N.J. Admin. Code § 10:49-5.2

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

Section 10:49-5.2 - Services available to beneficiaries eligible for, or children who are presumptively eligible for, the regular Medicaid and NJ FamilyCare-Plan A programs

(a) The services listed below shall be provided under the managed care program:

1. Advanced practice nurse services;

2. Chiropractic services;

3. Clinic services in an independent outpatient health care facility, other than hospital, that provides Family Planning, Dental, Optometric, Ambulatory Surgery services, or FQHCs;

4. Dental services;

5. Early and Periodic Screening, Diagnosis, and Treatment for beneficiaries under age 21 (EPSDT): A preventative health care program for beneficiaries under age 21 designed for early detection, diagnosis and treatment of correctable abnormalities. This program supplements the general medical services otherwise available;

6. 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 are not covered by the New Jersey Medicaid or NJ FamilyCare-Plan A program.

7. Hearing aid services;

8. Home care services (home health care except for the Aged, Blind and Disabled population (ABD));

9. Hospice services including room and board services in a nursing facility (available to dually eligible Medicare/Medicaid or dually eligible Medicare/NJ FamilyCare-Plan A beneficiaries);

10. Hospital services--inpatient:

i. General acute care hospitals;

ii. Special hospitals; and

iii. Rehabilitation hospitals;

11. Hospital services--outpatient;

12. Laboratory (clinical);

13. Medical supplies and durable medical equipment;

14. Mental health and substance abuse services for clients of the Division of Developmental Disabilities (DDD), excluding partial care and partial hospitalization services;

15. Nurse-midwifery services;

16. Optometric services;

17. Optical appliances;

18. Prescription drugs (except for ABD and all other dual eligible beneficiaries);

19. Physician services;

20. Podiatric services;

21. Prosthetic and orthotic devices;

22. Radiological services;

23. Non-lower mode transportation services, which include ambulance, mobility assistance vehicle, and mobile intensive care units;

24. Audiology services;

25. Organ transplants, recipient and donor costs;

26. Emergency medical care; and

27. Treatment for conditions categorized as altering the mental status of an individual and that are organic in nature.

(b) The following services are available on a fee-for-service basis:

1. Case management services (Mental Health Program);

2. Religious non-medical health care services, (see Hospital Services Manual);

3. Environmental lead inspection services-rehabilitative services;

4. Medical day care services;

5. Mental health services, including partial care and partial hospitalization services;

6. Mental health rehabilitation services including:

i. Residential child care facilities (see N.J.A.C. 10:77 and 10:127);

ii. Children's group homes (see N.J.A.C. 10:77 and 10:128);

iii. Psychiatric community residences for youth (see N.J.A.C. 10:37B and 10:77);

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

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

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

vii. Programs for Assertive Community Treatment (PACT) Services (see N.J.A.C. 10:37J and 10:76); and

viii. Adult mental health rehabilitation services provided in/by community residence programs (see N.J.A.C. 10:37A and 10:77A);

7. Nursing facility services, including intermediate care facilities for the mentally retarded.

i. Any additional Intermediate Care Facility/Mental Retardation (ICF/MR) beds or new ICF/MR facilities shall be approved by the Division of Developmental Disabilities (DDD) prior to application for reimbursement as a Medicaid/NJ FamilyCare provider;

8. Rehabilitative services (Payments are made to eligible Medicaid/NJ FamilyCare-Plan A providers only. No payment is made to privately practicing therapists).

i. Physical therapy, as provided by a home health agency, independent clinic, nursing facility, hospital outpatient department, or in a physician's office.

ii. Occupational therapy, as provided by a home health agency, independent clinic, nursing facility, or hospital outpatient department.

iii. Speech-language pathology services, as provided by a home health agency, independent clinic, nursing facility, hospital outpatient department, or in a physician's office.

iv. School based rehabilitation services under EPSDT;

9. Personal care assistance services;

10. Elective, induced abortions and related services;

11. Lower mode transportation services;

12. Sex abuse examinations;

13. Family planning services and supplies when furnished by a non-HMO, that is a Medicaid/NJ FamilyCare participating provider;

14. Home health care services for the ABD population;

15. Prescription drugs (legend and non-legend) covered by the Medicaid program) for the ABD population and all other dual eligible individuals;

16. Mental health services for enrollees who are not clients of the Division of Developmental Disabilities (DDD), including atypical antipsychotic medications;

17. Substance abuse services, including diagnosis, treatment, detoxification;

18. Methadone, Suboxonee and Subutex maintenance and administration for the treatment of substance abuse;

19. Inpatient psychiatric services, except for residential treatment centers, for beneficiaries under age 21 or age 65 and older if such services are:

i. Provided under the direction of a physician;

ii. In a facility or program that is accredited by the Joint Commission on Accreditation of Health Care Organizations; and

iii. Meets all Federal and State requirements.

20. Inpatient psychiatric programs for children 21 years of age and under; and

21. All services offered under approved waiver and demonstration programs.

(c) All Medicaid and NJ FamilyCare Plan A beneficiaries shall be eligible to receive all of the services specified in (a) above on a fee-for-service basis during the presumptive eligibility period, and through the time that they select and are enrolled into a managed care organization, if managed care is applicable.

N.J. Admin. Code § 10:49-5.2

Amended by R.1994 d.600, effective 12/5/1994.
See: 26 N.J.R. 3345(a), 26 N.J.R. 4762(a).
Amended by R.1997 d.354, effective 9/2/1997.
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
Amended section name; substituted "beneficiaries" for "recipients" throughout; in (a)4, inserted reference to FQHCs; in (a)8, amended Department name and N.J.A.C. reference; and in (a)28, deleted reference to livery transportation.
Amended by R.1998 d.116, effective 1/30/1998 (operative February 1, 1998; to expire July 31, 1998).
See: 30 N.J.R. 713(a).
In (a), inserted references to NJ KidCare--Plan A throughout.
Amended by R.1998 d.143, effective 3/16/1998.
See: 29 N.J.R. 543(a), 30 N.J.R. 1081(a).
In (a), inserted a new 6, and recodified former 6 through 28 as 7 through 29.
Adopted concurrent proposal, R.1998 d.426, effective 7/24/1998.
See: 30 N.J.R. 713(a), 30 N.J.R. 3034(a).
Readopted provisions of R.1998 d.116 without change.
Amended by R.2000 d.266, effective 7/3/2000.
See: 32 N.J.R. 159(a), 32 N.J.R. 2493(a).
Added (b).
Amended by R.2000 d.309, effective 8/7/2000.
See: 32 N.J.R. 1342(a), 32 N.J.R. 2900(a).
In (a), inserted a new 2, recodified former 2 through 26 as 3 through 27, inserted "services including" in the new 13, inserted a new 28, recodified former 27 through 29 as 29 through 31, added v in the new 30, and substituted a reference to mobility assistance vehicles for a reference to invalid coaches and substituted a reference to county boards of social services for a reference to county welfare agencies in the new 31.
Amended by R.2001 d.144, effective 5/7/2001.
See: 32 N.J.R. 4387(a), 33 N.J.R. 1378(b).
Rewrote (a)19.
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
In (a), substituted "Religious non-medical health care services," for "Christian Science Sanatoria" in 4, added 20i.
Amended by R.2003 d.89, effective 3/3/2003.
See: 34 N.J.R. 1593(a), 35 N.J.R. 1281(a).
In (a), rewrote 19 and substituted "NJ FamilyCare" for "or KidCare" in 30.
Amended by R.2003 d.479, effective 12/15/2003.
See: 35 N.J.R. 2146(a), 35 N.J.R. 5584(a).
In (a)19, inserted a new iv and recodified former iv as new v and rewrote new v.
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)19, added vi.
Amended by R.2004 d.334, effective 9/7/2004.
See: 36 N.J.R. 312(a), 36 N.J.R. 4136(a).
In (a), added a new 1, recodified former 1 as 2, and deleted former 2.
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), rewrote 19.
Amended by R.2005 d.98, effective 4/4/2005.
See: 36 N.J.R. 1158(a), 37 N.J.R. 1022(a).
In (a)19, added a new vi, recodified existing vi, vii as vii, viii.
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); added new (b); recodified former (b) as (c); and in (c), inserted "on a" and "basis".