N.J. Admin. Code § 10:49-5.6

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:49-5.6 - Services available and unavailable to beneficiaries eligible for, or who are presumptively eligible for, NJ FamilyCare-Plan B or C

(a) Except for the exceptions at 10:79-6.5, which concern services for newborns enrolling into NJ FamilyCare-Plan C, the services listed below are available to beneficiaries eligible for NJ FamilyCare-Plan B or C, through an HMO selected by the NJ FamilyCare-Plan B or C beneficiary.

1. Advance practice nurse services;

2. Audiology services;

3. Chiropractic services;

4. Clinic services (services in an independent outpatient health care facility, other than hospital, that provides services such as, dental, optometric, ambulatory surgery, etc.);

5. Clinical nurse specialist services;

6. Dental services;

7. Durable medical equipment;

8. Early and periodic screening, and diagnosis medical examinations, dental, vision and hearing services, and lead screening services. Includes only those treatment services identified through the examination that are available under the HMO contract or covered fee-for-service program;

9. Emergency room services;

10. 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;

i. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical and clinic) visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures are not covered by the New Jersey Medicaid or NJ FamilyCare program.

11. Federally qualified health center primary care services;

12. Hearing aid services;

13. Home health care services;

i. Exception: personal care assistant services;

14. Hospice services;

15. Hospital services--inpatient:

i. General hospitals;

ii. Special hospitals; and

iii. Rehabilitation hospitals;

16. Hospital services--outpatient;

17. Laboratory (clinical);

18. Medical supplies and equipment;

19. Nurse-midwifery services;

20. Optometric services;

21. Optical appliances;

22. Organ transplant services, donor and recipient costs;

23. Prescription drug services;

24. Physician services;

25. Podiatric services;

26. Prosthetic and orthotic devices;

27. Private duty nursing;

28. Radiological services; and

29. Transportation services, limited to ambulance, MICU's and invalid coach.

(b) The services listed below are available to beneficiaries eligible for NJ FamilyCare-Plan B or C under fee-for-service:

1. Religious non-medical health care institution care and services;

2. Clinic services (services in an independent outpatient health care facility, other than hospital) for family planning services, mental health or substance abuse treatment services;

3. Elective/induced abortion services;

4. Emergency room services for treatment of mental health disorder or for substance abuse;

5. 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;

i. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical and clinic) visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures are not covered;

6. Hospital services--inpatient, for:

i. Psychiatric hospitals;

ii. Inpatient psychiatric programs for children 19 years of age and under; and

iii. Acute care or special hospital services if provided for mental health or substance abuse services;

7. Mental health services provided by practitioners, such as physicians, psychologists, and certified nurse practitioners/clinical nurse specialists;

i. NJ FamilyCare-Plan B and C beneficiaries under age 19 who are receiving services under the Division of Child Behavioral Health Services may be eligible for additional mental health and mental health rehabilitation services as authorized by the Contracted Systems Administrator (CSA). (See 10:49-5.6(d).)

8. Outpatient hospital services for family planning, mental health and substance abuse treatment services;

9. Rehabilitative services, including physical, occupational and speech therapy, limited to 60 days per type of therapy per year;

10. Sex abuse examinations;

11. Substance abuse services provided by practitioners, including physicians, psychologists, advanced practice nurses; and

12. Targeted case management services for the chronically ill.

(c) Services not covered under Plan B and C shall be as follows:

1. Unless listed in (a) and (b) above, no other services are covered by NJ FamilyCare-Plan B or C.

2. Services not covered shall include, but shall not be limited to:

i. Nursing facility services, except the Medicare Part A copayments for the first 30 days of skilled nursing care;

ii. Intermediate care facilities for mental retardation (ICFs/MR);

iii. Personal care services;

iv. Medical day care services;

v. Lower mode transportation;

vi. Any item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished at the direction or on the prescription of a physician, individual or entity, during the period when such physician, individual or entity is excluded from participation in the Medicaid and NJ FamilyCare programs, and when the physician, individual or entity furnishing such item or service has received written notice from the Division that the physician, individual or entity has been excluded from participation in the Medicaid and NJ FamilyCare programs;

vii. Programs for Assertive Community Treatment (PACT) services; and

viii. Adult mental health rehabilitation services provided in/by community residence programs (see N.J.A.C. 10:37A and 10:77A).

(d) Additional mental health and mental health rehabilitation services as listed below may be available to beneficiaries under age 19 who are eligible for NJ FamilyCare-Plan B or C under fee-for-service who are receiving services from the Division of Child Behavioral Health Services. All services shall first be authorized by the CSA or other agent authorized by the Department of Human Services and shall be included in an approved plan of care.

1. Care coordination by a care management organization (CMO) (see N.J.A.C. 10:73);

2. Mental health rehabilitation services provided in residential childcare facilities (as defined in N.J.A.C. 10:127 and licensed by DHS/DYFS), children's group homes (as defined in N.J.A.C. 10:128 and licensed by DHS/DYFS), or psychiatric community residences for youth (as defined in N.J.A.C. 10:37B and licensed by DHS/DMHS);

3. Behavioral assistance services for children, youth or young adults under EPSDT (see N.J.A.C. 10:77-4 );

4. Mobil response and stabilization management services for children, youth or young adults under EPSDT (see N.J.A.C. 10:77-6 ); and

5. Intensive in-community mental health rehabilitation services for children, youth or young adults (see N.J.A.C. 10:77-5 ).

(e) All presumptively eligible NJ FamilyCare-Plan B and C beneficiaries shall be eligible to receive all the services specified in (a) and (b) above for fee-for-service during the presumptive eligibility period, which shall include the services that are otherwise only available through the managed care organizations. The provision of the managed care services fee-for-service shall be limited to the presumptive eligibility period. The additional mental health services listed in (d) above may be available to children, youth or young adults under the age of 19 who are receiving services from the Division of Child Behavioral Health Services during their period of presumptive eligibility.

N.J. Admin. Code § 10:49-5.6

New Rule, R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 with changes, effective 9/21/1998.
Amended by R.2000 d.266, effective 7/3/2000.
See: 32 N.J.R. 159(a), 32 N.J.R. 2493(a).
Added (d).
Amended by R.2001 d.144, effective 5/7/2001.
See: 32 N.J.R. 4387(a), 33 N.J.R. 1378(b).
Added (c)2vi.
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
In (b)1, substituted "Religious non-medical health care institution" for "Christian Science sanatoria"; in (c), added "for youth (as defined in N.J.A.C. 10:37B and licensed by DMHS); and" at the end of vi and added vii.
Amended by R.2003 d.89, effective 3/3/2003.
See: 34 N.J.R. 1593(a), 35 N.J.R. 1281(a).
Rewrote (c)2.
Amended by R.2003 d.479, effective 12/15/2003.
See: 35 N.J.R. 2146(a), 35 N.J.R. 5584(a).
In (c)2vi, added "or behavioral assistance services for children/youth or young adults (see N.J.A.C. 10:77-4)" to the end of the paragraph.
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).
In (c)2, added ix.
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), added a new 1, recodified existing 1 as 2, deleted existing 2; in (b), substituted "advanced practice nurses" for "certified nurse practitioners/clinical nurse specialists" in 7 and 10.
Amended by R.2005 d.68, effective 2/22/2005.
See: 36 N.J.R. 379(a), 37 N.J.R. 659(a).
In (b), added 7i; rewrote (c)2; added (d); recodified existing (d) as (e) and added the third sentence.
Amended by R.2005 d.98, effective 4/4/2005.
See: 36 N.J.R. 1158(a), 37 N.J.R. 1022(a).
Rewrote (d) and (e).
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
In (a)8, inserted "medical" and ", and lead screening services"; deleted former (a)12; recodified former (a)13 through 29 as (a)12 through 28; rewrote (a)22, in (a)28 and (b)6ii, inserted "and" at the end; deleted former (a)30; recodified former (a)31 as (a)29; in the introductory paragraph of (b)6, substituted ", for:" for a semicolon at the end; deleted (b)6iv and (b)6iv(1); deleted former (b)8; recodified former (b)9 as new (b)8; added new (b)9 and (b)10; and recodified former (b)10 and (b)11 as (b)11 and (b)12.