N.J. Admin. Code § 10:60-3.8

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

Section 10:60-3.8 - Limitations on personal care assistant services

(a) Medicaid/NJ FamilyCare reimbursement shall not be made for personal care assistant services provided to Medicaid/NJ FamilyCare-Plan A beneficiaries in the following settings:

1. A residential health care facility;

2. A Class C boarding home;

3. A hospital;

4. A nursing facility;

5. DDD group homes, skill development homes, supervised apartments or other congregate living programs where personal care assistance is provided as part of a service package which is included in the living arrangement;

6. Adult day health care and pediatric day health care centers;

7. TBI community residential service facilities; and

8. Adult Family Care, Assisted Living Program, and Assisted Living Residence.

(b) Except as specified under the personal preference program, personal care assistant services provided by a family member shall not be considered covered services and shall not be reimbursed by the New Jersey Medicaid/NJ FamilyCare-Plan B and C programs. No exceptions will be granted for legally responsible relatives (that is, a spouse or legal guardian of an adult, or a parent/legal guardian of a minor child). Exceptions for other family members or relatives to provide personal care assistant services may be granted on a case-by-case basis at the discretion of the Director of the Division of Disability Services, if requested by the PCA provider agency. Such exceptions may be granted only with valid justification regarding the need for the service and documentation of the unavailability of another PCA. Renewal of approved exceptions shall be requested annually, accompanied by valid justification and documentation of the beneficiary's circumstances. Exceptions and renewals shall be based on the individual circumstances of the beneficiary and in all cases shall require the PCA to be:

1. A currently certified homemaker/home health aide;

2. An employee of the home health agency requesting the exception; and

3. Directly supervised by a registered nurse employed by the PCA provider agency.

(c) Personal care assistance services shall not be approved or authorized when the purpose of the request is to provide:

1. Respite care;

2. Supervision, as a stand-alone service, regardless of age of the beneficiary;

3. Companionship;

4. Child care or babysitting;

5. Routine parenting tasks and/or teaching of parenting skills;

6. Services to individuals with mental health service needs, which are provided by the Division of Mental Health and Addiction Services.

7. Services to beneficiaries with a medical diagnosis that does not indicate functional limitations (for example, high cholesterol);

8. Services to beneficiaries with acute short-term diagnosis (for example, a fracture) that is expected to heal;

9. Services to beneficiaries that are limited to non-hands-on personal care needs as described in N.J.A.C. 10:60-3.3(b) and (c).

(d) Personal care assistant services shall not be reimbursed if the personal care assistant resides in the beneficiary's home, except as provided in (b) above and 10:60-3.9.

(e) Personal care assistant services provided in places of employment shall not replace or duplicate those employer-provided services or accommodations mandated by the Americans with Disabilities Act of 1990, P.L. 101-336, 42 U.S.C. § 12111. Tasks that are considered part of a beneficiary's job duties such as, reading business/office correspondence, organizing files and answering telephones shall not be reimbursable personal care assistant services.

(f) Personal care assistant services in educational settings shall not replace or duplicate those services mandated by the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. §§ 1400 et seq., and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794. Tasks that are required for the beneficiary to obtain access to educational or classroom learning materials, such as note taking, shall not be reimbursable personal care assistant services.

(g) Personal care assistant services shall be limited to a maximum of 40 hours per calendar work week and shall be prior authorized in accordance with N.J.A.C. 10:60-3.9. Additional hours of service may be approved by the Division of Disability Services (DDS) or DMAHS on a case-by-case basis, based on exceptional circumstances.

(h) Personal care assistant services authorized for two or more beneficiaries living in the same residence shall require a combination of individual personal care services to address hands-on care needs and group hours to address the non-personal care needs (that is, meal preparation, shopping, laundry, housekeeping) for billing purposes.

(i) PCA units of service that are unused for any reason including, but not limited to, illness of the beneficiary or home health aide, or hospitalization of the beneficiary or aide, are not permitted to be saved and carried over for use on a subsequent date(s).

N.J. Admin. Code § 10:60-3.8

Amended by 50 N.J.R. 1992(b), effective 9/17/2018

Amended by 54 N.J.R. 1721(a), effective 9/6/2022