N.J. Admin. Code § 10:52A-3.1

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:52A-3.1 - Eligibility for APH services

(a) In order to be eligible for APH services, an individual shall first be determined to be an eligible beneficiary in the Medicaid/NJ FamilyCare program in accordance with the Division's rules.

(b) In order to be eligible for APH services, a beneficiary shall be at least 18 years of age or older, unless prior authorized by DMAHS.

(c) In order to be eligible for APH services, a beneficiary shall:

1. At the time of referral or as a result of psychiatric evaluation provided or arranged for, have at least one of the following primary DSM-IV-TR diagnoses on Axis I:

i. Schizophrenia or Other Psychotic Disorders (298.9, 295.xx);

ii. Major Depressive Disorder (296.xx);

iii. Bipolar Disorders (296.xx, 296.89);

iv. Delusional Disorder (297);

v. Schizoaffective Disorder (295.7);

vi. Anxiety Disorders (300.xx); or

vii. A covered psychiatric disorder diagnosis consistent with codes, Axis I-V of the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR as amended and supplemented, including some 301.XX Axis II codes if the personality disorder is considered in the severe range and the beneficiary is at high risk of psychiatric hospitalization;

2. Have disordered thinking or mood, bizarre behavior or psychomotor agitation or retardation to a degree that interferes with activities of daily living or abilities to fulfill family, student or work roles to such an extent that a structured intensive treatment program is needed and cannot adequately be addressed at a less restrictive level of care; the beneficiary also has a need for prescribed psychotropic medications or has a need for assistance with medication adherence; and

3. Have a Global Assessment of Functioning (GAF) Scale score of between 30 and 60, as found in the DSM-IV-TR page 32.

(d) In order to be eligible for APH services, a beneficiary shall be referred by the local designated screening center or psychiatric emergency service as a diversion from hospitalization or by an inpatient psychiatric facility if the treating psychiatrist or APN clearly justifies acute clinical need. Additionally, for a beneficiary to receive APH services, the beneficiary must receive, from the referring treatment team, a certification containing the clinical evidence necessary to support the referral, documenting the required specific conditions contained in (c)1, 2, and 3 above.

(e) In the case of a beneficiary who has previously been admitted to an APH program, in order to be eligible for APH services, the beneficiary shall be readmitted to an APH program only through a referral from the local designated screening center or psychiatric emergency service as a diversion from hospitalization or by an inpatient psychiatric facility if the treating psychiatrist or APN clearly justifies acute clinical need. Additionally, for a beneficiary to receive APH services, the beneficiary must receive, from the referring treatment team, a certification containing the clinical evidence necessary to support the referral, documenting the required specific conditions contained in (c)1, 2, and 3 above.

N.J. Admin. Code § 10:52A-3.1