N.J. Admin. Code § 10:50-1.4

Current through Register Vol. 56, No. 12, June 17, 2024

Section 10:50-1.4 - Services covered by the New Jersey Medicaid/NJ FamilyCare program

(a) All non-emergency medical transportation services shall be provided by an independent transportation broker under contract with the Department of Human Services. These services may include, but are not limited to:

1. Ground ambulance service (non-emergency);

2. Mobility assistance vehicle service;

3. Livery services, including modified livery services;

4. All lower-mode transportation services, including arranging for transportation by taxi, train, bus, plane, other public conveyance, or mileage reimbursement for the use of an individual's vehicle; and

5. Fixed wing air transportation services.

(b) All emergency ground transportation services and all rotary wing air ambulance services are provided by independent transportation providers enrolled in accordance with N.J.A.C. 10:49-3.2 and this chapter.

1. For beneficiaries enrolled in managed care, all emergency transports, including ground and rotary wing air transports, as well as their associated loaded mileage costs, shall be the responsibility of the managed care organization.

(c) Ground ambulance service is a covered service under the following conditions:

1. When such service is not free and available in the community;

2. When the service is the least expensive mode of transportation suitable to the individual's needs, as indicated in N.J.A.C. 10:50-1.6(a);

3. When the service is provided as specified in the rules of DOH at N.J.A.C. 8:40 or 8:41, as applicable;

4. When the use of any other method of transportation is medically contraindicated;

5. The ambulance crew shall comply with the duties of staff as specified in New Jersey State Department of Health and Senior Services rule N.J.A.C. 8:40-6.4;

6. Hospital-based Mobile Intensive Care Unit/Advanced Life Support (MICU/ALS) service and associated Ambulance/Basic Life Support (Ambulance/BLS) service are reimbursable by the Medicaid/NJ FamilyCare fee-for-service program only when billed on a single claim by the hospital providing the MICU/ALS service. Transportation companies providing the Ambulance/BLS service associated with a MICU/ALS run shall bill the hospital providing the MICU/ALS service and shall not bill the Medicaid/NJ FamilyCare program directly for this service.

i. A non-hospital-based MICU/ALS services provider acting on behalf of a hospital or consortium to provide MICU/ALS services to Medicaid/NJ FamilyCare beneficiaries may bill the Medicaid/NJ FamilyCare program directly for this service if the entity has received a Certificate of Need approval and has been licensed by DOH as an MICU/ALS service provider in accordance with N.J.A.C. 8:41-2. Existing prohibitions on additional reimbursement to nursing homes for such services and on reimbursement for services provided by volunteer ambulance organizations and existing provisions regarding Ambulance/BLS services remain intact. See N.J.A.C. 10:50-1.6(k) and 10:52-2.16(b)3.

7. The Division will pay, on behalf of eligible Medicaid/NJ FamilyCare beneficiaries who are also eligible for Medicare, the full amount of any Medicare deductible and coinsurance costs for covered MICU/ALS and Ambulance/BLS services provided to such beneficiaries. Code A0434 shall be used when submitting claims for such ambulance specialty care transport services. See N.J.A.C. 10:50-2.2(a).

(d) An air ambulance (fixed wing or rotary wing), under extenuating circumstances, may be used as a carrier to transport the sick, injured, or disabled Medicaid/NJ FamilyCare fee-for-service beneficiary.

1. The service is restricted to the emergency condition where transportation by air is medically considered the only acceptable form of travel and the conditions are such that its utilization is feasible. The Division retains the option to utilize this form of transportation in such situations where, at the program's discretion, it could represent a significant cost savings when compared to ground ambulance or mobility assistance vehicle service involving trips covering similarly long distances.

i. For fee-for-service beneficiaries needing rotary wing air ambulance services, these services shall be provided by independent air ambulance providers.

ii. For fee-for-service beneficiaries needing fixed wing air ambulance services, the air ambulance service shall be arranged through the transportation broker but reimbursed fee-for-service.

2. The service shall be provided as specified in the rules of DOH at N.J.A.C. 8:41, Advanced Life Support Services, Mobile Intensive Care Programs, Specialty Care Transport Services, and Air Medical Services.

N.J. Admin. Code § 10:50-1.4

Repeal and New Rule, R.1990 d.592, effective 12/3/1990.
See: 22 New Jersey Register 1513(a), 22 New Jersey Register 3620(c).
Section was "Livery Service."
Prior rulemakings are as follows:
Amended by R.1974 d.52, effective 3/15/1974.
See: 6 New Jersey Register 12(a), 6 New Jersey Register 150(a).
Amended by R.1980 d.93, effective 3/1/1980.
See: 12 New Jersey Register 21(a), 12 New Jersey Register 193(e).
New Rule, R.1988 d.262, effective 6/6/1988.
See: 19 New Jersey Register 2103(a), 20 New Jersey Register 1214(a).
Prior authorization was repealed.
Administrative Correction to (a)5.
See: 23 New Jersey Register 63(a).
Amended by R.1991 d.167, effective 4/1/1991.
See: 23 New Jersey Register 5(a), 23 New Jersey Register 1006(a).
In (a)3: added reference to Department of Health rules; deleted (a)3i-xix conditions because of inclusion of DOH rules. Also deleted (a)3xix (1)-(3) and (a)4, recodifying (a)5-7 as (a)4-6, with no change in text. In (c)2: deleted language regarding livery service from non-medical facilities.
Amended by R.1992 d.83, effective 2/18/1992.
See: 23 New Jersey Register 3619(a), 24 New Jersey Register 610(a).
Stylistic revisions throughout. In (a)5, deleted "or helicopter" and added "fixed wings." In (a)5i, added "ground" describing ambulance.
Amended by R.1992 d.447, effective 11/16/1992.
See: 24 New Jersey Register 2517(a), 24 New Jersey Register 4264(a).
Revised N.J.A.C. references in section. Added new (b)3v. In (c)3iii: revised vehicle age to eight model years from six model years.
Amended by R.1994 d.402, effective 8/1/1994 (operative August 15, 1994).
See: 26 New Jersey Register 1425(a), 26 New Jersey Register 3211(b).
Amended by R.1999 d.5, effective 1/4/1999.
See: 30 New Jersey Register 3625(a), 31 New Jersey Register 58(a).
Substituted references to beneficiaries for references to recipients throughout; substituted "mobility assistance vehicle" for "invalid coach" throughout; inserted references to NJ KidCare fee-for-service throughout; in (a), substituted a reference to the Division for a reference to the New Jersey Medicaid Program in the 5i, and inserted a reference to the NJ KidCare program in 6; and in (b)2, changed N.J.A.C. reference in the introductory paragraph.
Amended by R.1999 d.370, effective 11/1/1999.
See: 31 New Jersey Register 847(a), 31 New Jersey Register 3325(a).
Rewrote the section.
Amended by R.2000 d.501, effective 1/16/2001.
See: 32 New Jersey Register 2397(a), 33 New Jersey Register 322(a).
Added (d) and (e).
Amended by R.2002 d.170, effective 6/3/2002.
See: 34 New Jersey Register 635(a), 34 New Jersey Register 1925(a).
Rewrote the section.
Amended by R.2006 d.213, effective 6/19/2006.
See: 37 N.J.R. 4850(a), 38 N.J.R. 2713(a).
In (a)3, substituted "Specific Mobility Assistance Vehicle Service Requirements" for "Specific Transport Ambulance Requirements" and "Specific Basic Life Support Ambulance Service Requirements" for "Specific Emergency Ambulance Requirements"; substituted "6.4" for "6.21" in (a)5; in (a)6, substituted "wing or rotary wing" for "wings"; added (a)8; in (b)3, substituted "5" for "4" and inserted "Service" following "Vehicle"; substituted "5.4" for "4.8" in (b)5; and substituted "5.2(b)" for "4.1(b)" in (b)6.

Amended by 54 N.J.R. 620(b), effective 4/4/2022