New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 59 - MEDICAL SUPPLIER MANUAL
Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT
Section 10:59-1.3 - Requirements for program participation as a medical supplier
Universal Citation: NJ Admin Code 10:59-1.3
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Effective July 1, 2006, P.L. 2006, c. 45 and P.L. 2007, c. 111, as amended by P.L. 2007, c. 336, require the Division to institute a moratorium on, among other services, medical supply services.
1. Any provider that was not an approved Medicaid or NJ FamilyCare fee-for-service provider of medical supply services prior to July 1, 2006 is ineligible to become an approved fee-for-service provider of such services for Medicaid or NJ FamilyCare, unless the Division determines that the provider meets the special needs of the Division.
2. Special needs criteria for medical supplier provider applicants are as follows:
i. Sufficient access analysis: Using geo-accessing, the Division will determine whether the beneficiaries living in an area in which the provider is located, or intends to locate, have sufficient access to the Medicaid or NJ FamilyCare-covered service that the provider intends to offer. For example, if a mileage standard for a service is one provider in six miles or two providers in 12 miles, sufficient access exists under the moratorium for that service when a beneficiary has access to a minimum of one participating provider within six miles or two participating providers within 12 miles of the beneficiary's residence. Mileage standards are set forth below:
| Miles per One | Miles per Two | Miles per One | Miles per Two |
|---|---|---|---|
| Provider-Urban | Providers-Urban | Provider-Non urban | Providers-Non |
| urban | |||
| six Miles | 12 Miles | 15 Miles | 25 Miles |
ii. Special needs analysis: After the Division performs a sufficient access analysis, the Division will perform a special needs analysis utilizing the following criteria:
(1) The number of beneficiaries in the area in question who may have special needs;
(2) Capacity limits and service offerings of existing providers and the provider applicant;
(3) The provider applicant's availability, as revealed in its proposed minimum and maximum hours of service, including whether the provider will offer a level of service not currently available, such as a 24-hour access system, emergency services and home delivery of services;
(4) Whether the provider applicant is a specialty medical services provider deemed by DMAHS to fill a need for specific medical supply that would not otherwise be filled; and
(5) A provider that is selected to provide institutional pharmaceutical services to a facility that is a newly licensed institution, or a replacement provider that shall provide identical services to an existing licensed institution, may also be approved for participation as a provider of medical supply services under the moratorium if the provider provides a level of services acceptable to the Department of Health and Senior Services and meets all applicable State and Federal rules and regulations. Additionally, institutional providers of pharmaceutical services may be approved as providers of medical supply services for the purpose of billing Medicare Part B for covered medical supply services and Medicare Part D services.
3. Situations not subject to the moratorium for fee-for-service providers of medical supply services are as follows:
i. A change of ownership only;
ii. A change of location only: A provider that has not changed ownership on or after July 1, 2006, which changes location on or after July 1, 2006 and prior to November 7, 2011, or which changes location to a location within the State of New Jersey on or after November 7, 2011, and continues to operate as a Medicaid or NJ FamilyCare provider at the new location, continues to provide the same level of services and delivery and meets all applicable State and Federal rules and regulations;
iii. Medicare is the primary payer. Situations where Medicare is the primary payer and the provider bills for cross-over claims and wraparound Medicare Part D payments; and
iv. A pharmacy that sells medical supplies.
4. A pharmacy provider is not approved to be a provider of medical supply services based on licensure as a pharmacy. Licensed pharmacies shall file a separate provider application to request participation as a provider of medical supply services.
(b) Subject to the moratorium set forth in (a) above, in order to participate in the New Jersey Medicaid/NJ FamilyCare Program, a medical supplier shall:
1. Be an established place of business as a medical supplier in New Jersey;
2. Be a pharmacy operating under a valid permit issued by the New Jersey State Board of Pharmacy;
3. Be an out-of-State medical supplier who is an approved Medicaid provider in their state of residence; or
4. Be a manufacturer of medical supplies for which there is a special need, as determined at the sole discretion of the Division; however, participation by such manufacturers is limited to providing the specific items specially needed as identified in writing by the Division; such manufacturers may be enrolled without a need to comply with the separate provisions of (c)1 and 2 below.
(c) In order to participate in the New Jersey Medicaid/NJ FamilyCare Program, a medical supplier shall:
1. Maintain a previously approved or fixed, established place of business located in a commercial zone which shall be open and accessible to the general public during normal business hours;
2. Display a sign of identification, external to the interior business site, visually recognized by the general public;
3. Receive approval from the New Jersey Medicaid/NJ FamilyCare program for each site from which equipment and supplies are distributed and/or delivered;
4. Comply with the requirements described at 10:49-3.2 if the medical supplier is to fill an order written by a physician or other practitioner who has an ownership interest in the supplier's business;
5. Notify the State's fiscal agent and file a new application within 60 days of a change in ownership and/or location; and
6. Agree to permit properly identified representatives of the New Jersey Medicaid/NJ FamilyCare program to:
i. Inspect the original prescription or the Certificate of Medical Necessity (CMN) on file;
ii. Audit records pertaining to costs of medical supplies and equipment provided to Medicaid/NJ FamilyCare beneficiaries; and
iii. Inspect private sector records, where deemed necessary, to comply with Federal regulations to determine a provider's usual and customary charge to the public.
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.
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