N.J. Admin. Code § 10:49-1.5

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:49-1.5 - Compliance with the Patient Protection and Affordable Care Act, Health Care and Education Reconciliation Act of 2010, and Federal regulations

(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.

N.J. Admin. Code § 10:49-1.5

Repealed by R.1997 d.354, effective 9/2/1997.
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
Section was "Prepaid health plans".
New Rule, R.2013 d.052, effective 4/1/2013.
See: 44 N.J.R. 2941(a), 45 N.J.R. 737(a).
Section was "Reserved".