N.J. Admin. Code § 10:155-1.14

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:155-1.14 - Eligible health services

(a) Categories of incurred expenses, which are related to the medical care of a child with an illness or condition eligible for consideration in assessing whether a family has reached its eligibility standard include, but are not limited to, the following:

1. Physician-authorized ancillaries (labs, x-rays);

2. Specialized pediatric ambulatory care, including physician-authorized rehabilitative therapies (for example, speech, occupational, and physical), physician-authorized care for treatment of substance use disorders and behavioral health care, dental care, eye care, and chiropractic care;

3. Care in an acute hospital in New Jersey (treatment for acute and chronic conditions and treatment of substance use disorders and behavioral health conditions);

4. Care in acute hospitals in other states (treatment for acute and chronic conditions and treatment of behavioral health conditions, including substance use disorders);

5. Physicians and nursing services, including immunization services, in all settings;

6. Care in specialty hospitals (for example, rehabilitative, psychiatric);

7. Long term care (respite care, hospice care, residential care, or other care);

8. Home health care (physician-authorized home health aide, physician-authorized public health nurse, physician-authorized private duty nurse or other care);

9. Pharmaceuticals (physician-authorized Federal Drug Administration approved over-the-counter and prescription drugs related to the medical condition and physician-authorized Federal Drug Administration approved medical formulas);

10. Disposable medical supplies (physician-authorized over-the-counter and prescribed supplies);

11. Durable medical equipment (for example, physician-authorized ventilators, prostheses);

12. Home modification that is related to the medical condition of the child at the time the expenses were incurred;

13. Purchase of a specialized, modified vehicle and any subsequent modifications that are related to the medical condition of the child at the time the expenses were incurred;

14. Experimental medical treatment/experimental drugs in connection with an FDA-approved clinical trial, which are provided by licensed health care providers. Applications involving experimental treatment/experimental drugs may require additional review;

15. Reasonable funeral expenses, including professional services, arrangement and supervision, facility charges, transportation (hearse and one family car), casket costs and vault or cremation urn. Excluded items include, but are not limited to, flowers, prayer cards, books, headstones, name plates and soloist/organist; and

16. Family transportation and travel-related expenses including, but not limited to, mileage allowance, tolls, parking receipts, and temporary shelter costs related to the medical condition.

(b) Fifty percent of a health coverage premium, including supplemental and dependent coverage that is paid by a family, not to exceed 50 percent of total eligible expenses, when accompanied by eligible expenses in (a) above shall be counted toward calculating eligibility, but shall not be considered an eligible expense for reimbursement from the Fund.

N.J. Admin. Code § 10:155-1.14

Adopted by 50 N.J.R. 1278(a), effective 5/21/2018