N.J. Admin. Code § 10:59-1.9

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

Section 10:59-1.9 - Dual Medicare/Medicaid/NJ FamilyCare coverage

(a) When a Medicaid/NJ FamilyCare beneficiary also has Medicare coverage, the Medicaid/NJ FamilyCare program requires that Medicare benefits be used first and to the fullest extent. Responsibility for payment by the New Jersey Medicaid/NJ FamilyCare program shall be limited to the unsatisfied deductible and/or coinsurance to the extent that the combined Medicare/Medicaid/NJ FamilyCare payment does not exceed the Medicaid/NJ FamilyCare maximum allowable.

(b) In those instances where Medicare policy disallows reimbursement for an item/service under certain circumstances, for example, a special wheelchair for a NF resident, the provider shall obtain prior authorization from the Medicaid/NJ FamilyCare--Plan A program and submit a hard copy claim to the Medicaid/NJ FamilyCare--Plan A program with an Explanation of Benefits from Medicare attached.

(c) Medicare/Medicaid/NJ FamilyCare claims shall be filed timely, in accordance with N.J.A.C. 10:49-7.2.

(d) When a beneficiary is eligible for Medicare/Medicaid/NJ FamilyCare coverage, a Medicare/Medicaid/NJ FamilyCare claim will cross over from the Medicare DMERC Region A to the Medicaid/NJ FamilyCare fiscal agent. There are instances, however, where claims will not cross over from Medicare to Medicaid/NJ FamilyCare, for example, claims denied by Medicare or claims where the Medicaid/NJ FamilyCare fiscal agent is unable to match pertinent identifying data (see N.J.A.C. 10:49-7.2(d)3 for further instructions).

(e) There are situations in which Medicare coverage differs significantly from coverage considered medically necessary by the Medicaid/NJ FamilyCare program. In these situations, the provider may request PA from the Medicaid/NJ FamilyCare program prior to requesting Medicare payment.

1. The provider must request PA for the higher level of service under the procedure code assigned by the Division for "reconciliation of downgraded Medicare/Medicaid/NJ FamilyCare claims."

(f) For dually eligible beneficiaries, Medicaid/NJ FamilyCare coverage shall be based on Medicare policy as it relates to rental and/or purchase of supplies and DME except as described at (e) above.

N.J. Admin. Code § 10:59-1.9

Amended by R.1998 d.382, effective 7/20/1998.
See: 30 N.J.R. 1255(b), 30 N.J.R. 2646(b).
In (a), inserted "to the extent that the combined Medicare/Medicaid or Medicare/NJ KidCare payment does not exceed the Medicaid or NJ KidCare maximum allowable" at the end, and inserted references to NJ KidCare and substituted beneficiary for recipient throughout the section.
Amended by R.2006 d.297, effective 9/5/2006.
See: 38 N.J.R. 1371(b), 38 N.J.R. 3578(a).
Section was "Dual Medicare/Medicaid or NJ KidCare coverage". Substituted "FamilyCare" for "KidCare" throughout; and in (c), inserted "and Medicare/NJ FamilyCare".

Amended by 53 N.J.R. 1278(b), effective 8/2/2021