N.J. Admin. Code § 8:85-1.3

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:85-1.3 - Program participation

(a) An NF shall comply with the following requirements in order to be eligible to participate in the New Jersey Medicaid program. An in-State NF shall:

1. Be licensed by the Department in accordance with N.J.A.C. 8:39;

2. Be certified by the Department, and in the case of both Medicare and Medicaid, by the Centers for Medicare & Medicaid Services (CMS), which assures that the NF meets the Federal requirements for participation in Medicaid and Medicare;

3. Be approved for participation as an NF provider by the New Jersey Medicaid program. This includes the filing of a New Jersey Medicaid Provider Application PE-1 that establishes eligibility to receive direct payment for services to recipients under the New Jersey Medicaid program (see N.J.A.C. 8:85 Appendix A, incorporated herein by reference, as posted at www.state.nj.us/health/ltc/formspub.htm), the signing of a Participation Agreement PE-3, which is the participation agreement between the nursing facility and DHSS, which stipulates that an NF shall provide all NF services required by this chapter (see N.J.A.C. 8:85 Appendix B, incorporated herein by reference, as posted at www.state.nj.us/health/ltc/formspub.htm) and submittal of the CMS-1513 that is required to be completed before the State agency or Federal agency will enter into a contract for reimbursement of medical services, Ownership and Control Interest Disclosure Statement (see N.J.A.C. 8:85 Appendix C, incorporated herein by reference, as posted at www.state.nj.us/health/ltc/formspub.htm). The agreement for participation in the New Jersey Medicaid program stipulates that an NF shall provide all NF services required by this chapter. Continued participation as a New Jersey Medicaid provider will be subject to recertification by the Department and compliance with all Federal and State laws, rules and regulations. If recertification by the Department is denied, the Department's Office of Provider Enrollment shall notify the nursing facility that its provider agreement is not being continued.

4. File with the Department a completed cost report for the nursing facility as required pursuant to 8:85-3.2.

5. In accordance with 42 C.F.R. 483.12(d)(1)(i)(ii), not require residents or potential residents to waive their rights to Medicare or Medicaid; and not require oral or written assurance that residents or potential residents are not eligible for, or will not apply for Medicare or Medicaid benefits;

6. Accept as payment in full the Medicaid program's reimbursement for all covered services delivered during that period when, by mutual agreement between Medicaid and the facility, the beneficiary is under the provider's care, in accordance with 42 CFR § 447.15 and 30:4D-6(c); and

7. Except as provided in (a)7i below, by December 1, 1997, be certified by Medicare as a provider of skilled nursing services for no less than seven percent of the facility's total licensed long-term care beds.

i. This requirement shall not apply if a nursing facility cannot be certified as a Medicare skilled nursing facility due to its inability to meet structural requirements for a physical plant as required by the Medicare certification process.

ii. Upon receipt of the application, the Department shall determine whether the facility shall be recommended for Medicare certification in accordance with 42 CFR Part 483. If the facility cannot be certified for Medicare participation, the Department shall provide the facility with the reasons for the certification denial in writing.

N.J. Admin. Code § 8:85-1.3

Amended by R.1998 d.177, effective 4/6/1998.
See: 29 N.J.R. 4614(a), 30 N.J.R. 1284(b).
In (a), inserted "to be eligible" following "order" in the introductory paragraph, and added 7.
Recodified from N.J.A.C. 10:63-1.3 and amended by R.2005 d.389, effective 1/17/2006.
See: 36 N.J.R. 4700(a), 37 N.J.R. 1185(a), 38 N.J.R. 674(a).
Rewrote the section.
Amended by R.2011 d.121, effective 4/18/2011.
See: 42 N.J.R. 1793(a), 43 N.J.R. 961(c).
In the introductory paragraph of (a), substituted "An" for "A"; and rewrote (a)3 and (a)4.