New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 49 - ADMINISTRATION MANUAL
Subchapter 24 - WORK FIRST NEW JERSEY/GENERAL ASSISTANCE CLAIMS PROCESSING
Section 10:49-24.3 - Services available under the Work First New Jersey/General Assistance (WFNJ/GA) program which shall be processed by the fiscal agent
Universal Citation: NJ Admin Code 10:49-24.3
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The Medicaid/NJ FamilyCare fiscal agent shall reimburse only those WFNJ/GA program covered services listed below in this subsection when provided in an ambulatory setting, except as specified in 10:49-24.4(a)14. These services include:
1. Advanced practice
nurse services (for specific information, see N.J.A.C. 10:58A);
2. Abortion (elective/induced);
3. Acupuncture;
4. ADDP covered anti-retroviral
drugs;
5. Ambulance;
6. Ambulatory surgery;
7. Blood and blood plasma;
8. Case management services for the
chronically mentally ill (for specific information, see N.J.A.C.
10:73);
9. Chiropractic services
(for specific information, see N.J.A.C. 10:68);
10. Clinic services (services in an
independent outpatient health care facility, ambulatory care facility,
ambulatory surgical center, ambulatory care/family planning/surgical facility,
drug treatment center, Federally qualified health center, free-standing
end-stage renal dialysis facility), such as dental, family planning,
laboratory, mental health, minor surgery, personal care assistance, podiatry,
radiology, rehabilitation, or vision care (for specific information, see
N.J.A.C. 10:66), except that:
i. Professional
services provided by a residential alcohol or drug abuse treatment facility to
an individual residing in the facility shall not be processed;
11. Dental services, including
dentures (for specific information, see N.J.A.C. 10:56);
12. Durable medical equipment;
13. 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, except that:
i. Services
provided primarily for the diagnoses and treatment of infertility, including
sterilization reversals, and related office (medical and clinic) visits, drugs,
laboratory services, radiological and diagnostic services and surgical
procedures shall not be processed.
14. Hearing aid services (for specific
information, see N.J.A.C. 10:64);
15. Home care services, including home health
care (for specific information, see N.J.A.C. 10:60);
16. Hospice services, except those provided
in a nursing home facility (for specific information, see N.J.A.C. 10:53A).
i. The following hospice services shall be
processed under the WFNJ/GA program:
(1)
Routine home care rate;
(2)
Continuous home care rate; and
(3)
Drugs and biologicals co-payment (rendered in places other than long-term care
facilities).
ii. The
following hospice services shall not be processed under the WFNJ/GA program:
(1) Inpatient respite care rate;
(2) General inpatient care;
(3) Therapeutic leave days;
(4) Bed hold days;
(5) Hospice Respite Care; and
(6) Room and board;
17. Laboratory (clinical) services
(for specific information, see N.J.A.C. 10:61);
18. Medical supplies and equipment (for
specific information, see N.J.A.C. 10:59);
19. Mental health services (for specific
information, see N.J.A.C. 10:66);
20. Non-maternity nurse-midwifery services,
such as family planning (for specific information, see N.J.A.C.
10:58);
21. Optometric services
(for specific information, see N.J.A.C. 10:62);
22. Optical appliances (for specific
information, see N.J.A.C. 10:62);
23. Personal care assistant;
24. Thermograms;
25. Thermography;
26. Pharmaceutical services (for specific
information, see N.J.A.C. 10:51);
i. Prior
authorization shall be required where patterns of medically harmful or
inappropriate use of specific drugs, therapeutic drug classes, enteral
nutritional supplements, needles and syringes have been identified, or for
claims originating in certain municipalities where such patterns have been
identified; and
ii. Effective with
claims for dates of service on or after August 7, 2000, the Division's
processing of claims for certain antiretroviral drugs shall be accomplished
under the AIDS Drug Distribution Program (ADDP), administered by the Department
of Health and Senior Services (DHSS), except for emergency supplies as
authorized under WFNJ/GA to avert a lapse in treatment. These drugs shall
include, but may not be limited to: thymidine nucleosides, thymidine analogs,
protease inhibitors, nucleoside analog reverse transcriptase inhibitors,
non-nucleoside reverse transcriptase inhibitors, carbocyclic nucleoside
analogs, purine nucleoside analogs of deoxyadenosine, and primidine nucleoside
analogs;
27. Physician
services (for specific information, see N.J.A.C. 10:54);
28. Podiatric services (for specific
information, see N.J.A.C. 10:57);
29. Prosthetic and orthotic devices (for
specific information, see N.J.A.C. 10:55);
30. Psychological service (for specific
information, see N.J.A.C. 10:67);
31. Radiological services (for specific
information, see N.J.A.C. 10:54);
32. Rehabilitative services (for specific
information, see N.J.A.C. 10:66). Payments shall be made to eligible Medicaid
providers only. No payment shall be made to privately practicing therapists who
are not Medicaid providers. Rehabilitative services include:
i. Physical therapy;
ii. Occupational therapy;
iii. Speech-language pathology services;
and
iv. Audiology
services;
33.
Transportation services which include ambulance and mobility assistance vehicle
(for specific information, see N.J.A.C. 10:50 and 10:66);
34. Medicare coinsurance and/or deductible
for services specified in (a)1 through 23 above, if otherwise reimbursed by the
New Jersey Medicaid program; and
35. Inpatient services provided by Mt. Carmel
GuildHospital located in Newark, New Jersey.
(b) Adult mental health rehabilitation services provided in/by community residence programs (see N.J.A.C. 10:77A) shall not be eligible for reimbursement by DMAHS, but may be eligible for reimbursement by the Division of Mental Health Services (DMHS).
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.