New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 142 - PERSONAL PREFERENCE PROGRAM
Subchapter 1 - GENERAL PROVISIONS
Section 10:142-1.4 - Definitions
The following words and terms, when used in this chapter, shall have the following meanings unless the context indicates otherwise:
"Activities of daily living (ADLs)" are tasks that determine a participant's ability to self-care. Examples include, but are not limited to:* eating, bathing, dressing, toileting, transferring (walking), and continence, which can be provided by a personal care assistant.
"Adverse agency action" is defined as an administrative action performed resulting in either a denial, reduction, or disenrollment of services, a denial of a request for an exception, a denial of a request for increase in service benefits, or a failure to act upon a request for services within prescribed time frames. Such actions may be performed by either: a managed care organization (MCO) or by the Division.
"Authorized representative" is defined as a surrogate decision maker, who is at least 18 years of age, serves in an unpaid capacity, and is present and available to meet in person with the participant on a regular basis, to provide assistance with choices and decision making, and ensuring that services are being performed in accordance with the cash management plan. Types of authorized representatives include the following:
1. "Pre-determined representative" is used in circumstances where a representative has been court appointed;
2. "Voluntary representative" is used in circumstances where the participant chooses to use someone of his or her choosing to assist with managing the program;
3. "Mandated representative" is a term and condition for continued participation in the program, which is used in circumstances, such as misspending of cash allocation, or when the nature of one's disability involves diminished cognitive functioning, resulting in the inability to self-direct services; or
4. "Surrogate representative" is used in circumstances in which the pre-determined representative (under paragraph 1 above) selects another individual to act in his or her place.
"Budget" means the value of a cash management plan (CMP).
"Budget authority" means the participant, or authorized representative, where appropriate, has the responsibility to manage his/her budget, determine the types of goods and services to be purchased, and establish their worker's wage rates.
"Care manager (CM)" means an individual employed by a managed care organization (MCO), or by a State-contracted care management agency, who provides enrollee-centered, goal-oriented, culturally relevant assistance to assure that an enrollee receives needed services in a supportive, effective, efficient, timely, and cost-effective manner.
"Cash and counseling" is defined as a system for delivery of personal care services using the concept of consumer direction, which is the foundation of the Personal Preference Program. A monthly allowance is issued to the participant in place of traditional personal care assistance (PCA) services, who, with the guidance of a consultant, purchases, goods, and services to meet personal care needs.
"Cash management plan (CMP)" means a document used by the Personal Preference Program participant to define the services the participant needs and to budget the monthly cash allowance accordingly. The CMP is a mandatory document prepared by the participant, and made effective following approval by the State Program Manager or designated State staff. The CMP serves as the participant's budget document for the program and must be adhered to for the length of enrollment in the program. The CMP shall be amended as necessary to reflect changes in the awarded and approved services.
"Centers for Medicare and Medicaid Services" (CMS) means the Federal agency within the U.S. Department of Health and Human Services that works with the State to administer Medicaid.
"Consultant" is defined as an individual employed by the counseling agency, or counseling entity, that is under contract with the Division. The consultant provides counseling services related to consumer direction to participants and their representatives, and provides front line support to guide individuals in effectively managing their roles as a participant in a participant directed program. The consultant provides programmatic counseling and assists in the development of the participant's budget, as well as updates, as necessary.
"Counseling agency" also referred to as "counseling entity" means an agency that is under contract directly with either the State of New Jersey or the Vendor Fiscal Employer Agent to serve as a source of consultant services and provide financial counseling for Personal Preference Program participants.
"Department" means the New Jersey Department of Human Services (DHS).
"Division" means the Division of Disability Services (DDS) within the New Jersey Department of Human Services, which is responsible for the administration of the Personal Preference Program (PPP). The DDS may alternately be referred to as the "State Program Office."
"Division of Medical Assistance and Health Services (DMAHS)" means the agency within the New Jersey Department of Human Services, that administers the New Jersey managed care organization (MCO) contract on behalf of the Department. DHS is the single State Medicaid agency in New Jersey, and DMAHS is designated as the Medicaid administrative authority.
"Domestic household employee" means a person who is an employee of the participant and provides personal care services and supports to a participant, who is enrolled in the Personal Preference Program as defined in I.R.C. §§ 31.3306(c)(2)-1(a)(2).
"Employer authority" means the participant, or their authorized representative, where appropriate, has the responsibility for hiring, supervising, managing, and firing workers. If combined with budget authority, the participant, or authorized representative, sets the rate of pay for workers.
"Fair hearing" means a hearing held by the Office of Administrative Law (OAL) under N.J.S.A. 52:14B-1 et seq., and 52:14F-1 et seq., and N.J.A.C. 1:1-1 and 10:6.
"Fee for service (FFS)" means the method used for Medicaid reimbursement based on its payment for specific services covered by the DMAHS, but not covered by the MCO, which are rendered to an eligible participant, in accordance with N.J.A.C. 10:49.
"Home visit" means a face to face visit with a program consultant that is performed routinely, in the participant's home, with the presence of the participant and representative, where appropriate, for the purpose of evaluating how well service needs are being met through the cash management plan. Completion of the visit by telephone, "skyping," or other communications technology are not acceptable under the program.
"Managed care organization (MCO)" refers to a health maintenance organization (HMO) that is under contract with the State of New Jersey, Division of Medical Assistance and Health Services (DMAHS), for the provision of health care services for consumers that are eligible for Medicaid benefits, as defined by Article 1, page 15 of the MCO contract.
"Medicaid fiscal agent" means an entity under contract with the State of New Jersey that processes and adjudicates provider claims on behalf of the New Jersey Medicaid Program.
"Medicaid provider" means any agency meeting applicable requirements and standards for participation in the New Jersey Medicaid Program, meeting the requirements at N.J.A.C. 10:49-3.1.
"Medical facility" means a nursing home, residential, or rehabilitation facility, assisted living facility, or hospital that provides medical and personal care for individuals with chronic illness or disability(ies).
"Participant" means an individual who is receiving services under the Personal Preference Program in New Jersey.
"Participant directed goods and services" means equipment or supplies in lieu of hands on personal care provided by an assistant employed by the participant not otherwise afforded through Medicaid or the Medicaid State Plan.
"Participant directed services" means an approach to service delivery that affords participants choice and control over the services they receive and the individuals who provide them. The participant requiring services makes the choices about what, when, where, and from whom he or she receives services, based upon the underlying assumption that the participant knows best about his/her wants and needs.
"Personal care assistance services" also known as PCA services, means a Medicaid service pursuant to N.J.A.C. 10:60-3.1, which provides for assistance with personal care, household duties, and health-related tasks performed by a qualified individual in a beneficiary's place of residence, under the supervision of a registered professional nurse, as certified by a physician in accordance with a written plan of care. PCA services are alternatively known as traditional agency services, or traditional model.
"Personal care assistant" means a person who is employed by a Medicaid provider agency to provide personal care assistance services, and who meets the qualifications set forth at N.J.A.C. 10:60-1.2.
"Reassessment" is a face-to-face home visit defined as N.J.A.C. 10:60-3.5(a) 3. Completion of the reassessment visit by telephone, "skyping," or other communications technology are not acceptable under the program.
"Risk assessment profile" means a tool used to evaluate individual risk, safety, and planning for mitigation of risk for the participant. The tool addresses cognitive, hearing/communication, ambulation, nutritional, functional, and structural limitation factors, and evaluates a participant's need of an emergency back-up plan for incorporation into the cash management plan.
"Self-direction" also known as "consumer direction" or "participant direction," means a service delivery model that emphasizes autonomy and empowerment by expanding the participant's degree of choice and control over his or her long-term services and supports. Under this model, participants and their authorized representatives or family members serve as the common law employer, and with training and guidance, are responsible for directly hiring, training, supervising, firing their paid caregivers, and making informed decisions about their own care.
"State program office" is also known as the Division of Disability Services, under the New Jersey Department of Human Services, and is the agency responsible for the administration of the Personal Preference Program.
"Vendor fiscal employment agent (VF/EA)" means an entity, under contract with the State of New Jersey, which provides a range of fiscal and business services to participants enrolled in the Personal Preference Program.
"Worker" means a domestic household employee hired by, and who performs duties in and around the home, for a Personal Preference Program participant. A worker shall be employed for no more than 40 hours per calendar week across all programs and shall be exempt from overtime pay. Individuals who reside in the same residence as the participant they serve, and who qualify for the Live In Exception pursuant to IRS Notice 2014-7, 2014-4 I.R.B. 445, may work over 40 hours a week for their standard pay rate, and shall remain exempt from overtime pay.
