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New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

V

Health Services

Chapter:

A

Health Services

11-14-2011

Subchapter:

2

Medicaid

Issuance:

100

Medicaid

 

Purpose                                                                                11-10-97

 

Medicaid is a state and federally supported medical assistance program designed to make payments to medical care providers for medical care and rendered to certain individuals whose resources are determined to be inadequate to secure quality medical care at their own expense, and who qualify for a categorical assistance program such as SSI/Medicaid Only, or State financial Public Assistance programs.

 

Legal Authority                                                                   3-23-81

 

Title XIX of the Federal Social Security Act established the Medicaid Program. The New Jersey Medical Assistance and Health Services Act of 1968 established a program of medical assistance and services for defined groups of persons. The 1968 Act implemented the Title XIX provisions of the Social Security Program. This program commonly known as "Medicaid" or "Title XIX" is referred to in New Jersey as the New Jersey Medicaid Program.

 

Administration of the Program, Department of Human Services       11-14-2011

 

The Department of Human Services is the administrative unit of State government which has the responsibility for the Medical Assistance Program and is designated under Federal law as the "single state agency."

 

Division of Medical Assistance and Health Services

 

The Division of Medical Assistance and Health Services is the administrative unit of the Department responsible for the general policies governing administration of Medical Assistance and for affecting the issuance of rules, regulations, and administrative communications to implement statutory provisions and to coordinate the administration of Medical Assistance with the public welfare program. The Division of Medical Assistance and Health Services:

 

•     Provides for the payment of claims;

 

•     Evaluates health services rendered under the program;

 

•     Maintains administrative liaison with the other Departmental divisions, and

 

•     Provides a professional medical and paramedical staff.

 

Medical Assistance Customer Centers (MACC)

 

The Division of Medical Assistance and Health Services operates Medical Assistance Customer Centers throughout the State.  See the list of MACCs at http://www.state.nj.us/humanservices/dmahs/info/resources/macc/MACC_Directory.pdf.

 

The Medical Assistance Customer Centers provide an array of services to the beneficiary and provider communities including but not limited to:

 

•     Serving as a liaison to providers of health services;

 

•     Providing information about Medicaid to recipients and members of the community;

 

•     Providing information about Medicaid to, and cooperating with, appropriate agencies in order to ensure maximum utilization of the services available through the Medicaid Program;

 

•     Providing prior authorization of services;

 

•     Providing service referrals; and

 

•     Providing information, advice and counsel about New Jersey Care 2000, which is managed health care.

 

Professional staff of the MACC are responsible for the evaluation of any of the health services which require prior authorization such as long term care and home health care services.

 

Within each MACC is a separate functional area operated by the Department of Health and Senior Services, known as the Long-Term Care Field Office (LTCFO/DHSS). This unit authorizes and monitors services provided to beneficiaries in Long-Term Care Nursing Facilities, Assisted Living and Medical Day Care Services delivered to seniors. Its primary function is to conduct Long-Term/Nursing Facility pre-admission screening (PAS), pre-admission screening and annual resident reviews of mentally disabled individuals, and clinical quality assurance of care.

 

Any questions with respect to the policy, regulations or procedures of the Medicaid Program should be directed to the appropriate MACC.

 

 

Observance of Religious Belief                                      2-5-88

 

Nothing in the Program shall be construed to require any person to undergo any medical screening, examination, diagnosis or treatment or to accept any other health care or services provided under the Program for any purpose (other than for the purpose of discovering and preventing the spread of infection or contagious disease or for the purpose of protecting environmental health) if such person or his parent or guardian object thereto on religious grounds.

 

Civil Rights                                                                          2-5-88

 

Federal regulations require that services provided to covered persons are given without discrimination on the basis of race, color, religious belief, gender, or national origin. Therefore, payments are limited to providers of service who are in compliance with the non-discrimination requirements of Title VI of the Civil Rights Act and Section 504 of the Rehabilitation Act of 1973.

 

Confidentiality of Records                                               2-5-88

 

All medical records, computer data, and other information of covered persons acquired under this Program shall be confidential and shall not be released by the Program without the written consent of the covered person or his authorized representative. This shall not preclude the release of statistical or summary data or information in which covered persons are not, and cannot be identified, nor shall it preclude the exchange of information between individuals or institutions providing care, contractors and State or local official agencies. Disclosure without consent of the covered person shall be limited to purposes directly connected with the administration of the Program pursuant to Federal and State laws and regulations.

 

Right to Fair Hearing                                                         11-10-97

 

At the time of determination of eligibility for Medicaid, applicants are advised of their right to a fair hearing. A request for a fair hearing pertaining to CP&P Medicaid eligibility determination is directed to the:

 

Administrative Hearing Coordinator

Division of Child Protection and Permanency,

Capital Center, 50 East State Street,

Trenton, New Jersey 08625

 

 Medicaid applicants and eligible persons may request a fair hearing if:

 

•     A claim is denied, or

 

•     A claim is not acted on with reasonable promptness, or

 

•     An action affecting the receipt, termination, reduction or suspension of Medicaid assistance is taken.

 

At the time of notice to the applicant/eligible person of an adverse action, the applicant/eligible person is advised again of his right to a fair hearing. In order to obtain a fair hearing, for an adverse action the person should submit a written request within 20 days from the receipt of notice of the adverse action to:

 

Director, Division of Medical Assistance and Health Services

CN 712

Trenton, New Jersey 08625