC SCREENI…

(a) Home health care services covered by the New Jersey Medicaid/NJ FamilyCare fee-for-service programs are limited to those services provided directly by a home health agency approved to participate in the New Jersey Medicaid/NJ FamilyCare program or through arrangement by that …

Notes N.J. Admin. Code § 10:60-2.10 Recodified to N.J.A.C. 10:60-6.4 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a). Section was "Basis for reimbursement for Model Waiver services".

Notes N.J. Admin. Code § 10:60-2.11 Recodified to N.J.A.C. 10:60-6.5 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a). Section was "Procedures used as financial controls".

Notes N.J. Admin. Code § 10:60-2.12 Recodified to N.J.A.C. 10:60-7.1 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a). Section was "AIDS Community Care Alternatives Program (ACCAP)".

Notes N.J. Admin. Code § 10:60-2.13 Recodified to N.J.A.C. 10:60-7.2 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a). Section was "Application process for ACCAP".

Notes N.J. Admin. Code § 10:60-2.14 Recodified to N.J.A.C. 10:60-7.3 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a). Section was "Eligibility criteria".

Notes N.J. Admin. Code § 10:60-2.15 Recodified to N.J.A.C. 10:60-7.4 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a). Section was "ACCAP services".

Notes N.J. Admin. Code § 10:60-2.16 Recodified to N.J.A.C. 10:60-7.5 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a). Section was "Basis for reimbursement for ACCAP services".

(a) To qualify for payment of home health services by the New Jersey Medicaid/NJ FamilyCare fee-for-service program, the beneficiary's need for services shall be certified in writing to the home health agency by the attending physician/ practitioner. The nurse or therapist shall …

(a) An interdisciplinary plan of care shall be developed by agency personnel in cooperation with the attending physician/practitioner, and be approved by the attending physician/practitioner. It shall include, but not be limited to, medical, nursing, therapies, nutrition, home he…

(a) Clinical records containing pertinent past and current information, recorded according to accepted professional standards, shall be maintained by the home health agency for each beneficiary receiving home health care services. The clinical record shall include, at a minimum, …

(a) Effective for services rendered on or after January 1, 1999, home health agencies shall be reimbursed the lesser of reasonable and customary charges or the service-specific unit rates described in this subsection. The following are the service-specific Statewide unit rates by…

(a) When the cost of home care services is equal to or in excess of the cost of institutional care over a protracted period (that is, six months or more), the Division retains the right to limit or deny the provision of home care services on a prospective basis. (b) For limitatio…

Notes N.J. Admin. Code § 10:60-2.7 Recodified to N.J.A.C. 10:60-6.1 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a). Section was "Model Waiver Programs".

Notes N.J. Admin. Code § 10:60-2.8 Recodified to N.J.A.C. 10:60-6.2 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a). Section was "Eligibility requirements for Model Waivers".

Notes N.J. Admin. Code § 10:60-2.9 Recodified to N.J.A.C. 10:60-6.3 by R.2001 d.14, effective 1/2/2001. See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a). Section was "Services included under the Model Waiver programs".

(a) Personal care assistant services shall be provided by a certified licensed home health agency, a certified hospice agency or by a health care service firm that is accredited, initially, and on an on-going basis, by an accrediting body approved by DMAHS. (b) Personal care assi…

(a) Beneficiaries may be approved for a transfer of service agency provider for good cause situations, including, but not limited to: 1. The current provider agency is unable to staff the case at the level of care approved by the Division; that is, staffing shortages, staffing ca…

(a) Personal care assistant services shall be reimbursable when provided to Medicaid/NJ FamilyCare beneficiaries in their place of residence or place of employment, or at a post-secondary educational or training program. The term "place of residence" shall include, but is not lim…

(a) Hands-on personal care assistant services are described as follows: 1. Activities of daily living (ADL) shall be performed by a personal care assistant, and include, but are not limited to: i. Care of the teeth and mouth; ii. Grooming, such as care of hair, including shampooi…

(a) To qualify for payment of personal care assistant services by the New Jersey Medicaid/NJ FamilyCare fee-for-service program, the beneficiary's need for services shall be certified in writing to the health care services firm by a physician/practitioner as medically necessary, …

(a) The duties of the registered professional nurse in the PCA program are as follows: 1. The registered professional nurse, in accordance with the physician's/practitioner's certification of need for care, shall perform an assessment and prepare a plan of care for the personal c…

(a) Recordkeeping for personal care assistant services shall include the following: 1. Clinical records and reports shall be maintained for each beneficiary, covering the medical, nursing, social, and health-related care in accordance with accepted professional standards. Such in…

(a) Personal care assistant services shall be reimbursed on a per unit, fee-for-service basis for weekday, weekend, and holiday services. Nursing assessment and reassessment visits under this program shall be reimbursed on a per visit, fee-for-service basis. 1. When provided to b…

(a) Medicaid/NJ FamilyCare reimbursement shall not be made for personal care assistant services provided to Medicaid/NJ FamilyCare-Plan A beneficiaries in the following settings: 1. A residential health care facility; 2. A Class C boarding home; 3. A hospital; 4. A nursing facili…

(a) All personal care assistant (PCA) services shall be prior authorized, regardless of the number of hours requested per week. (b) Prior approval for PCA services shall be obtained in accordance with the following procedures: 1. For fee-for-service cases, a registered nurse empl…

Notes N.J. Admin. Code § 10:60-4.1 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

Notes N.J. Admin. Code § 10:60-4.2 Reserved by 50 N.J.R. 1992(b), effective 9/17/2018

(a) Private duty nursing (PDN) services shall be provided by a licensed certified home health agency, licensed hospice agency or an accredited healthcare services firm approved by DMAHS. The healthcare services firm shall be accredited, initially and on an ongoing basis, by an ac…

(a) A provider of private duty nursing services shall be reimbursed by the New Jersey Medicaid/ NJ FamilyCare program on a fee-for-service basis for services provided as authorized by the individual's service plan prepared by the waiver case manager. Providers shall be precluded …

(a) There is no 24-hour coverage except for a limited period of time under the following emergency circumstances and when prior authorized by the MCO: 1. For brief post-hospital periods while the caregiver(s) adjust(s) to the new responsibilities of caring for the discharged bene…

(a) To be considered for EPSDT/PDN services, the beneficiary shall be under 21 years of age, enrolled in the Medicaid/NJ FamilyCare program and referred by a parent, primary physician/practitioner, hospital discharge planner, Special Child Health Services case manager, Division o…

(a) Individuals under 21 years of age who are enrolled in the Medicaid/NJ FamilyCare programs, and who require private duty nursing services, which will allow them to be cared for in a community setting, may be referred for EPSDT/PDN services. 1. Individuals eligible for Medicaid…

(a) The following requirements shall apply to EPSDT/PDN services: 1. Private duty nursing shall be provided for eligible FFS beneficiaries in the community only and not in hospital inpatient or nursing facility settings. 2. DMAHS shall determine and approve the total PDN hours fo…