N.J. Admin. Code § 10:49-24.3

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:49-24.3 - Services available under the Work First New Jersey/General Assistance (WFNJ/GA) program which shall be processed by the fiscal agent

(a) The Medicaid/NJ FamilyCare fiscal agent shall reimburse only those WFNJ/GA program covered services listed below in this subsection when provided in an ambulatory setting, except as specified in 10:49-24.4(a)14. These services include:

1. Advanced practice nurse services (for specific information, see N.J.A.C. 10:58A);

2. Abortion (elective/induced);

3. Acupuncture;

4. ADDP covered anti-retroviral drugs;

5. Ambulance;

6. Ambulatory surgery;

7. Blood and blood plasma;

8. Case management services for the chronically mentally ill (for specific information, see N.J.A.C. 10:73);

9. Chiropractic services (for specific information, see N.J.A.C. 10:68);

10. Clinic services (services in an independent outpatient health care facility, ambulatory care facility, ambulatory surgical center, ambulatory care/family planning/surgical facility, drug treatment center, Federally qualified health center, free-standing end-stage renal dialysis facility), such as dental, family planning, laboratory, mental health, minor surgery, personal care assistance, podiatry, radiology, rehabilitation, or vision care (for specific information, see N.J.A.C. 10:66), except that:

i. Professional services provided by a residential alcohol or drug abuse treatment facility to an individual residing in the facility shall not be processed;

11. Dental services, including dentures (for specific information, see N.J.A.C. 10:56);

12. Durable medical equipment;

13. Family planning services, including medical history and physical examination (including pelvic and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling, except that:

i. Services provided primarily for the diagnoses and treatment of infertility, including sterilization reversals, and related office (medical and clinic) visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures shall not be processed.

14. Hearing aid services (for specific information, see N.J.A.C. 10:64);

15. Home care services, including home health care (for specific information, see N.J.A.C. 10:60);

16. Hospice services, except those provided in a nursing home facility (for specific information, see N.J.A.C. 10:53A).

i. The following hospice services shall be processed under the WFNJ/GA program:

(1) Routine home care rate;

(2) Continuous home care rate; and

(3) Drugs and biologicals co-payment (rendered in places other than long-term care facilities).

ii. The following hospice services shall not be processed under the WFNJ/GA program:

(1) Inpatient respite care rate;

(2) General inpatient care;

(3) Therapeutic leave days;

(4) Bed hold days;

(5) Hospice Respite Care; and

(6) Room and board;

17. Laboratory (clinical) services (for specific information, see N.J.A.C. 10:61);

18. Medical supplies and equipment (for specific information, see N.J.A.C. 10:59);

19. Mental health services (for specific information, see N.J.A.C. 10:66);

20. Non-maternity nurse-midwifery services, such as family planning (for specific information, see N.J.A.C. 10:58);

21. Optometric services (for specific information, see N.J.A.C. 10:62);

22. Optical appliances (for specific information, see N.J.A.C. 10:62);

23. Personal care assistant;

24. Thermograms;

25. Thermography;

26. Pharmaceutical services (for specific information, see N.J.A.C. 10:51);

i. Prior authorization shall be required where patterns of medically harmful or inappropriate use of specific drugs, therapeutic drug classes, enteral nutritional supplements, needles and syringes have been identified, or for claims originating in certain municipalities where such patterns have been identified; and

ii. Effective with claims for dates of service on or after August 7, 2000, the Division's processing of claims for certain antiretroviral drugs shall be accomplished under the AIDS Drug Distribution Program (ADDP), administered by the Department of Health and Senior Services (DHSS), except for emergency supplies as authorized under WFNJ/GA to avert a lapse in treatment. These drugs shall include, but may not be limited to: thymidine nucleosides, thymidine analogs, protease inhibitors, nucleoside analog reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, carbocyclic nucleoside analogs, purine nucleoside analogs of deoxyadenosine, and primidine nucleoside analogs;

27. Physician services (for specific information, see N.J.A.C. 10:54);

28. Podiatric services (for specific information, see N.J.A.C. 10:57);

29. Prosthetic and orthotic devices (for specific information, see N.J.A.C. 10:55);

30. Psychological service (for specific information, see N.J.A.C. 10:67);

31. Radiological services (for specific information, see N.J.A.C. 10:54);

32. Rehabilitative services (for specific information, see N.J.A.C. 10:66). Payments shall be made to eligible Medicaid providers only. No payment shall be made to privately practicing therapists who are not Medicaid providers. Rehabilitative services include:

i. Physical therapy;

ii. Occupational therapy;

iii. Speech-language pathology services; and

iv. Audiology services;

33. Transportation services which include ambulance and mobility assistance vehicle (for specific information, see N.J.A.C. 10:50 and 10:66);

34. Medicare coinsurance and/or deductible for services specified in (a)1 through 23 above, if otherwise reimbursed by the New Jersey Medicaid program; and

35. Inpatient services provided by Mt. Carmel GuildHospital located in Newark, New Jersey.

(b) Adult mental health rehabilitation services provided in/by community residence programs (see N.J.A.C. 10:77A) shall not be eligible for reimbursement by DMAHS, but may be eligible for reimbursement by the Division of Mental Health Services (DMHS).

N.J. Admin. Code § 10:49-24.3

Special amendment, R.2002 d.214, effective 6/10/2002.
See: 34 N.J.R. 2338(a).
Rewrote the section.
Amended by R.2004 d.8, effective 1/5/2004.
See: 35 N.J.R. 2620(a), 35 N.J.R. 4204(a), 36 N.J.R. 189(a).
Added (b).
Amended by R.2004 d.334, effective 9/7/2004.
See: 36 N.J.R. 312(a), 36 N.J.R. 4136(a).
In (a), inserted "/NJ FamilyCare" following "Medicaid" in the introductory paragraph, added a new 1, recodified existing 1 through 7 as 2 through 8, and deleted existing 8.
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
In the introductory paragraph of (a)16, substituted a period for a semicolon at the end; in the introductory paragraphs of (a)16i and (a)16ii, deleted ", with corresponding HCPCS,"; in (a)16i(1) through (a)16i(3) and (a)16ii(1) through (a)16ii(6), deleted the HCPCS code from the beginning; and in (a)16i(3), substituted "long-term" for "long term".