Current through Register Vol. 56, No. 18, September 16, 2024
(a) Notwithstanding
any other provision of N.J.A.C. 10:49 through 10:79A, and except as provided in
(c) and (d) below, the New Jersey Medicaid/NJ FamilyCare program (including,
but not limited to, the program's administration, reimbursement, payment,
provider screening, provider enrollment, provider termination, provider
exclusion, program integrity, use of managed care, beneficiary enrollment,
beneficiary services, appeal procedures, and fraud and abuse control), will be
operated in accordance with all of the mandatory Federal requirements described
in (a)1 through 6 below that were created under the Patient Protection and
Affordable Care Act, 111 P.L. 148 (PPACA), as amended and supplemented, the
Health Care and Education Reconciliation Act of 2010, 111 P.L. 152 (HCERA), as
amended and supplemented, and the implementing Federal regulations adopted at
76 FR 5862 through 5971, as amended and supplemented, in order to ensure
compliance with the mandatory provisions of those Federal Acts and regulations.
1. The program will, as required by section
6501 of PPACA at
42 U.S.C. §
1396a(a), as amended and
supplemented, or by Federal regulations adopted in the Federal Register on
February 2, 2011, at 76 FR 5862 through 5971, as amended and supplemented, deny
enrollment or terminate the participation of any individual or entity in the
New Jersey Medicaid/NJ FamilyCare program, if (subject to such exceptions as
are permitted with respect to exclusion under sections 1128(c)(3)(B) and
1128(d)(3)(B) of the Social Security Act (
42
U.S.C. §§
1320a-7(c)(3)(B) and
(d)(3)(B)) participation of such individual
or entity is terminated under title XVIII, XIX, or XXI of the Social Security
Act (
42 U.S.C. §§
1395 et seq.,
42 U.S.C.
1396 et seq., or
42 U.S.C.
1397 aa et seq.) or under the Medicaid
program or Children's Health Insurance program of any other state, and no
payment shall be made by the program with respect to any item or service
furnished by such individual or entity during such period.
2. No payment for items or services provided
under the Medicaid/NJ FamilyCare program shall be made to any financial
institution or entity located outside of the United States, as required by
section 6505 of PPACA, at
42 U.S.C. §
1396a(a) 80, as amended and
supplemented.
3. A voluntary
election to have payment made for hospice care for a child shall not constitute
a waiver of any rights of the child to be provided with, or to have payment
made under the Medicaid/NJ FamilyCare program for, services that are related to
the treatment of the child's condition for which a diagnosis of terminal
illness has been made, as required by section 2302 of PPACA, at
42
U.S.C. §§
1396d
(o)(1) and 1397jj(a)(23), as amended and
supplemented.
4. Separate payments
will be made to providers administering prenatal labor and delivery or
postpartum care in a freestanding birth center, as required by section 2301 of
PPACA, at
42
U.S.C. §§
1396d and
1396a(a)(10)(A),
as amended and supplemented.
5.
Medicaid coverage will be provided for counseling and pharmacotherapy to
pregnant women for cessation of tobacco use, and cost-sharing for these
services is prohibited, as required by section 4107 of PPACA, at
42
U.S.C. §§
1396d,
1396r-8,
and
1396o,
as amended and supplemented.
6.
Payments for primary care services furnished in 2013 and 2014 will be made as
required by section 1202(a) of HCERA, at
42 U.S.C. §§
1396a and
1396u-2(f),
as amended and supplemented or by any Federal regulations implementing that
section, as amended and supplemented.
(b) Notwithstanding any other provision of
N.J.A.C. 10:49 through 10:79A, and except as provided in (c) and (d) below, all
beneficiaries, providers, suppliers, applicants to become beneficiaries,
applicants to become providers, applicants to become suppliers, managed care
entities, providers of services or goods to managed care entities, fiscal
agents, and parties that submit claims on behalf of health care providers, as
well as the owners, officers, directors, contractors, subcontractors, agents,
and employees of all such entities, are subject to, and shall comply with, all
of the Federal requirements regarding any such individuals or entities under
PPACA, as amended and supplemented, HCERA, as amended and supplemented, and the
Federal regulations at 76 FR 5862 through 5971, as amended and supplemented,
and the Federal regulations adopted at 76 FR 32816 through 32838, as amended
and supplemented, that are described in (b)1 through 7 below, which
requirements regarding such individuals or entities are collectively
incorporated herein by reference. Such requirements are in addition to, and not
in derogation of, any other legal requirements that apply to any such
individual or entity under any other State or Federal law, rule, or regulation.
The definitions of terms applicable to this subsection are identical to those
definitions used by PPACA, HCERA, and the Federal regulations cited in this
subsection. The requirements are:
1. All
program integrity, screening, oversight, reporting, disclosure, moratorium,
compliance, enrollment, payment adjustment, suspension of payment, inclusion of
information, and National Provider Identifier provisions described under
section 6401 and 6402 of PPACA, as amended and supplemented, or under the
Federal regulations adopted at 76 FR 5862 through 5971, as amended and
supplemented;
2. All face-to-face,
medical review and certification requirements described under sections 3132 and
6407 of PPACA, as amended and supplemented, or under the Federal regulations
adopted at 76 FR 5862 through 5971, as amended and supplemented;
3. All requirements to register with the
State or with the Federal government as described at section 6503 of PPACA, as
amended and supplemented, or under the Federal regulations adopted at 76 FR
5862 through 5971, as amended and supplemented;
4. All requirements to submit data elements
as determined necessary by the Secretary for program integrity, program
oversight, and administration, effective with respect to contract years
beginning on or after January 1, 2010 as described at section 6504 of PPACA, at
42 U.S.C. §§
1396b(r)(1)(F) and
1396b(m)(2)(A)(xi),
as amended and supplemented, or under the Federal regulations adopted at 76 FR
5862 through 5971, as amended and supplemented;
5. The prohibition on payment for items or
services provided under the Medicaid/NJ FamilyCare program to any financial
institution or entity located outside of the United States, as described at
section 6505 of PPACA, as amended and supplemented, or under the Federal
regulations adopted at 76 FR 5862 through 5971, as amended and
supplemented;
6. All requirements
regarding reporting and returning of overpayments, as described at section 6402
of PPACA, as amended and supplemented, or under the Federal regulations adopted
at 76 FR 5862 through 5971, as amended and supplemented, unless a more
expedited timeframe for reporting and returning overpayments exists within this
chapter; and
7. The prohibition on
payments for any health care acquired conditions in accordance with section
2702 of PPACA, as amended and supplemented, or under the Federal regulations
adopted at 76 FR 32816 through 32838, as amended and supplemented.
(c) The provisions of (a) or (b)
above shall not apply in specific instances in which:
1. The Federal government has granted a
waiver from compliance with a Federal requirement and the Division chooses to
exercise its authority under that waiver; or
2. The Division determines that exercise of
such provision would cause program expenditures to exceed amounts appropriated
by law for any portion of the program.
(d) The provisions of (a) and (b) above
specifically do not address State compliance with any provision of any Federal
law or regulation that would expand eligibility under any program to any new
groups, categories, or individuals.
