N.J. Admin. Code § 10:72-3.10

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:72-3.10 - Emergency services for aliens and limited prenatal care for aliens

(a) Any alien who is not an eligible alien as specified in N.J.A.C. 10:72-3.2(c) and (d), shall be ineligible for Medicaid benefits. Any such alien shall be, if a resident of New Jersey and if he or she meets all other Medicaid eligibility requirements, entitled to Medicaid coverage for the treatment of an emergency medical condition only.

1. An emergency medical condition is one of sudden onset that manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

i. Placing the patient's health in serious jeopardy;

ii. Serious impairment to bodily functions; or

iii. Serious dysfunction of any bodily organ or part.

2. An emergency medical condition shall include all labor and delivery for a pregnant woman. It does not include routine prenatal or post-partum care.

3. Services related to an organ transplant procedure are not covered under services available for treatment of an emergency medical condition.

(b) Limited prenatal care shall be provided by the Division to alien pregnant women who would be eligible for New Jersey Care ... Special Medicaid Programs or NJ FamilyCare services but for their immigration status. Services available through NJSPCP shall be limited to pregnancy-related services provided at a clinic or at a hospital, and shall include primary care, radiology, and clinical laboratory services or, in the case of radiology and clinical laboratory services, ordered by a clinic. In addition, pregnancy-related pharmaceuticals dispensed at a clinic or a hospital are covered. No other services shall be provided.

1. Services available through NJSPCP shall be limited to pregnancy-related services provided at a clinic or at a hospital, including primary care, radiology, and clinical laboratory services, or, in the case of radiology and clinical laboratory services, ordered by a clinic. In addition, pregnancy-related pharmaceuticals dispensed at a clinic or a hospital shall be covered. No other services shall be provided. Services eligible for reimbursement shall be directly related to the beneficiary's primary diagnosis. For dates of service before October 1, 2015, the eligible beneficiary's primary diagnosis shall be one or more of the pregnancy-related diagnostic codes: 640 through 648.9 or V22 through V23.89, as found in the ICD-9-CM (International Classification of Diseases). For dates of service on or after October 1, 2015, the eligible beneficiary's primary diagnosis for limited prenatal care shall be one or more of the pregnancy-related diagnostic codes: O09 through O16, O20 through O21, O23 through O26, O28 through O31, O36, O44 through O48, or Z33 through Z34, as found in the ICD-10-CM (International Classification of Diseases).

i. Labor and delivery services shall not be covered by the NJSPC program, but may be provided through the Medical Emergency Payment Program for Aliens, in accordance with the provisions of N.J.A.C. 10:49-5.4.

2. Eligible services, as described in (b)1 above, shall be reimbursed if the services were rendered to an eligible individual on or after July 1, 2001 and before the termination of the NJSPC program.

3. When the appropriated funds have been expended, the program will terminate.

N.J. Admin. Code § 10:72-3.10

Amended by 48 N.J.R. 962(b), effective 6/6/2016