New Jersey Administrative Code

(a) A field audit shall be subject to the following: 1. "Completion of the field audit" for nursing facility providers for purposes of N.J.S.A. 30:4D-17(f) shall be defined in the following manner:i. For all such audits and audit recovery cases pending on March 1, 1983, it shall …

All of the relevant provisions pertaining to fraud and abuse, third-party liability and administrative and judicial remedies that are contained in the following sections of N.J.S.A. 30:4D-1 et seq. and this chapter are fully applicable to all of the programs administered in whole…

(a) The Division of Medical Assistance and Health Services may pay a monetary reward for information that leads to the recovery of at least $ 100.00 from individuals or entities that have engaged in health care-related fraud or abuse including ineligible receipt of benefits invol…

(a) Correctly paid benefits shall only be recoverable from the estate of an individual who was 65 years of age or older when the individual received medical assistance if: 1. The individual leaves no surviving spouse; 2. For estates of individuals who died between February 1, 198…

(a) The "Special Status Program" either restricts the Medicaid or NJ FamilyCare beneficiary(s) listed on the HBID Card to a single provider, except in a medical emergency, or warns providers that the beneficiary's card has been used by an unauthorized person or persons, or for an…

(a) The Commissioner, Department of Human Services; Director, Division of Medical Assistance and Health Services; Assistant Director, Office of Program Integrity Administration; and the Commissioner or Deputy Commissioner, Department of Health and Senior Services, or anyone servi…

(a) The purpose of this section is to define areas of responsibility and establish basic principles and procedures in those collection activities in which the Division of Medical Assistance and Health Services (DMAHS), the Division of Family Development (DFD) and/or a county welf…

(a) A provider shall not pay nor require payment of an administrative charge or service fee for the privilege of doing business with another provider or for services for which reimbursement is included as part of the Medicaid or NJ FamilyCare fee. 1. An example of a prohibited pr…

Payment shall be made by the Department of Human Services/Division of Medical Assistance and Health Services to the CWA for conducting investigations and for determining whether applicants qualify for benefits under the New Jersey Medicaid or NJ FamilyCare program. Notes N.J. Adm…

Program manuals and other policy issuances, which affect the public, including the Medicaid Agent's rules and regulations governing eligibility, need and amount of assistance, beneficiary's rights and responsibilities, and services offered by the Medicaid Agent, shall be maintain…

(a) In order to facilitate public access, a current copy of material described in N.J.A.C. 10:49-15.1 shall be made available without charge to custodians who request the material for this purpose. (b) Custodians shall meet the following requirements:1. They shall be centrally lo…

(a) The specific policy materials necessary for an applicant or beneficiary (or his or her representative) to determine whether a fair hearing should be requested, or to prepare for a fair hearing, shall be reproduced without charge upon request. (b) The Medicaid Agent may impose…

This subchapter sets forth the basic parameters for demonstration projects established pursuant to N.J.S.A. 30:4D-1 et seq., as amended, and Section 1115 of the Social Security Act. Any time a demonstration project is implemented, New Jersey Medicaid providers will receive inform…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Principal" means all Division management personnel. "Project" means any demonstration project authorized through a waiver by the Secret…

The Medicaid Agent may implement projects directly or through contractual arrangements with any legal entity, including, but not limited to, corporations organized pursuant to Title 14A, New Jersey statutes (N.J.S.A. 14A:1-1 et seq.) and Title 15 revised statutes (R.S. N.J.S.A. 1…

(a) The following shall apply to all projects implemented under this subchapter: 1. All projects shall have approval from the United States Department of Health and Human Services; 2. All projects entered into under this subchapter shall be subject to all relevant State and Feder…

The Commissioner of Human Services and the Commissioner of Health and Senior Services, in addition to any and all other authority, shall have the authority to totally suspend or partially reduce payment in order to enforce compliance with this subchapter. Notes N.J. Admin. Code §…

(a) EPSDT is a federally mandated comprehensive child health program for Medicaid beneficiaries from birth through 20 years of age. The Omnibus Budget Reconciliation Act of 1989 (OBRA '89) codified EPSDT. Accordingly, the term "EPSDT Services" means the following: 1. EPSDT Screen…

HealthStart is a program which provides comprehensive maternity care services for all pregnant women (including those determined to be presumptively eligible) and child health care services for children (through two years of age) who are eligible for Medicaid benefits. Detailed i…

Medicaid beneficiaries are: those eligible for all services under the regular New Jersey Medicaid program (see N.J.A.C. 10:49-2.2 below); those eligible for a limited range of services under the Medically Needy program (see N.J.A.C. 10:49-2.3 below) and those eligible for a limit…

(a) Each Medicaid or NJ FamilyCare beneficiary, except Nursing Facility beneficiaries, will be issued a Health Benefits Identification (HBID) Card for identification purposes. Each beneficiary will be issued an HBID Emergency Services Letter to use as identification when seeking …

(a) In the event a beneficiary is unable to produce an HBID card or an HBID Emergency Services Letter or the provider wants more current eligibility data (see N.J.A.C. 10:49) and the beneficiary's Medicaid or NJ FamilyCare Eligibility Identification Number or the Card Control Num…

(a) Each Medicaid or NJ FamilyCare beneficiary will be issued a permanent, plastic identification card, the Health Benefits Identification (HBID) Card. The front of the card will include the beneficiary's name and a 16-digit Card Control Number (CCN). The back of the card will in…

(a) A New Jersey Medicaid provider may verify a person's Medicaid eligibility by using the identification information on either: 1. Health Benefits Identification (HBID) Card (see N.J.A.C. 10:49-2.15); 2. HBID Emergency Services Letter (see N.J.A.C. 10:49-2.15); or 3. "Validation…

Notes N.J. Admin. Code § 10:49-2.14 Recodified from N.J.A.C. 10:49-2.12 and amended by R.1997 d.354, effective 9/2/1997. See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a). Substituted references to beneficiary for references to recipient throughout; in (a)2, substituted "Medicaid Eligibi…

(a) The HBID Card (see Appendix, N.J.A.C. 10:49) is issued to: 1. Persons (aged, blind and disabled) determined by the Social Security Administration to be eligible for Supplemental Security Income (SSI) and their spouses, if eligible as an essential person; 2. Persons determined…

(a) The FD-34 Form, Validation of Eligibility (see Appendix, N.J.A.C. 10:49) identifies a Medicaid beneficiary who resides in a State or county institution. 1. The validation form shall be prepared and completed by the authorized Medicaid representative at the State or County ins…

(a) If a person has not applied for benefits, is unable to pay for services provided, and appears to meet the requirements for eligibility for the New Jersey Medicaid or NJ FamilyCare program, the provider shall encourage the person, or his or her representative, to apply for ben…

§ 10:49-2.18 - Reserved Notes N.J. Admin. Code § 10:49-2.18

For any alien who does not qualify for Medicaid or NJ FamilyCare-Plan A based on his or her alien status, and thus is potentially eligible for Medicaid or NJ FamilyCare-Plan A payment for emergency services only (see N.J.A.C. 10:49-5.4, Medicaid or NJ FamilyCare-Plan A Emergency …

(a) The eligibility rules for persons eligible under the regular New Jersey Medicaid program are included in N.J.A.C. 10:69, 10:70, 10:71, 10:72, 10:78 and 10:79. (b) The following groups may be eligible for medical and health services covered under the New Jersey Medicaid progra…

(a) The eligibility rules for persons eligible under the Medically Needy program are included in N.J.A.C. 10:70. (b) A Medicaid beneficiary under the Medically Needy program is limited to those medical services listed in N.J.A.C. 10:49-5.3. Services shall be provided in conjuncti…

(a) Individuals who may not be eligible for regular Medicaid benefits or Medical Needy may be eligible for selected services under the Home and Community-Based Services Waiver Programs under special eligibility rules. A brief overview of these programs and their rules may be foun…

(a) Children under the age of 19 whose family income does not exceed 133 percent of the Federal poverty level may be eligible for NJ FamilyCare-Plan A services pursuant to the eligibility rules at N.J.A.C. 10:78 and 10:79. (b) Children under the age of 19 with family incomes abov…

There are variations to the routine procedure for determining Medicaid eligibility. These variations are relevant to applying for eligibility for a newborn infant or for an inpatient upon admission to a hospital (see N.J.A.C. 10:49-2.7); to determining presumptive eligibility for…

(a) There are limited variations to the eligibility process for a newborn infant of a woman who is a Medicaid beneficiary. The policy and procedures follow: 1. Although both the mother and newborn infant may be Medicaid beneficiaries on the date of delivery, the newborn infant is…

(a) "Presumptive eligibility" means an expedited process whereby selected certified HealthStart Comprehensive Maternity Care providers make preliminary Medicaid eligibility determinations on behalf of pregnant women (see HealthStart in applicable Provider Services Manuals and N.J…

(a) Any person applying for Medicaid or NJ FamilyCare-Plan A benefits shall be asked if he or she has unpaid medical bills incurred within the three-month period immediately prior to the month of application for Medicaid or NJ FamilyCare-Plan A. 1. Medically Needy applicants (see…

The Medicaid/NJ FamilyCare Managed Care Program is a program under which Health Maintenance Organizations (HMOs) contract with the Department of Human Services to provide health care services to Medicaid beneficiaries. Requirements governing HMO providers and services are codifie…

Under the Medicaid/NJ FamilyCare Managed Care Program, HMOs are reimbursed through a capitation payment system whereby DMAHS pays an HMO a set amount for the services it provides to beneficiaries, as described in N.J.A.C. 10:74. Notes N.J. Admin. Code § 10:49-21.2 Amended by R.20…

(a) The Medicaid/NJ FamilyCare Managed Care Program is a mandatory enrollment program for AFDC and AFDC-related New Jersey Care pregnant women and children, Aged, Blind and Disabled (ABD) individuals without Medicare and NJ FamilyCare beneficiaries and is offered to the Medicare-…

(a) The following services are provided under the Medicaid/NJ FamilyCare Managed Care Program: 1. Primary and specialist care; 2. Preventive health care and counseling; 3. Early and Periodic Screening, Diagnostic and Treatment (EPSDT); 4. Audiology Services; 5. Organ transplants,…

(a) Home and Community-Based Services Waivers are five-year, renewable Federal waiver programs, prepared by the Division of Medical Assistance and Health Services in response to the Omnibus Budget Reconciliation Act of 1981 ( Section 2176, Public Law 97-35 and amendments under P.…

(a) The New Jersey Medicaid program has received waivers for the following programs: 1. Community Care Program for the Elderly and Disabled (CCPED); 2. Community Resources for Persons with Disability (CRPD); 3. AIDS Community Care Alternatives Program (ACCAP); 4. Traumatic Brain …

(a) The Division of Medical Assistance and Health Services provides oversight to the following Home and Community-Based Services Waivers, which are administered by the Division of Disability Services (DDS): Community Resources for Persons with Disability (CRPD); AIDS Community Ca…

(a) Any questions regarding the Community Resources for Persons with Disability (CRPD), AIDS Community Care Alternatives Program (ACCAP) or Traumatic Brain Injury (TBI) Program waivers may be directed to the Division of Disability Services, by calling 1-888-285-3036 or 1-609-292-…

Notes N.J. Admin. Code § 10:49-22.5 Repealed by R.2008 d.230, effective 8/4/2008. See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a). Section was "Community Care Program for the Elderly and Disabled (CCPED)".

Notes N.J. Admin. Code § 10:49-22.6 Amended by R.1997 d.354, effective 9/2/1997. See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a). Section recodified from N.J.A.C. 10:49-17.3; in (b), substituted "beneficiary" for "recipient"; in (c)1, 2 and 4 inserted N.J.A.C. references; and in (c)5, …

Notes N.J. Admin. Code § 10:49-22.7 Amended by R.1997 d.323, effective 8/4/1997. See: 29 N.J.R. 403(b), 29 N.J.R. 3487(a). In (b), amended internal cite; in (c)2, substituted "age of 13" for "age of five"; in (c)5, substituted "Individuals under the age of ... categorically needy…

Notes N.J. Admin. Code § 10:49-22.8 New Rule, R.1994 d.426, effective 8/15/1994. See: 26 N.J.R. 1566(a), 26 N.J.R. 3466(b). Amended by R.1997 d.354, effective 9/2/1997. See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a). Section recodified from N.J.A.C. 10:49-17.5; substituted references …