New Jersey Administrative Code

(a) Certain services, such as medical and surgical specialties, chiropractic, dental, mental health, podiatric, and vision care, shall be initiated by the attending physician as either a request for a "consultation" or as a "referral for examination and treatment". (b) A consulta…

(a) All facilities shall assist Medicaid beneficiaries to obtain mental health care through a licensed psychiatrist or psychologist, who shall provide, or make provision for, routine and emergency services. (b) An initial consultation for mental health services shall be performed…

(a) These rules describe the methodology to be used by the State of New Jersey, Department of Health and Senior Services (Department), to establish prospective per diem rates for the provision of nursing facility services to residents under the State's Medicaid program. (b) The D…

(a) For each cost report identified in N.J.A.C. 8:85-3.8, the Department shall establish the direct care rate component. 1. A case mix portion percentage shall be established by dividing the cost report's normalized direct care case mix cost per diem established in N.J.A.C. 8:85-…

(a) The Department shall determine the facility fair rental value allowance for each Class I NF and Class II NF. 1. The new construction value per bed shall be $ 89,000. 2. The age of each NF for the July 1, 2010 through June 30, 2011 rate year shall be determined using the FRV D…

(a) The provider tax pass-through per diem for the rate year shall equal the per diem tax paid by the nursing facility for the calendar year preceding the rate year divided by the total resident days, including all taxable and non-taxable days, as reported on the NHA-100s encompa…

(a) For each rate year, the total adjusted case mix rate for each Class I NF and Class II NF shall be the sum of the direct care rate component, the operating and administrative rate component, the fair rental value allowance, phase-in provisions identified in N.J.A.C. 8:85-3.16 …

For publicly owned or operated governmental NFs and SCNFs, the Department shall make a full cost rate calculation that is equal to 100 percent of the facility's allowable costs divided by total patient days as determined from the most recent validated cost report identified in N.…

(a) Effective for dates of service between July 1, 2010 and June 30, 2011, the rates for a Class III NF, Special Care Nursing Facility (SCNF), shall be the facility rate as of June 30 preceding the rate year adjusted by the percent change allowed for in N.J.A.C. 8:85-3.13(c). 1. …

(a) For dates of service from July 1, 2010 through June 30, 2011, for Class I NFs and Class II NFs, the total adjusted case mix rate, exclusive of the provider tax pass-through per diem, shall be no more than $ 5.00 above the total reimbursement rate, exclusive of the provider ta…

(a) When an NF believes that, owing to an unusual situation, the application of these rules results in an inequity (except for the application of N.J.A.C. 8:85-3.2(f) ), two levels of appeals are available: a level I appeal heard by representatives of the Department; and a Level …

(a) For any facility that transfers ownership, the rate, cost reports and case mix indices established for the old owner shall pass to the new owner. (b) New Class I NFs and Class II NFs shall be subject to the following:1. The direct care limit for the applicable Class of NF sha…

Any changes to the Federal MDS required by 42 CFR 483.20 and set forth in the Resident Assessment Instrument (RAI) published by CMS, and available at www.cms.gov, which are incorporated herein by reference, as amended and supplemented, shall only apply to rate quarters subsequent…

(a) Nursing facilities shall furnish required cost reports to the Department of Health and Senior Services, Office of Nursing Facility Rate Setting and Reimbursement, by May 31 following the end of each calendar year for a cost reporting period ending December 31. 1. Effective fo…

(a) The following information maintained by the Department for the purposes of rate-setting or administering other duties under this chapter shall not be considered "government records" subject to public access or inspection within the meaning of the "Open Public Records Act,"N.J…

Notes N.J. Admin. Code § 10:166-3.21 Recodified to N.J.A.C. 8:85-3.17 by R.2011 d.121, effective 4/18/2011. See: 42 N.J.R. 1793(a), 43 N.J.R. 961(c). Section was "Appeals process". Recodified from N.J.S.A. 8:85-3.21 by 56 N.J.R. 2242(a), effective 11/18/2024

Notes N.J. Admin. Code § 10:166-3.22 New Rule, R.2001 d.1, effective 1/2/2001. See: 32 N.J.R. 2859(a), 33 N.J.R. 54(a). Recodified from N.J.A.C. 10:63-3.25 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). Changed N.J.A…

Notes N.J. Admin. Code § 10:166-3.23 Recodified from N.J.A.C. 10:63-3.23 and repealed 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, Transitional relief for salary region adjustment; State Fiscal Year 1994. Recodifi…

Notes N.J. Admin. Code § 10:166-3.24 Recodified from N.J.A.C. 10:63-3.24 and repealed 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, Transitional relief for salary region adjustment; State Fiscal Year 1995. Recodifi…

(a) For dates of service on or after July 1, 2010, Class I and Class II prospective rates will be case mix rates for two classes of NFs: 1. Class I Proprietary and Voluntary NFs. 2. Class II Governmental NFs. To qualify as a Class II Governmental NF, the NF shall meet all of the …

(a) An NF shall electronically transmit MDS assessment information in a complete, accurate and timely manner. 1. The Department shall provide a Preliminary Resident Roster to an NF based on the NF's transmitted MDS assessment information for a calendar quarter, when that informat…

(a) In order to equitably develop and calculate limits and prices, the following computation will be made for all cost reports effective for periods ending before December 31, 2010: 1. General fringe benefits will be allocated to function as a percentage of salaries reported to d…

(a) For the purpose of calculating the limit and price as set forth in N.J.A.C. 8:85-3.9 and for adjusting the operating and administrative price between rebasing years as set forth in N.J.A.C. 8:85-3.8(c)2, the Department shall calculate an index factor using the most recent ind…

(a) Effective for dates of service on or after July 1, 2010, for Class I and Class II NFs, each facility's rate shall be comprised of: 1. The facility's direct care case mix rate component and direct care non-case mix rate component; 2. The operating and administrative price; 3. …

(a) The Department shall establish the database used to derive the direct care limit and operating and administrative price used in rates for dates of service July 1, 2010 through June 30, 2011.1. Each Class I NF and Class II NF in operation as a Medicaid certified NF as of May 1…

(a) The Department shall establish the direct care limit for each Class I and Class II nursing facility. 1. For each cost report identified in N.J.A.C. 8:85-3.8, the Department shall fringe the direct care case mix costs and direct care non-case mix costs, as set forth in N.J.A.C…

(a) Any cost report submitted by a Medicaid participating nursing facility (NF) which is selected for audit on or after February 7, 1983 may be audited within three years of the due date of the cost report or the date it is filed, whichever is later. This requirement shall be sat…

(a) For the exclusive purpose of calculating interest, under N.J.S.A. 30:4D-17(f), "completion of the field audit" for nursing facility providers shall be defined in the following manner:1. For all such audits and audit recovery cases pending on February 7, 1983, it shall mean th…

(a) The Department will calculate final per diem rates based on audit adjustment reports. (b) The final per diem rates determined based on (a) above cannot exceed the prospective rates previously paid. (c) Settlement after final rate calculation will be for fraud and/or abuse col…

(a) Upon receipt, from the Director of the Division of Taxation in the New Jersey Department of the Treasury, or the Director's designee, of the total amount of provider tax monies available for reimbursement to nursing facilities effective July 1 of each year from the Nursing Ho…

(a) It is intended that Pharmaceutical Assistance to the Aged and Disabled (PAAD) shall extend assistance to certain persons whose level of income disqualifies them for medical assistance under the New Jersey Medical Assistance and Health Services Act, but who have significant ne…

(a) The New Jersey Program of Pharmaceutical Assistance to the Aged and Disabled (PAAD) was established by Chapter 194, Laws of 1975, as amended by: 1. Chapter 194, Laws of 1975, effective August 21, 1975. Amended by Chapter 312, Laws of 1975, effective February 19, 1976; 2. Chap…

The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise: "Annual income" means all income from whatever source derived, actually received or anticipated. "Anticipated income" means the amounts of i…

(a) To be considered a special needs trust, the trust shall include the following provisions: 1. The trust shall specifically state that the trust is for the sole benefit of the trust beneficiary; 2. The trust shall specifically state that its purpose is to permit the use of trus…

The Department of Human Services is the administrative unit of the State government which has control over the administration of PAAD. Under the terms of the PAAD law, this Department is responsible for the general policies governing administration of PAAD, and for effecting the …

The Division of Medical Assistance and Health Services is the administrative unit of the Department of Human Services that performs certain administrative functions for, or in conjunction with, the Department. Notes N.J. Admin. Code § 10:167-3.2

The Pharmaceutical Assistance to the Aged and Disabled is the program in the Department which has the direct responsibility for the processing of eligibility applications from applicants. Notes N.J. Admin. Code § 10:167-3.3

By statute, the Pharmaceutical Assistance to the Aged and Disabled Program is limited to payment or reimbursement to pharmacies for the reasonable cost of prescription drugs for eligible persons, which exceeds the PAAD co-pay and to Medicare Part D authorized prescription drug pl…

(a) Reimbursement for PAAD prescriptions shall be made only to pharmacies located in New Jersey except as indicated in (b)1 below and operating under a valid permit from the Board of Pharmacy of the State of New Jersey. In order to become an approved provider, such a pharmacy mus…

(a) Whenever PAAD is the primary payer and any interchangeable drug product is available for the prescription written, the PAAD Program shall reimburse for multisource generic drugs without prior authorization, but not for multisource brand name drugs without prior authorization.…

(a) No direct payment to beneficiaries shall be made under the PAAD Program, except as noted in (b) below. The beneficiary must pay the pharmacy a nonrefundable PAAD co-pay per prescription or per purchase of insulin, insulin syringes, insulin needles or syringes and needles for …

(a) The Department shall pay Medicare Part D premiums to the PDP on behalf of PAAD beneficiaries in accordance with the Fiscal Year 2016 Appropriations Act, P.L. 2015, c. 63, approved June 26, 2015, as amended and supplemented by subsequent State appropriations acts. 1. If the PD…

The application process includes all activity relating to a request for eligibility determination. It begins with the receipt by the Department of an eligibility application and continues in effect until there is an official disposition of the request by the Department. Notes N.J…

(a) In those instances where the applicant is incompetent or incapable of filing an eligibility application on his or her own behalf, the Department shall accept any one of the following listed in the order of priority, as an authorized agent for the purpose of initiating such ap…

(a) The PAAD eligibility effective date for an initial PAAD applicant, who meets all of the PAAD eligibility criteria, is the date when processing of a valid and complete eligibility application is completed by the PAAD program. (b) The PAAD program shall conduct periodic redeter…

(a) There may be exceptional cases where the processing of an eligibility application cannot be completed within a normal 30-day period. Where substantially reliable evidence either of eligibility or ineligibility is still lacking; the application shall be continued in pending st…

(a) The Commissioner shall establish operating policies within the Department to expedite the processing of applications and assure the maximum possible compliance with the standards set forth in this manual. (b) The Department has the responsibility for reviewing a statistically…