New Jersey Administrative Code

A presumptively eligible pregnant woman must contact the county welfare agency during the presumptive eligibility period so that a face-to-face interview can be scheduled. As part of the eligibility determination process for Medicaid, the pregnant woman must be interviewed by cou…

(a) For a presumptively eligible pregnant woman who is subsequently determined ineligible for Medicaid benefits:1. The county welfare agency is not required to provide either timely or adequate notice for the end of the presumptive eligibility. The pregnant woman has no right to …

This subchapter describes the presumptive eligibility process for children, up to the age of one year, who may meet the eligibility requirements for New Jersey Care ... Special Medicaid Programs. The presumptive eligibility determination makes it possible for a child or the child…

All beneficiaries of presumptive eligibility for children who make an application for presumptive eligibility benefits for any Medicaid or NJ FamilyCare program shall be limited to one continuous presumptive eligibility period during the year, which shall be counted from the firs…

(a) The period of presumptive eligibility shall begin on the date an approved presumptive eligibility entity determines that, based on information provided by the family of the presumptive eligibility beneficiary, the child(ren) meets the requirements and standards of this chapte…

(a) A qualified presumptive eligibility entity shall be a New Jersey Medicaid provider and: 1. An acute care hospital; 2. A local health department; or 3. A Federally Qualified Health Center (FQHC). (b) An eligible entity shall apply to the Division of Medical Assistance and Heal…

(a) From preliminary information provided by a parent, guardian, or caretaker relative, the approved presumptive eligibility entity shall determine if the child meets the eligibility criteria of this subchapter as it applies to children. The approving presumptive eligibility enti…

(a) Upon receipt of a properly completed certificate from the approved presumptive eligibility determination entity, Division staff shall: 1. Assign a presumptive eligibility number; 2. Create an eligibility record; 3. Issue a letter authorizing covered medical services until a p…

(a) Upon receipt of the certificate of presumptive eligibility and a referral, if completed, from the approved presumptive eligibility determination entity, the eligibility determination agency shall check the Medicaid, Medically Needy, and NJ FamilyCare Eligibility database for …

The parent, guardian, or caretaker relative of a presumptively eligible child shall contact the eligibility determination agency during the presumptive eligibility period by mailing an application to either the Statewide eligibility determination agency or arranging for a face-to…

(a) For a presumptively eligible child who is subsequently determined ineligible for Medicaid or NJ FamilyCare benefits: 1. The eligibility determination agency shall not be required to provide either timely or adequate notice for the end of the presumptive eligibility period. Th…

All presumptively eligible New Jersey Care ... Special Medicaid Programs children under the age of one year shall be eligible during the presumptive eligibility period to receive on a fee-for-service basis all the Medicaid services defined at N.J.A.C. 10:49-5.2. Notes N.J. Admin.…

The purpose of this subchapter is to provide the coverage stipulated in P.L. 2001, c. 186, effective July 27, 2001, for women who are New Jersey residents who are under the age of 65 and who have been screened for breast and cervical cancer in accordance with the Breast and Cervi…

The words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Creditable coverage" means, with respect to an individual, in accordance with Public Law 104-191, the Health Insurance Portability and Accountabi…

(a) An eligible individual shall: 1. Be a citizen or eligible qualified alien as defined in N.J.A.C. 10:72-3.2; 2. Be under 65 years of age; 3. Have been screened for breast or cervical cancer under the Federal Centers for Disease Control (CDC) Breast and Cervical Cancer Early De…

In accordance with Pub.L. 106-354 and 42 U.S.C. § 1396a(aa), an individual referred to the Division by a CDC funded screening center shall be determined to be presumptively eligible for medical assistance in accordance with N.J.A.C. 10:72-7.5. Notes N.J. Admin. Code § 10:72-8.4…

In the case of an individual qualified for services in accordance with this subchapter, the only medical assistance provided shall be payment for services provided during the period in which the individual requires treatment for breast or cervical cancer. Notes N.J. Admin. Code §…

(a) A redetermination of medical eligibility shall be made every six months, and shall be based upon the need for continuing treatment for breast or cervical cancer, as determined by the individual's treating physician. Continuing treatment shall not include routine monitoring se…

(a) The purpose of this subchapter is to establish requirements to implement the NJ WorkAbility program in accordance with N.J.S.A. 30:4D-1 et seq., as amended by P.L. 2000, c. 116, and in accordance with the Federal Ticket to Work and Work Incentives Improvement Act, Public Law …

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Applicant" means any person who has made application for purposes of becoming a "qualified applicant." "Commissioner" means the Commiss…

(a) Permanently disabled employed individuals who are 16 years of age or over, but under 65 years of age, shall be eligible to participate in the NJ WorkAbility program. (b) Either the Social Security Administration or the Division's Disability Review Team may make the determinat…

(a) The earned income of a qualified applicant, after disregards, shall not exceed 250 percent of the Federal poverty level for a family unit of one or two, as applicable. (b) The unearned income of a qualified applicant, after disregards, shall not exceed 100 percent of the Fede…

(a) Qualified applicants for NJ WorkAbility shall meet resources eligibility standards as defined in N.J.A.C. 10:71-4 in order to be eligible for benefits under this chapter. (b) In the determination of countable resources, N.J.A.C. 10:71-4.2 shall apply. (c) Eligibility shall no…

(a) An eligible individual with countable income in excess of 150 percent of the Federal poverty level shall pay a premium of $ 25.00 per month to the Division. (b) An eligible couple with countable income in excess of 150 percent of the Federal poverty level shall pay a premium …

Services available through the NJ WorkAbility program shall be provided by the Division through its existing contracts with health maintenance organizations and fee-for-service providers. Notes N.J. Admin. Code § 10:72-9.7 Amended by R.2002 d.317, effective 9/16/2002. See: 34 New…

(a) Applications shall be obtained from, and returned to, the county board of social services in the applicant's county of residence. (b) Information can be obtained from the Division of Disability Services by calling toll free 1-888-285-3036 or at the address below. Division on …

(a) This chapter outlines information about targeted case management services provided by approved New Jersey Medicaid/NJ FamilyCare program providers. (b)N.J.A.C. 10:73-2 describes the Case Management Program/Mental Health for Adults, providing a description of the individuals f…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context indicates otherwise: "Advocacy" means the ongoing process of assisting the beneficiary in receiving, and maintaining receipt of, all services and benefits to which he o…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context indicates otherwise: "Adult" means any individual over age 21, or an individual over age 18 who did not receive services from the Department of Children and Families…

Notes N.J. Admin. Code § 10:73-2.10 Amended by R.1994 d.585, effective 11/21/1994 (operative December 1, 1994). See: 26 N.J.R. 3350(a), 26 N.J.R. 4614(a). Amended by R.1996 d.363, effective 8/5/1996. See: 28 N.J.R. 1977(a), 28 N.J.R. 3788(a). Amended by R.2001 d.198, effective 6/…

(a) Clinical case management services shall include, but shall not be limited to, assessment, individualized service planning, services linkage, ongoing clinical support and advocacy (see N.J.A.C. 10:73-2.4(a) ). (b) There are three levels (risk categories) of clinical case manag…

Notes N.J. Admin. Code § 10:73-2.12 Amended by R.1994 d.585, effective 11/21/1994 (operative December 1, 1994). See: 26 N.J.R. 3350(a), 26 N.J.R. 4614(a). Amended by R.1996 d.363, effective 8/5/1996. See: 28 N.J.R. 1977(a), 28 N.J.R. 3788(a). Amended by R.2001 d.198, effective 6/…

(a) Case management providers shall keep such individual records as are necessary to fully disclose the kind and extent of services provided and shall assure that such information is available to the DMAHS or DMHAS or their agents, upon request. (b) The CMP/MH provider shall main…

(a) The CMP/MH is under the auspices of the Division of Mental Health and Addiction Services (DMHAS) and is administered jointly with the Division of Medical Assistance and Health Services, in accordance with N.J.A.C. 10:37, the DMHAS Community Mental Health Services rules, N.J.A…

(a) Clinical case management services under CMP/MH are targeted to adults with serious mental illness who are at high risk of hospitalization or deterioration in their functioning and who require an assertive community outreach service to meet their needs. This targeted group is …

(a) CMP/MH services for adults shall include, but shall not be limited to, assessment, service planning, services linkage, ongoing monitoring, ongoing clinical support, and advocacy. These services are described below: 1. Assessment means the ongoing process of identifying, revie…

(a) This section lists the specific provisions relevant to a provider who wishes to apply and be approved as a provider of CMP/MH services. N.J.A.C. 10:73-2.6 provides information about service responsibilities of the CMP/MH provider and N.J.A.C. 10:73-2.7 describes the responsib…

(a) The CMP/MH provider rendering services to adults shall: 1. Provide ongoing support to enrolled CMP/MH beneficiaries, in their own environment, who are at risk of hospitalization or deterioration in function, to enable them to function in the community and to enable them to ac…

(a) The case manager (CM) providing clinical case management services to adults shall: 1. Identify mentally ill beneficiaries in need of CMP/MH services regardless of residence (for example: homeless, shelter, family, boarding home); 2. Provide clinical assessment of the benefici…

Notes N.J. Admin. Code § 10:73-2.8 Administrative Change. See: 26 N.J.R. 797(b). Amended by R.1996 d.363, effective 8/5/1996. See: 28 N.J.R. 1977(a), 28 N.J.R. 3788(a). Recodified from N.J.A.C. 10:73-2.7 and amended by R.2001 d.475, effective 12/17/2001. See: 33 N.J.R. 349(a), 33…

(a) Reimbursement for services covered under the CMP/MH in accordance with this subchapter shall be determined by the Commissioner of the Department of Human Services. The provider of CMP/MH services shall be compensated on a fee-for-service basis. Reimbursement will be based upo…

(a) This subchapter sets forth the manner in which care management organization (CMO) services shall be provided to eligible Medicaid/NJ FamilyCare beneficiaries and children, youth and young adults receiving services under the Children's System of Care (CSOC), and shall apply to…

(a) The ISP shall include a copy of the DHS or DCF confidentiality agreement form signed by all participants to adhere to all rules and procedures governing beneficiary confidentiality. (b) The ISP shall be comprehensive in nature, strength based, and developed in partnership wit…

(a) The comprehensive ISP shall contain the following components: 1. Documentation of the participation of providers and local community partners and the integration of available and appropriate services and resources; 2. Documentation of the responsibilities, objectives, and req…

(a) The CMO shall review and update the ISP at least every three months, and more often if needed. The care manager shall work with the Child/Family Team to facilitate this process. (b) As part of the reviewed and amended ISPs, the Child/Family Team may need to change the composi…

Transition/discharge planning for children, youth and young adults receiving CMO services shall be considered within the context of the ongoing ISP process and shall guide the team process from the time of the referral. Notes N.J. Admin. Code § 10:73-3.13 New Rule, R.2006 d.421, …

(a) The Child/Family team shall develop a transition plan if one or more of the following criteria are met:1. The goals of the individual service plan (ISP) have been substantially achieved; 2. The Child/Family Team determines that the child, youth or young adult no longer requir…

(a) The Child/Family Team shall develop a discharge plan if one or more of the following criteria are met: 1. Active attempts to engage the family/guardian to participate in the CMO process, for a two-month period, have not been successful; 2. The family has moved out of the geog…

(a) Upon determination that a transition/discharge from CMO services is appropriate, the CMO shall assure that: 1. A comprehensive transition/discharge ISP shall be developed by the Child/Family Team, and documented by the CMO. The transition/discharge ISP shall include: i. The r…

(a) The CMO shall identify, in each ISP and subsequent ISP, potential crisis(es) and shall include, in the ISP, a crisis management plan for each child, youth or young adult and his or her family or other caregiver(s). The crisis management plan shall assure that services are ava…