N.J. Admin. Code § 10:49-5.7

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

Section 10:49-5.7 - Services available and unavailable to beneficiaries eligible for NJ FamilyCare-Plan D and Plan D for adults

(a) Except as indicated at N.J.A.C. 10:79-2.5, which concerns services for newborns enrolling into NJ FamilyCare-Plan C and D, the services listed below are available to beneficiaries eligible for NJ FamilyCare-Plan D and Plan D for Adults, when medically necessary and provided through the network of an HMO selected by the NJ FamilyCare-Plan D beneficiary.

1. Advanced practice nurses;

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

3. Dental services for individuals under the age of 19 years that are necessary to prevent disease, promote oral health, and restore oral structures to health and function, including the treatment of emergency conditions;

4. Emergency room services;

5. 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 NJ FamilyCare program;

6. Federally qualified health center primary care services;

7. 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 aide when the purpose of the treatment is skilled care, medical social services, which are necessary for the treatment of the beneficiary's medical condition;

i. Personal care assistant services are not covered;

8. Hospice services;

9. Hospital services--inpatient;

10. Hospital services--outpatient;

11. Laboratory (clinical);

12. Nurse-midwifery services;

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

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

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

16. Prescription drug services;

i. Exception: Over-the-counter drugs are not covered;

17. Physician services;

18. Podiatric services;

i. Exception: Coverage excludes routine foot care;

19. 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;

20. Private duty nursing care, only when authorized by the HMO;

21. Radiological services;

22. Inpatient rehabilitative 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. Well child care including immunizations, lead screening and treatments;

25. Maternity and related newborn care; and

26. Diabetic supplies and equipment.

(b) The services listed below shall be available to beneficiaries eligible for NJ FamilyCare-Plan D under fee-for-service.

1. Services for mental health or behavioral conditions;

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

(1) A NJ FamilyCare-Plan D beneficiary under age 21 who is receiving services under the Division of Child Behavioral Health Services may secure additional inpatient psychiatric services provided in a psychiatric hospital, if authorized by the Contracted Systems Administrator (CSA) or other agent designated by the Department of Human Services (see N.J.A.C. 10:77-5.7(d) );

ii. Outpatient benefits for short-term, outpatient evaluative and crisis intervention or home health mental health services, limited to 20 visits per year;

(1) When authorized by the Division of Medical Assistance and Health Services, inpatient benefit exchanges are allowed. One mental health inpatient day may be exchanged for up to 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 out patient visits.

(2) When authorized by the Division of Medical Assistance and Health Services, inpatient benefit exchanges are allowed. 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.

(3) A NJ FamilyCare-Plan D beneficiary under age 21 who is receiving services under the Division of Child Behavioral Health Services may secure additional outpatient mental health services, if authorized by the Contracted Systems Administrator (CSA) or other agent designated by the Department of Human Services (see N.J.A.C. 10:77-5.7(d) );

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

2. 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 per contract year, 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; and

3. Elective/induced abortion services.

(c) Services not covered under Plan D are as follows:

1. Unless listed in (a) and (b) above, no other services are covered by NJ FamilyCare-Plan D.

2. Services not covered include, but are not limited to:

i. Services that are not medically necessary;

ii. Private duty nursing unless authorized by the HMO;

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

iv. Personal care assistant services;

v. Medical day care services;

vi. Chiropractic services;

vii. Dental services except for those available under (a)3 above;

viii. Orthotic devices;

ix. Targeted case management for the chronically ill;

x. Inpatient psychiatric programs for children age 19 years and under, unless the beneficiary is also receiving services under the Division of Child Behavioral Health Services and is receiving services as part of a plan of care authorized by the Contracted Systems Administrator or other agent authorized by the Department of Human Services;

xi. Religious non-medical health care institution care and services;

xii. Durable medical equipment;

xiii. EPSDT services;

(1) Refer to (a)24 above concerning the coverage of well child care including immunizations, lead screening and treatments;

xiv. Transportation, including non-emergency ambulance, invalid coach and lower mode transportation;

xv. Hearing aid services;

xvi. Blood and blood plasma;

(1) Administration, processing of blood, processing fees and fees related to autologous blood donations are covered;

xvii. Cosmetic services;

xviii. Custodial care;

xix. Special and remedial educational services;

xx. Experimental and investigational services;

xxi. Infertility services;

xxii. Medical supplies;

(1) Diabetic supplies are a covered service;

xxiii. Rehabilitative services for substance abuse;

xxiv. Weight reduction programs or dietary supplements;

(1) Surgical operations, procedures or treatment of obesity, shall not be covered, except when specifically approved by the HMO;

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

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

xxvii. Nursing facility (long term care) services;

xxviii. Recreational therapy;

xxix. Sleep therapy;

xxx. Court ordered services;

xxxi. Thermograms and thermography;

xxxii. Biofeedback;

xxxiii. Radial keratotomy;

xxxiv. Respite care;

xxxv. Any item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished at the direction or on the prescription of a physician, individual or entity, during the period when such physician, individual or entity is excluded from participation in the Medicaid and NJ FamilyCare programs, and when the physician, individual or entity furnishing such item or service has received written notice from the Division that the physician, individual or entity has been excluded from participation in the Medicaid and NJ FamilyCare programs;

xxxvi. Programs for Assertive Community Treatment (PACT) services;

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

xxxviii. Skilled nursing facility services.

(d) Additional mental health and mental health rehabilitation services as listed below may be available to beneficiaries under age 21 who are eligible for NJ FamilyCare-Plan D 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. 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);

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

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

5. 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 § 10:49-5.7

New Rule, R.1999 d.211, effective 7/6/1999 (operative August 1, 1999).
See: 31 N.J.R. 998(a), 31 N.J.R. 1806(a), 31 N.J.R. 2879(b).
Amended by R.2001 d.144, effective 5/7/2001.
See: 32 N.J.R. 4387(a), 33 N.J.R. 1378(b).
Added (c)2xxxiv.
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
In (c)2, substituted "Religious non-medical health care institution" for "Christian science sanatoria" in xi and added xxxiv.
Special amendment, R.2003 d.98, effective 1/31/2003.
See: 35 N.J.R. 1303(a).
Rewrote (c)2.
Amended by R.2003 d.89, effective 3/3/2003.
See: 34 N.J.R. 1593(a), 35 N.J.R. 1281(a).
In (c)2, added xxxvi and xxxvii.
Amended by R.2003 d.479, effective 12/15/2003.
See: 35 N.J.R. 2146(a), 35 N.J.R. 5584(a).
In (c)2xxxiv, inserted "or behavioral assistance services for children/youth or young adults (see N.J.A.C. 10:77-4)" at the end of the paragraph.
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 (c)2, added xxxviii.
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), rewrote 1.
Amended by R.2005 d.68, effective 2/22/2005.
See: 36 N.J.R. 379(a), 37 N.J.R. 659(a).
In (b), added 1i(1) and 1ii(3); rewrote (c); added (d).
Amended by R.2005 d.98, effective 4/4/2005.
See: 36 N.J.R. 1158(a), 37 N.J.R. 1022(a).
Rewrote (d).
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
In (a)3, inserted "and sealants"; in the introductory paragraph of (a)5, inserted a comma following "services"; in (a)5i, substituted "NJ" for "New Jersey"; in (a)7, inserted a comma following "beneficiary" and "services", and deleted "and short-term physical, speech or occupation therapy with the same limitations described in (a)22 below" from the end; rewrote (a)20; in (c)2xiv, substituted "Transportation" for "Routine transportation" and "non-emergency" for "non emergency"; in (c)2xxxvi, deleted "and" from the end; in (c)2xxxvii, substituted "; and" for a period at the end; and added (c)2xxxviii.
Amended by R.2014 d.011, effective 1/6/2014.
See: 45 N.J.R. 715(a), 46 N.J.R. 77(a).
Rewrote (a)3; and in (c)2vii, substituted "those available under (a)3 above" for "preventive dentistry for children under age 12".