N.J. Admin. Code § 10:59-1.4

Current through Register Vol. 56, No. 8, April 15, 2024

Section 10:59-1.4 - Non-covered items or services

(a) The New Jersey Medicaid/NJ FamilyCare program does not cover medical supplies and durable medical equipment under the following conditions:

1. A particular item of DME is not covered when, in the opinion of the Division, the item is not considered cost-effective or safe and effective for the treatment of a beneficiary's medical condition;

2. Items available without charge through programs of other public or voluntary agencies (for example: New Jersey State Department of Health and Senior Services, Heart Association, American Cancer Society) are not covered;

3. Supplies which are administered or directly furnished by practitioners or by home health agencies as part of per visit reimbursement are not covered separately;

4. Medical supplies, routinely used DME and other therapeutic equipment/supplies essential to furnish the services offered by a facility for the care and treatment of its residents are considered part of the NF's per diem and therefore, not covered. Examples of this type of equipment and supplies include, but are not limited to, the following:

i. Administration pumps;

ii. Aspirators;

iii. Canes;

iv. Communication equipment (life-safety devices including alarms and apnea monitors);

v. Crutches;

vi. Enteral nutritional supplements and related supplies (including IV poles and enteral pumps);

vii. Geri-chairs;

viii. Hospital beds (including mattress and side rails);

ix. IPPB machines;

x. IV supplies and related equipment;

xi. Lifts;

xii. Low end pressure relief systems, for example, mattress overlays, mattress replacements, powered mattress systems and air powered flotation beds;

xiii. Nebulizers;

xiv. Oxygen and related equipment;

xv. Traction apparatus;

xvi. Walkers;

xvii. Standard wheelchairs and accessories including adjustable leg rests and detachable armrests; and

xviii. Medical supplies, for example, incontinency pads, bandages, dressings, compresses, sponges, plasters, tapes, cellu-cotton or other types of pads used to save labor or linen, colostomy bags, hot water bags, thermometers, catheters, rubber gloves, and disposable syringes.

5. Exceptions to (a)4 above include certain durable medical equipment not routinely used in a nursing facility and which is required due to the medical need of the individual resident;

6. Items not meeting the definitions of medical supplies and DME outlined at 10:59-1.2, Definitions;

7. Delivery and shipping costs;

8. Services being provided to a beneficiary who loses eligibility, except as described at 10:49-5.4(a)9; and

9. Travel time, except for services provided by a pedorthist.

(b) Non-covered items include, but are not limited to, the following:

1. Bags (douche, enema, ice);

2. Beds (waterbeds);

3. Environmental control equipment, including electronic devices intended to control or alter the environment, such as lighting, telephones and appliances; air conditioners; humidifiers; dehumidifiers and air filtering systems with the exception of vaporizers and cool mist humidifiers;

4. Exercise equipment;

5. Eye patches;

6. First aid supplies or medicine chest items (gauze, adhesive tape, bandages, and cotton);

7. Footwear, orthopedic, and foot orthotics, except when attached to a brace or bar or when part of a normal post-operative or post-fracture treatment program, or when used to correct or adapt to gross foot deformities (see N.J.A.C. 10:57);

8. Hot water bottles;

9. Infant formula (standard);

10. Inflatable rubber invalid rings;

11. Lifts (chair or seat);

12. Mattresses (orthopedic or mattresses without FDA approval);

13. Nasal aspirators;

14. Pads (heating, hydrocollators, sanitary, thermophore);

15. Personal incidentals, including items for personal cleanliness, body hygiene, and grooming, for example, standard toothbrushes, mouthwashes, dentifrices, deodorant soaps, cosmetics, shaving items, and so forth;

16. Plastic gloves;

17. Protein nutritional supplements in which the quantity dispensed exceeds a 34-day supply;

18. Scales (bathroom);

19. Specialized infant formulas in which the quantity dispensed exceeds a 34-day supply;

20. Stainless steel bedpans or urinals;

21. Syringes (bulb, enema);

22. Thermometers (axillary, ear, oral, rectal); and

23. Tongue blades (sterile, non-sterile).

N.J. Admin. Code § 10:59-1.4

Amended by R.1997 d.251, effective 6/16/1997.
See: 28 N.J.R. 2481(a), 28 N.J.R. 3221(a), 29 N.J.R. 2690(a).
Inserted new (b)17 and 19, and recodified former (b)17 as (b)18, and (b)18 through 21 as (b)20 through 23.
Amended by R.2001 d.64, effective 2/20/2001.
See: 32 N.J.R. 4098(a), 33 N.J.R. 661(c).
In (a)1 and (a)8, substituted references to beneficiaries for recipients, and also in (a)8, updated an N.J.A.C. reference.
Amended by R.2006 d.297, effective 9/5/2006.
See: 38 N.J.R. 1371(b), 38 N.J.R. 3578(a).
In the introductory paragraph of (a), inserted "/NJ Family Care".