N.J. Admin. Code § 10:52A-3.2

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

Section 10:52A-3.2 - Eligibility for PH services

(a) In order to be eligible for PH services, an individual shall first be determined to be an eligible beneficiary in the Medicaid/NJ Family Care program in accordance with the Division's eligibility rules at N.J.A.C. 10:49, 10:69, 10:71, 10:72, 10:78 and 10:79.

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

(c) In order to be eligible for PH services, a beneficiary shall at the time of referral:

1. Have a primary diagnosis as set forth in N.J.A.C. 10:52A-3.1(c)1;

2. Have impaired functioning, which necessitates learning critical skills in order to achieve valued community roles and community integration in at least one of the following domains on a continuing, intermittent basis for at least one year or have recently decompensated to a significantly impaired status:

i. Maintenance of personal self-care;

ii. Development of interpersonal relationships;

iii. Ability to work;

iv. Ability to receive an education;

v. Ability to live in the community; or

vi. Ability to acquire or maintain safe, affordable housing when at risk of requiring a more restrictive living situation; and

3. Have a Global Assessment of Functioning (GAF) Scale scores of between 30 and 70, as set out in the DSM-IV-TR page 32.

(d) In order to be eligible for PH services, a beneficiary shall be referred by the APH or be significantly impaired such that a need for PH exists, and receive from the interdisciplinary treatment team certification containing the clinical evidence to justify the necessity for a beneficiary to receive PH services, documenting the beneficiary's specific conditions contained in (c)1, 2 and 3 above.

N.J. Admin. Code § 10:52A-3.2