N.J. Admin. Code § 10:60A-3.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:60A-3.1 - Functional assessment of Medicaid/NJ FamilyCare beneficiaries

(a) PMDC admission and Medicaid/NJ FamilyCare reimbursement for PMDC shall be contingent upon a Medicaid/NJ FamilyCare beneficiary's receipt of authorization from the Department pursuant to N.J.A.C. 10:60A-3.4 and the performance of an initial functional assessment of the Medicaid/NJ FamilyCare beneficiary by professional staff designated by the Department that results in a determination that the Medicaid/NJ FamilyCare beneficiary is a medically complex and/or technology-dependent child who requires PMDC facility services pursuant to N.J.A.C. 10:60A-5.

(b) The initial functional assessment shall consist of:

1. An interview with the Medicaid/NJ FamilyCare beneficiary's parent(s);

2. Observation of the Medicaid/NJ FamilyCare beneficiary;

3. A review of the Medicaid/NJ FamilyCare beneficiary's medical status in the past six months with attention to changes in symptoms, feeding, medications, or activity and intervening events, such as hospitalization or acute illness;

4. A detailed review of the skilled nursing needs of the Medicaid/NJ FamilyCare beneficiary during a typical 24-hour period, including, but not limited to:

i. Dependence on mechanical ventilation;

ii. The presence of a tracheostomy requiring frequent suctioning;

iii. The presence of pulmonary insufficiency requiring positioning, suctioning and/or chest physical therapy;

iv. The need for enteric feeding complicated by either gastroesophageal reflux and risk of aspiration or by a need for frequent venting of the tube, or both;

v. The presence of diabetes requiring frequent blood sugar testing and medication adjustment;

vi. The presence of a seizure disorder manifested by frequent and prolonged seizures requiring emergency medication administration;

vii. The presence of moderate persistent or severe persistent asthma requiring nebulizer treatments more than twice a day and frequent medication adjustment in accordance with the Asthma Guidelines; and/or

viii. The need for intermittent bladder catheterization;

5. A detailed review of all other elements of the Medicaid/NJ FamilyCare beneficiary's care needs during a typical 24-hour period, including a review of:

i. Who provides care to the beneficiary;

ii. The types of care the beneficiary receives;

iii. The locations at which the beneficiary receives each type of care; and

iv. If the beneficiary receives private-duty nursing, the quantity of time (that is, the number of hours) during which, and the times and locations at which, the beneficiary receives private-duty nursing;

6. An evaluation and consideration of information about the Medicaid/NJ FamilyCare beneficiary's medical, rehabilitative, developmental, and psychosocial needs received from the nursing director, the child's primary health care provider, and/or other healthcare professionals who have current and relevant knowledge of the Medicaid/NJ FamilyCare beneficiary; and

7. A review of the family composition, ages of any siblings residing with the Medicaid/NJ FamilyCare beneficiary, and the available community support.

(c) Based on the results of the functional assessment performed pursuant to (b) above, professional staff designated by the Department shall make a determination whether the Medicaid/NJ FamilyCare beneficiary is a technology-dependent child and/or a medically complex child and, therefore, is clinically eligible to receive PMDC services.

(d) Professional staff designated by the Department performing the functional assessment shall document, in writing, the results of the functional assessment, which writing shall contain, at a minimum, the following:

1. Medicaid/NJ FamilyCare beneficiary identification information, including name, date of birth, sex, address, telephone number, and Medicaid/NJ FamilyCare identification number;

2. A narrative of the Medicaid/NJ FamilyCare beneficiary's current medical status, past medical history, and any additional considerations;

3. A determination that the Medicaid/NJ FamilyCare beneficiary is or is not a technology-dependent child and/or a medically complex child and a written summary of findings supporting that determination; and

4. The name and title of the professional staff designated by the Department who performed the functional assessment and the date the functional assessment was completed.

(e) Professional staff designated by the Department shall perform a functional assessment:

1. Prior to initial provision of services to a Medicaid/NJ FamilyCare beneficiary;

2. When the interdisciplinary plan of care reflects a change in status that may alter a PMDC beneficiary's eligibility to receive PMDC; and

3. At least every 180 days after the initial and each subsequent assessment.

N.J. Admin. Code § 10:60A-3.1

Amended and Recodified from 10:166-3.1 by 56 N.J.R. 262(a), effective 2/20/2024