N.J. Admin. Code § 10:49-5.10

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

Section 10:49-5.10 - Services available to beneficiaries eligible for NJ FamilyCare-Plan I

(a) The services listed below are available to beneficiaries eligible for NJ FamilyCare-Plan I, on a fee-for-service basis, when medically necessary:

1. Advanced practice nurse services;

2. Clinic services (services in an independent outpatient health care facility, other than a hospital, that provides covered ambulatory care services);

3. Emergency room services;

4. Family planning services including medical history and physical examination (including pelvic and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling.

i. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical and clinic) visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures shall not be covered by the NJ FamilyCare program;

5. Federally qualified health center primary care services;

6. Home health care services, limited to skilled nursing for a home bound beneficiary which is provided or supervised by a registered nurse, and home health aid services when the purpose of the treatment is skilled care; medical social services which are necessary for the treatment of the beneficiary's medical condition; and short-term physical, speech or occupation therapy with the same limitations described in (a)21 below;

i. Personal care assistant services are not covered;

7. Hospice services;

8. Hospital services--inpatient;

9. Hospital services--outpatient;

10. Laboratory (clinical);

11. Nurse-midwifery services;

12. Optometric services, including one routine eye examination per year;

13. Optical appliances, limited to one pair of glasses or contact lenses per 24 month period;

14. Organ transplant services which are non-experimental or non-investigational;

15. Prescription drug services, except that over-the-counter drugs are not covered;

16. Physician services;

17. Podiatric services, except that routine foot care is not covered;

18. Prosthetic appliances, limited to initial provision of prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease or injury or congenital defect;

i. Coverage includes repair and replacement when due to congenital growth;

19. Private duty nursing only when authorized by DMAHS;

20. Radiological services;

21. Outpatient rehabilitative services, including physical, occupational and speech therapy for non-chronic conditions and acute illnesses and injuries. Outpatient rehabilitation benefits are limited to treatment over a period of 60 consecutive business days per incident of illness or injury beginning with the first day of treatment, except that:

i. Speech therapy services rendered for treatment of delays in speech development, unless resulting from disease, injury or congenital defects are not covered;

22. Inpatient rehabilitation services, including physical, occupational and speech therapy for non-chronic conditions and acute illnesses and injuries;

23. Transportation services, limited to ambulance for medical emergency only;

24. Maternity and related newborn care;

25. Diabetic supplies and equipment;

26. Services for mental health or behavioral conditions;

i. Inpatient hospital services, including psychiatric hospitals, limited to 35 days per year;

ii. Outpatient benefits for short-term, outpatient evaluative and crisis intervention or home health mental health services, limited to 20 visits per year. When authorized by the Division of Medical Assistance and Health Services, inpatient benefit exchanges are allowed, as follows:

(1) One mental health inpatient day may be exchanged for up to four home health visits or four outpatient services, including partial care. This is limited to an exchange of up to a maximum of 10 inpatient days for a maximum of 40 additional outpatient visits.

(2) One mental health inpatient day may be exchanged for two days of treatment in partial hospitalization up to the maximum number of covered inpatient days.

iii. Inpatient and outpatient services for substance abuse are limited to detoxification;

iv. Adult mental health rehabilitation services provided in/by community residence programs (see N.J.A.C. 10:77A) are not eligible for payment under NJ FamilyCare-Plan I; and

v. NJ FamilyCare-Plan I beneficiaries under age 21 who are receiving services under the Division of Child Behavior Health Services, may be eligible for additional mental health and mental health rehabilitation services as authorized by the Contracted Systems Administrator. (See N.J.A.C. 10:49-5.10(c); and

27. Elective/induced abortion services.

(b) Unless listed in (a) above, no other services shall be covered by NJ FamilyCare-Plan I. Services which shall not be covered include, but shall not be limited to:

1. Services that are not medically necessary;

2. Private duty nursing, unless prior authorized by the Division;

3. Intermediate care facilities for mental retardation (ICF/MR);

4. Personal care assistant services;

5. Medical day care services;

6. Chiropractic services;

7. Dental services;

8. Orthotic devices;

9. Targeted case management for the chronically ill;

10. Christian Science sanitaria care and services;

11. Durable medical equipment;

12. Routine transportation, including non-emergency ambulance, invalid coach and lower mode (car, taxi, bus) transportation;

13. Hearing aid services;

14. Blood and blood plasma, except that administration, processing of blood, processing fees and fees related to autologous blood donations shall be covered;

15. Cosmetic services;

16. Nursing facility (long term care) services;

17. Special and remedial educational services;

18. Experimental and investigational services;

19. Infertility services;

20. Medical supplies, except that diabetic supplies shall be a covered service;

21. Rehabilitative services for substance abuse (methadone maintenance is not covered);

22. Weight reduction programs or dietary supplements;

23. Acupuncture and acupuncture therapy, except when performed as a form of anesthesia in connection with covered surgery;

24. Temporomandibular joint disorder (TMJ) treatment, including treatment performed by prosthesis placed directly in the teeth;

25. Recreational therapy;

26. Sleep therapy;

27. Court ordered services;

28. Thermograms and thermography;

29. Biofeedback;

30. Radial keratomy;

31. Respite care;

32. Custodial care;

33. EPSDT services; and

34. Adult mental health rehabilitation services provided in/by community residence programs (see N.J.A.C. 10:77A).

(c) Additional mental health and mental health rehabilitation services as listed below shall be available to beneficiaries under age 21 who are eligible for NJ FamilyCare-Plan I under fee-for-service receiving services from the Division of Child Behavioral Health Services. All services shall first be authorized by the Contracted Systems Administrator or other agent authorized by the Department of Human Services and shall be included in an approved plan of care.

1. Care coordination by a care management organization (CMO) (see N.J.A.C. 10:73);

2. Psychiatric services provided in an inpatient psychiatric hospital setting (see N.J.A.C. 10:52);

3. Mental health rehabilitation services provided in residential childcare facilities (as defined in N.J.A.C. 10:127 and licensed by DHS/DYFS), children's group homes (as defined in N.J.A.C. 10:128 and licensed by DHS/DYFS), or psychiatric community residences for youth (as defined in N.J.A.C. 10:37B and licensed by DHS/DMHS);

4. Behavioral assistance services for children, youth or young adults (see N.J.A.C. 10:77-4);

5. Mobil response and stabilization management services for children, youth or young adults under EPSDT (see N.J.A.C. 10:77-6); and

6. Intensive in-community mental health rehabilitation services for children, youth or young adults under EPSDT (see N.J.A.C. 10:77-5).

N.J. Admin. Code § 10:49-5.10

Special New Rule, R.2003 d.98, effective 1/31/2003.
See: 35 N.J.R. 1303(a).
Amended by R.2004 d.8, effective 1/5/2004.
See: 35 N.J.R. 2620(a), 35 N.J.R. 4204(a), 36 N.J.R. 189(a).
In (a)25, added iv; in (b), added 34.
Amended by R.2005 d.68, effective 2/22/2005.
See: 36 N.J.R. 379(a), 37 N.J.R. 659(a).
In (a), added 25v; added (c).
Amended by R.2005 d.98, effective 4/4/2005.
See: 36 N.J.R. 1158(a), 37 N.J.R. 1022(a).
Amended (c) and added 6.
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
Rewrote (a)1 and (a)19; added new (a)22, and recodified former (a)22 through (a)26 as (a)23 through (a)27.