New Jersey Administrative Code

(a) As a condition of per diem reimbursement in accordance with N.J.A.C. 10:164-1.6, ADHS facilities shall provide the following to adult beneficiaries: 1. The services required as a condition of licensure at N.J.A.C. 8:43F; 2. The service(s) each adult beneficiary requires to be…

(a) Clinical eligibility for adult day health services shall be contingent upon receipt of prior authorization from the Department on the basis of: 1. The results of an assessment of the individual using an instrument prescribed by the Department and the eligibility criteria spec…

(a) The facility providing adult day health services shall agree to accept the reimbursement rates established by the Department as the total reimbursement for services provided to eligible Medicaid beneficiaries and to eligible beneficiaries enrolled in the HCEP or in the JACC. …

(a) An adult beneficiary who chooses to request to transfer from one ADHS facility to another ADHS facility shall submit a transfer request, in accordance with (b) below, to: 1. The facility to which the beneficiary chooses to request to transfer; or 2. The beneficiary's case or …

Notes N.J. Admin. Code § 10:164-1.8 Recodified to N.J.A.C. 8:86-1.6 by R.2005 d.390, effective December 19, 2005 (operative February 1, 2006). See: 36 N.J.R. 5262(a), 37 N.J.R. 385(b), 4968(a). Section was "Basis of payment."

Notes N.J. Admin. Code § 10:164-1.9 Repealed by R.2005 d.390, effective December 19, 2005 (operative February 1, 2006). See: 36 N.J.R. 5262(a), 37 N.J.R. 385(b), 4968(a). Section was "Disaster plan."

(a) The New Jersey Medicaid Program adopted the Centers for Medicare and Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS). The HCPCS codes as listed in this subchapter are relevant to certain Medicaid and HCEP adult day health services. A separate billing…

(a) HCPCS codes for adult day health services are as follows: HCPCS Code Description Z0300 Initial visit, speech-language pathology services Z0310 Initial comprehensive speech-language pathology evaluation Z0270 Initial visit, physical therapy 92507 Speech-language pathology serv…

(a) This chapter sets forth the procedures for establishing planning and service areas within the State, and designating Area Agencies on Aging, consistent with the Older Americans Act of 1965, and amendments thereto, 42 U.S.C. §§ 3001 et seq. (b) This chapter sets forth the proc…

"Area Agency on Aging" means a public or private nonprofit agency designated by the State Division in accordance with this chapter and 45 C.F.R. § 1321.17 to act as the central coordinating and planning body for older adult services within a PSA. "Area Plan" means the document co…

(a) The State Division shall provide no less than 60 days written notice of any intended action to define or redefine a PSA, or designate or revoke an Area Agency on Aging designation, except that this requirement shall not apply to PSAs and Area Agency on Aging designations esta…

(a) The State Division shall divide the State into distinct PSAs, based on the following factors: 1. The geographic distribution of older individuals in the State; 2. The incidence of the need for supportive services, nutrition services, multi-purpose senior centers, and legal as…

(a) A PSA designation shall be subject to the following minimum standards: 1. The PSA shall encompass a unit of general purpose local government with a population of 100,000 or more; or 2. The PSA shall encompass any region within the State recognized for purposes of area-wide he…

(a) The State Division shall designate one Area Agency on Aging for each PSA. (b) An Area Agency on Aging shall be one of the following: 1. An established office of aging operating within a PSA; 2. Any office or agency of a unit of general purpose local government or combination …

(a) The State Division shall not revoke a designation unless notice and a public hearing has been held in accordance with N.J.A.C. 10:165-1.3. (b) In addition to providing notice in accordance with (a) above, the State Division shall provide personal written notice to the designa…

(a) The State Division may revoke the status of an agency or organization as the Area Agency on Aging when the State Division determines that: 1. The agency or organization has not complied with Federal and State requirements for Area Agencies on Aging, as delineated in 42 U.S.C.…

This chapter addresses the provision of quality, cost-prudent health care services available to New Jersey Medicaid eligible children and adults in a nursing facility (NF) and addresses the provision of and reimbursement for services required to meet the individual's medical, nur…

(a) The Department recognizes that there may be problems in relocating infirm aged persons from a NF. The purpose of this rule is to specify the circumstances in which the involuntary transfer of a Medicaid beneficiary in a NF is authorized and to establish conditions and procedu…

Notes N.J. Admin. Code § 10:166-1.11 Recodified from N.J.A.C. 10:63-1.11 and repealed by R.2005 d.389, effective 1/17/2006. See: 36 New Jersey Register 4700(a), 37 New Jersey Register 1185(a), 38 New Jersey Register 674(a). Section was "NF authorization process". Recodified from …

(a) Clinical audit is a method of utilization control under the enforcement authority of Section 1902(a)(30)(A) of the Social Security Act, to monitor the continued utilization of and payment for NF care and services reimbursable under the Medicaid program. Clinical audit has as …

(a) An individual clinical record shall be maintained for each Medicaid beneficiary covering his or her medical, nursing, social and related care in accordance with accepted professional standards and licensing standards as set forth by the Standards for Licensure of Long-Term Ca…

(a) The bed reserve policy for hospital admissions is as follows: 1. The NF shall reserve and hold the same room and the same bed of the Medicaid beneficiary transferred to a general or psychiatric hospital for a period not to exceed 10 days. The NF shall determine the individual…

(a) The Department will receive, document and investigate complaints from multiple sources and take appropriate corrective action as required. It is the Department's policy that the source of the complaint be held confidential, unless disclosure permission is obtained from the co…

(a) After provision for the resident's Personal Needs Allowance (PNA) is met, and then after provision for other allocations such as maintenance of spouse and/or dependent's home are satisfied, the remainder of the Medicaid beneficiary's income shall be applied to the cost of car…

(a) The NF shall ensure that each resident and his or her representative are informed of their rights upon admission and provided with a written statement of all resident rights, in accordance with 42 CFR 483.10 through 483.15, the Nursing Home Resident Rights Act, N.J.S.A. 30:13…

(a) The New Jersey Medicaid Program will reimburse for NF services provided to combination Medicare/Medicaid beneficiaries only after Medicare covered benefits have been fully utilized or when medically necessary services are not covered by the Medicare Program. (Exceptions--see …

The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise. "Advance directive" means a written instruction relating to the provision of health care when the individual is incapacitated, such as a liv…

(a) An NF shall comply with the following requirements in order to be eligible to participate in the New Jersey Medicaid program. An in-State NF shall: 1. Be licensed by the Department in accordance with N.J.A.C. 8:39; 2. Be certified by the Department, and in the case of both Me…

(a) NFs which are approved for participation as providers of service under the New Jersey Medicaid program shall be prohibited under Section 6(a) of P.L. 1985, c. 303 from soliciting or accepting payment, any type of gift, money, contribution, donation or other consideration as a…

Notes N.J. Admin. Code § 10:166-1.5 Recodified from N.J.A.C. 10:63-1.5 and amended by R.2005 d.389, effective 1/17/2006. See: 36 N.J.R. 4700(a), 37 N.J.R. 1185(a), 38 N.J.R. 674(a). Section was "Occupancy level"; in introductory paragraph (a), substituted "beneficiaries" for "and…

(a) The Department shall terminate a NF's Medicaid provider agreement if: 1. The Long-Term Care Licensing and Certification Program of the Department or the Centers for Medicare & Medicaid Services (CMS) determines that the NF is no longer certified to provide NF services. In tha…

(a) Any NF whose certification or Medicaid Provider Agreement is denied, terminated or not renewed shall have the opportunity to request a full evidentiary hearing before an administrative law judge, in accordance with the New Jersey Administrative Procedure Act, N.J.S.A. 52:14B-…

(a) Pursuant to N.J.S.A. 30:4D-17.10, a Medicaid-participating NF shall not admit an individual who is financially eligible for Medicaid or who may become financially eligible for Medicaid within 180 days of admission to the NF, or, regardless of payment source, an individual wit…

(a) The NF shall establish a single waiting list in chronological order. The order of names shall be predicated upon the order in which a completed written application is received. Hospitalized individuals ready for readmission to the NF are to be added to the top of the list as …

(a) Eligibility for nursing facility (NF) services will be determined by the professional staff designated by the Department, based on a comprehensive needs assessment that demonstrates that the beneficiary requires, at a minimum, the basic NF services described in N.J.A.C. 8:85-…

(a) All facilities shall assist Medicaid beneficiaries to obtain dental care though a licensed dentist, who shall provide, or make provision for: 1. Appropriate consulting services; 2. In-service education to the facility; 3. Policies concerning oral hygiene; and 4. Routine and e…

(a) All facilities shall assist Medicaid beneficiaries to obtain podiatry care through a licensed podiatrist who shall provide, or make provision for: 1. Appropriate consulting services; 2. In-service education for the facility; 3. Policies concerning foot care; and 4. Routine an…

All facilities shall assist Medicaid beneficiaries to obtain chiropractic care through a licensed chiropractor who shall provide, or make provision for, routine and emergency services. Notes N.J. Admin. Code § 10:166-2.12 Recodified from N.J.A.C. 10:63-2.12 and amended by R.2005 …

(a) All facilities shall assist Medicaid beneficiaries to obtain vision care through a licensed ophthalmologist or optometrist who shall provide, or make provision for, routine and emergency services. (b) Policies and procedures regarding the provision of Vision Care services are…

(a) A NF shall have written agreements with one or more general hospitals or one or more clinical laboratories so that the facility can obtain laboratory services, including emergency services promptly. If the facility has its own laboratory capabilities, the services may not be …

(a) Medical supplies include incontinency pads, bandages, dressings, compresses, sponges, plasters, tapes, cellu-cotton or other types of pads used to save labor or linen, and other disposable items (for example, colostomy bags), hot water bags, thermometers, catheters, rubber gl…

If the NF has significant, unresolved or recurring problems, the NF shall be required to provide appropriate consultation in any service area until the problems are corrected. Notes N.J. Admin. Code § 10:166-2.16 Recodified from N.J.A.C. 10:63-2.16 by R.2005 d.389, effective 1/17…

(a) The NF shall assist a Medicaid beneficiary in obtaining transportation when the beneficiary requires a Medicaid-covered service or care not regularly provided by the NF. (b) If a transportation service is provided by the NF to an inpatient of the NF, no additional reimburseme…

(a) Beds are provided in rooms licensed by the New Jersey Department of Health and Senior Services. A NF providing care to children shall have available protective cribs for infants and small children, as well as appropriate furniture, sized and scaled for children. (b) Board sha…

(a) Housekeeping and maintenance services necessary to maintain a sanitary and comfortable environment and laundering of personal clothing (excluding dry cleaning) shall be required. Notes N.J. Admin. Code § 10:166-2.19 Recodified from N.J.A.C. 10:63-2.19 by R.2005 d.389, effecti…

(a) The NF shall provide 24-hour nursing services in accordance with the Department's minimum licensing standards set forth by the Standards for Licensure of Long-Term Care Facilities, N.J.A.C. 8:39, incorporated herein by reference, employing the service-specific case mix system…

(a) Medicaid beneficiaries residing in NFs shall not be eligible to receive Medicaid reimbursement for the following services: 1. Admission or continued care primarily for diet therapy of exogenous obesity, bed rest, rest cure, or care of non-medical nature; 2. Private duty nursi…

(a) A special care nursing facility (SCNF) is a nursing facility or separate and distinct SCNF unit within a Medicaid-certified conventional nursing facility which has been approved by the Department of Health and Senior Services to provide care to New Jersey Medicaid beneficiari…

(a) General requirements for physician services shall be as follows: 1. Each Medicaid beneficiary's care shall be under the supervision of a New Jersey licensed attending physician chosen by, or agreed to by, the Medicaid beneficiary, or if the beneficiary is incompetent, by the …

(a) Rehabilitative services include physical therapy, occupational therapy and speech-language pathology services provided by a qualified therapist for the purpose of attaining maximum reduction of physical or mental disability and restoration of the resident to his or her best f…