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PO Box 360
Trenton, NJ 08625-0360
|Fred M. Jacobs, M.D., J.D.|
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The Division of Aging and Community Services of the Senior Services and Health Systems Branch of the Department of Health and Senior Services (Department) is proposing to readopt N.J.A.C. 8:86, Adult and Pediatric Day Health Services (hereinafter ADHS or PDHS, respectively), with amendments and a proposed new rule. The notice of proposal appears in the
The Department is developing rulemaking to establish separate chapters addressing Medicaid participation and reimbursement standards for PDHS and governing PDHS facility licensure. The Department proposes to readopt the existing chapter, with the proposed revisions, to maintain the existing standards addressing both ADHS and PDHS together, pending the conclusion of that rulemaking process.
The Department is proposing technical amendments throughout the chapter to improve sentence structure and readability; to eliminate the passive voice; to correct grammar; to delete redundancies and inconsistencies; to add appropriate cross-references to existing licensure standards at N.J.A.C. 8:43F; and to reflect the renaming of programs and the correction of associated contact information.
Among proposed substantive revisions, the Department proposes amendments to add definitions of the terms “ADHS,” “Medicaid,” “medical appointment,” “PDHS,” and “rehabilitation service”; to restructure the definition of the term “ADL” to include the list of six separate activities of daily living; and to amend the definition of the term “legally authorized representative” to add references to domestic partners and civil union partners as persons with decision-making authority on behalf of beneficiaries.
The Department proposes amendments to the prior authorization process for Medicaid-reimbursable ADHS that would establish form submission requirements to request prior authorization to provide or continue to provide ADHS to potential beneficiaries or existing beneficiaries, to articulate how to obtain the required form; and to require case or care manager involvement in this process for potential or existing beneficiaries who participate in any program listed at N.J.A.C. 8:86-1.1(b) that requires case or care management.
The Department proposes amendments to identify the name of the monthly roster form, to update the reference to the Department’s forms page from which the monthly roster can be obtained, and to identify the information facilities must provide on the form.
The Department proposes amendments to facility service requirements to articulate that ADHS facilities must provide the services that adult beneficiaries require for clinical eligibility to participate in ADHS. In addition, the Department proposes to authorize, but not require, ADHS facilities to transport ADHS beneficiaries to their medical appointment(s) as an adult day health service that may be applied towards the minimum five hours of required services that each ADHS beneficiary must receive.
Proposed amendments to the ADHS prior authorization requirements would articulate that professional staff designated by the Department must perform clinical eligibility assessments for individuals or beneficiaries prior to the initial provision of ADHS; at least annually to redetermine a beneficiary’s clinical eligibility; and when a beneficiary presents a change in status that may alter the beneficiary’s eligibility for ADHS. Another proposed amendment regarding this topic would articulate a facility’s responsibility to either discharge or obtain clinical eligibility reassessment from the Department with respect to beneficiaries who present a change in status that may alter a beneficiary’s clinical eligibility to receive ADHS, to correspond with an existing identical requirement at N.J.A.C. 8:43F.
Additional proposed amendments addressing prior authorization would authorize ADHS facility RNs performing clinical eligibility assessments on the Department’s behalf to delegate the home visit component of the assessment in accordance with New Jersey State Board of Nursing licensure standards, would establish assessment form signature requirements, and would clarify participants’ fair hearing opportunity requirements. Proposed amendments would revise participant clinical eligibility requirements with respect to ADLs, including the deletion the imprecise phrases “some difficulty” and “greater level of impairment,” and would amend the discussion of the three conditions that render individuals ineligible to receive ADHS to delete the grammatically incorrect term “substantially identical” and replace it with the term “redundant,” with respect to a beneficiary’s receipt of such services.
The Department proposes to amend the methods by which facility administrators can verify the validity of beneficiaries’ financial coverage, to delete the requirement that facility inspectors review and inspect participants’ Medicaid identification cards, as coverage information does not appear on the card, and to establish that facility administrators should use one of the eligibility verification systems or tools identified at N.J.A.C. 10:49-2.11, such as the Recipient Verification Eligibility System. The Department proposes amendments to delete reference to CAP, to make the provision applicable to beneficiaries who are participants of a program, among a prescribed list of programs, that requires case management, and to require facility administrators for such beneficiaries to contact the care manager for documentation verifying financial coverage. Similarly, the Department proposes an amendment to delete reference to the inspection of a valid Individual Service Agreement and to require facility administrators to verify JACC beneficiaries’ financial coverage by contacting such beneficiaries’ case or care managers.
A proposed new rule at N.J.A.C. 8:86-1.7 would establish the process by which ADHS beneficiaries may transfer from one ADHS facility to another.
The public has until
Department of Health
P. O. Box 360, Trenton, NJ 08625-0360