DEPARTMENT OF HUMAN SERVICES



HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

Adult Mental Health Rehabilitation Services Provided In/By Community Residence Programs

Proposed Readoption with Amendments: N.J.A.C. 10:77A.

Authorized By: Jennifer Velez, Commissioner,

Department of Human Services.

Authority: N.J.S.A. 30:4D-1 et seq. and 30:4J-8 et seq.

Calendar Reference: See Summary below for explanation of the exception to rulemaking calendar requirements.

Agency Control Number: 08-P-16.

Proposal Number: PRN 2009 - 60.

Submit comments by May 1, 2009 to:

James M. Murphy

Division of Medical Assistance and Health Services

P.O. Box 712, Mail Code #31

Trenton, NJ 08625-0712

Fax: (609) 588-7672

Email: James.M.Murphy@dhs.state.nj.us

Delivery: 6 Quakerbridge Plaza

Mercerville, NJ 08619

The agency proposal follows:

Summary

Pursuant to N.J.S.A. 52:14B-5.1c, N.J.A.C. 10:77A, the Adult Mental Health Rehabilitation Services Provided In/By Community Residence Programs chapter, will expire on July 4, 2009.

The chapter contains requirements for Medicaid/NJ FamilyCare-approved Community Residence Programs who render Adult Mental Health Rehabilitation services. The Department has reviewed the chapter and finds that the rules should be readopted, with amendments, because they are necessary, reasonable, adequate, efficient and responsive to the purposes for which they were originally promulgated.

The proposed amendments in the readoption do not change the scope of provider eligibility. Proposed amendments relative to beneficiary eligibility recognize that these services are now available to all eligible adult NJ FamilyCare beneficiaries age 18 and older, except those in Plan G. NJ FamilyCare beneficiaries in Plans A, B, C and D under age 18 receive residential mental health rehabilitation services in accordance with N.J.A.C. 10:77-3. NJ FamilyCare Plan G beneficiaries may receive these services under the Division of Mental Health Services (DMHS) programs provided that they meet the DMHS criteria for services under N.J.A.C. 10:37A.

These services are rendered in/by community residential programs under contract with the DMHS and licensed in accordance with DMHS rules at N.J.A.C. 10:37A.

The chapter contains three subchapters: N.J.A.C. 10:77A-1, General Provisions, N.J.A.C. 10:77A-2, Program Operations and N.J.A.C. 10:77A-3, Healthcare Common Procedure Coding System (HCPCS), described immediately below.

Subchapter 1 contains sections, which include scope and purpose, definitions, provider participation and beneficiary eligibility. Subchapter 2 contains sections, which include program requirements, levels of care, nursing assessments, staff training, basis of reimbursement and recordkeeping. Subchapter 3 contains sections which include an introduction, HCPCS codes and a maximum fee allowance schedule.

Throughout the chapter, specifically at N.J.A.C. 10:77A-1.1(a), 1.4(a), 2.4(c) and 2.5(a), references to “Plan A” are deleted because these services are available to beneficiaries of all NJ FamilyCare Plans, except Plan G, as long as the beneficiary is an adult as defined at N.J.A.C. 10:77A-1.2 and 10:37A. NJ FamilyCare–Children’s Program beneficiaries are entitled to residential mental health rehabilitation services in accordance with N.J.A.C. 10:77-3.

At N.J.A.C 10:77A-1.2, proposed amendments add definitions for advanced practice nurse and registered professional nurse.

At N.J.A.C. 10:77-1.4(b) proposed amendments remove references to NJ FamilyCare Plans–B, C, and D because these services are now available to beneficiaries of those plans and remove the reference to NJ FamilyCare Plan-H because that plan no longer exists. Beneficiaries previously enrolled in NJ FamilyCare Plan-H now receive benefits under NJ FamilyCare Plan-D. Another proposed amendment would add a cross reference to N.J.A.C. 10:49-24.3, which states at subsection (b), that adult mental health rehabilitation services provided to Work First New Jersey/General Assistance program beneficiaries in/by community residences are not eligible for reimbursement.

At N.J.A.C. 10:77A-2.1, proposed amendments remove the reference to CSOCI, which is no longer a program of the Department.

At N.J.A.C. 10:77-2.4(b) proposed amendments require that training in CPR and First Aid shall be provided by a trainer certified by the American Heart Association or the Red Cross.

At N.J.A.C. 10:77A-2.4(b)2ii, a proposed amendment adds a reference to abdominal thrusts, which is current terminology used by some medical professionals for the Heimlich maneuver.

At N.J.A.C. 10:77A-3.1(b), proposed amendments remove the reference to the Level III HCPCS codes because the Centers for Medicare and Medicaid Services no longer allows the use of Level III codes and clarify that the HCPCS coding system is now a two-level system.

At N.J.A.C. 10:77A-3.1(b)1 a proposed amendment changes the name of “certified nurse practitioner/clinical nurse specialist” to the correct current professional term “advance practice nurse.”

At N.J.A.C. 10:77A-3.1(b)3, the definition of a Level III HCPCS code is being deleted because those codes are no longer used.

At N.J.A.C. 10:77A-3.1(c)2 proposed amendments revise the definition of the code narrative to indicate that the complete narrative definition for the code can be found at N.J.A.C. 10:77A-2.2, and remove the reference to the Level III HCPCS codes.

At N.J.A.C. 10:77A-3.1(d)1 a proposed amendment adds a description of the modifier “52”, which is used in the chapter to indicate which HCPCS code providers are to use when seeking reimbursement for services rendered in supervised apartment settings. The modifier was included in the original adoption of the chapter, effective January 5, 2005; however the description of the modifier was inadvertently not included. This proposed amendment does not change any existing policy. It only modifies the rule text to include the information.

The Department has determined that the comment period for this notice of proposal will be 60 days; therefore, pursuant to N.J.A.C. 1:30-3.3(a)5, this notice of proposal is exempt from the rulemaking calendar requirement.

Social Impact

The rules proposed for readoption with amendments will continue to have a positive impact on the 1,698 Medicaid/NJ FamilyCare beneficiaries who will continue to receive adult mental health rehabilitation community residence program services through the Division of Mental Health Services. Proposed amendments relative to beneficiary eligibility recognize that these services are now available to all eligible adult NJ FamilyCare beneficiaries, except those in Plan G. NJ FamilyCare-Children’s Program beneficiaries are entitled to residential mental health rehabilitation services in accordance with N.J.A.C. 10:77-3. NJ FamilyCare Plan G beneficiaries may be eligible to receive these services under DMHS programs provided that they meet the DMHS criteria for services under N.J.A.C. 10:37A.

The rules proposed for readoption with amendments will have a positive impact on the approximately 37 provider agencies, because the proposed amendments do not change provider eligibility or service delivery requirements and the providers will continue to receive reimbursement for provision of services.

Economic Impact

During State Fiscal Year 2008, the Division spent approximately $47.5 million (State and Federal share combined) for adult mental health rehabilitation services provided in community residences for approximately 1,698 Medicaid/NJ FamilyCare beneficiaries. The proposed amendments will not increase expenditures by the State.

The rules proposed for readoption with amendments will continue to have a positive economic impact on beneficiaries who will continue to receive services under the rules.

The rules proposed for readoption with amendments will continue to have a positive economic impact on providers because the readoption of the rules will ensure that the providers continue to receive reimbursement for provision of services.

Federal Standards Statement

Sections 1902(a)(10) and 1905(a) of the Social Security Act, 42 U.S.C. §§1396a(a)(10) and 1396d(a), respectively, specify who may receive services through a Title XIX Medicaid program.

Section 1905(a)(13) of the Social Security Act, 42 U.S.C. §1396d(a)(13), allows a state Medicaid program to offer diagnostic, screening, prevention and rehabilitation services, including medical or remedial services recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under state law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level.

Federal regulations at 42 CFR 440.130 describe diagnostic, screening, preventive and rehabilitative services, which include the nursing assessments and residential rehabilitation services addressed in these amendments.

The Department has reviewed the Federal statutory and regulatory requirements and has determined that the rules proposed for readoption with amendments do not exceed Federal standards. Therefore, a Federal standards analysis is not required.

Jobs Impact

The Department does not anticipate that the rules that are proposed for readoption with amendments will result in the creation or loss of jobs in the State of New Jersey.

Agriculture Industry Impact

Since the rules proposed for readoption with amendments concern the provision of adult mental health rehabilitation services in/by community residence programs, no impact on the agriculture industry in the State of New Jersey is expected to occur as a result of this rulemaking.

Regulatory Flexibility Analysis

The rules proposed for readoption with amendments will affect providers who provide mental health rehabilitation services to adult beneficiaries residing in the community, and who are, or will be, billing the Division directly for these services. Many of these providers may be considered small businesses under the terms of the Regulatory Flexibility Act, N.J.S.A. 52:14B-16 et seq. Therefore, a regulatory flexibility analysis is needed.

The rules proposed for readoption with amendments continue to contain recordkeeping and compliance requirements of providers. Providers are required to submit claims to the Division’s fiscal agent in approved formats and are required to maintain records of the services rendered. Most providers have already used this format and, therefore, are familiar with the procedure. For any new providers who are not familiar with the process, a toll-free number is available for on-going support as providers become familiar with the process. Other requirements placed on the providers result from licensing rules contained elsewhere in the New Jersey Administrative Code and are incorporated by reference into these rules. A very minor expense may be incurred as a result of the proposed amendment that would require CPR and First Aid Training by the American Heart Association or Red Cross; however, such staff training is necessary for the safety and health of all beneficiaries. The requirements contained in the rules proposed for readoption with amendments must be equally applicable to all providers regardless of size, because all claims must be submitted in a common format in order to assure that they can be electronically processed through the Division’s fiscal agent and all supporting documentation for those claims must be consistent throughout the provider community.

There should be no capital costs associated with these requirements, since the production of claims for reimbursement purposes can be done with existing staff or purchased as a service from billing agents. The production of claims does not require capital expenditures. The maintenance of records supporting the claims is required by statute. No professional services are required beyond those required by the rules for the purpose of service delivery to the beneficiaries.

Smart Growth Impact

Since the rules proposed for rules proposed for readoption with amendments concern the provision of adult mental health rehabilitation services in/by community residence programs which are already operational in existing residences, the Department anticipates that the proposed amendments will have no impact on the achievement of smart growth in New Jersey or on the implementation of the State Development and Redevelopment Plan.

Housing Affordability Impact

The rules proposed for readoption with amendments will have an insignificant impact on affordable housing in New Jersey and there is an extreme unlikelihood that the rules would evoke a change in the average cost associated with housing because the rules concern the provision of adult mental health rehabilitation services in/by community residence programs.

Smart Growth Development Impact

The rules proposed for readoption with amendments will have an insignificant impact on smart growth and there is an extreme unlikelihood that the rules would evoke a change in housing production in Planning Areas 1 or 2 or within designated centers under the State Development and Redevelopment Plan in New Jersey because the rules concern the provision of adult mental health rehabilitation services in/by community residence programs.

Full text of the rules proposed for readoption may be found in the New Jersey Administrative Code at N.J.A.C. 10:77A.

Full text of the proposal follows (additions indicated in boldface thus; deletions indicated in brackets [thus]):

SUBCHAPTER 1. GENERAL PROVISIONS

10:77A-1.1 Scope and purpose

(a) The subchapter sets forth the program standards pertaining to the provision of adult mental health rehabilitation services provided to New Jersey Medicaid/NJ FamilyCare[-Plan A] beneficiaries in/by community residence programs licensed under N.J.A.C. 10:37A.

(b) (No change.)

10:77A-1.2 Definitions

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

"Advanced practice nurse (APN)" means a person currently licensed to practice as a registered professional nurse who is certified by the New Jersey State Board of Nursing in accordance with N.J.A.C. 13:37, and with N.J.S.A. 45:11- 45 through 52, or similarly licensed and certified by a comparable agency of the state in which he or she practices.

. . .

“Registered professional nurse (RN)” means a person who is licensed by the New Jersey Board of Nursing as a professional nurse pursuant to N.J.S.A. 45:11-26 and in accordance with N.J.A.C. 13:37 or similarly licensed and certified by a comparable agency of the state in which he or she practices.

. . .

10:77A-1.4 Beneficiary eligibility

(a) Medicaid/NJ FamilyCare[-Plan A] beneficiaries shall be eligible for adult mental health rehabilitation (AMHR) services provided in/by community residence programs, if such services have been determined clinically necessary using the criteria established by the Division of Mental Health Services (see N.J.A.C. 10:37), or as authorized by any contracted agent of the Department of Human Services, which authorizes clinical need for mental health services for adults.

(b) NJ FamilyCare-Plan[s B, C, D, ]G [and H] beneficiaries are not eligible for AMHR services provided in/by community residence programs. (See N.J.A.C. 10:49-24.3)

(c) (No change.)

SUBCHAPTER 2. PROGRAM OPERATIONS

10:77A-2.1 Program requirements

(a) Adult mental health rehabilitation (AMHR) services provided in/by community residence programs to Medicaid/NJ FamilyCare[/ CSOCI] beneficiaries shall meet all program and licensure requirements contained in N.J.A.C. 10:37A, Community Residences for Mentally Ill Adults.

(b) – (c) (No change.)

10:77A-2.4 Staff training

(a) (No change.)

(b) In addition to the general training requirements at N.J.A.C. 10:37D–2.14, each provider shall develop, update and administer a comprehensive, competency-based training program for individuals providing adult mental health residential services. Competency based training programs involve measurable skill development and demonstrated, documented evidence of employee skill attainment. Training in CPR and First Aid shall be provided by an American Heart Association (AHA) or Red Cross certified trainer, which, upon successful completion of the training, issues a certificate to the employee confirming that competency was achieved. The DMHS will be responsible for monitoring the provider's training programs. The following topics, at a minimum, shall be included in the training curriculum:

1. (No change.)

2. Emergency preparedness, including, but not limited to:

i. (No change.)

ii. The Heimlich maneuver/abdominal thrusts;

iii. – iv. (No change.)

3. – 7. (No change.)

(c) All individuals who provide AMHR services, other than a psychiatrist, regardless of credentials, shall have completed the training required by (a) and (b) above in order for their service time to be counted toward the minimum service requirements necessary for Medicaid/NJ FamilyCare[-Plan A] reimbursement.

(d) (No change.)

10:77A-2.5 Basis of reimbursement

(a) Reimbursement for AMHR services provided in or by community residence programs to eligible Medicaid and NJ FamilyCare[-Plan A] beneficiaries shall be based on the site-specific levels of care delivered by each provider, in accordance with this chapter.

(b) – (g) (No change.)

SUBCHAPTER 3. HEALTHCARE COMMON PROCEDURE CODING SYSTEMS (HCPCS)

10:77A-3.1 Introduction

(a) (No change.)

(b) HCPCS is a [three] two-level coding system, as follows:

1. LEVEL I CODES (narratives found in the CPT): These codes are adapted from the Physicians Current Procedural Terminology, as amended and supplemented, published by the American Medical Association, 515 N. State Street, Chicago, IL 60610, incorporated herein by reference. The CPT codes are used primarily by physicians, podiatrists, optometrists, certified nurse-midwives, [certified nurse practitioners/clinical nurse specialists] advanced practice nurses, independent clinics and independent laboratories. Copyright restrictions make it impossible to print substantial excerpts from CPT procedure narratives for Level I codes. Thus, in order to determine those narratives, it is necessary to refer to the CPT.

2. (No change.)

[3. LEVEL III CODES: The narratives for Level III codes are found in this subchapter. These codes are assigned by the Division of Medical Assistance and Health Services to be used for those services that are unique to the New Jersey Medicaid/NJ FamilyCare programs.]

(c) Regarding specific elements of HCPCS codes which require the attention of providers, the lists of HCPCS code numbers for services are arranged in tabular form with specific information for a code given under columns with titles such as "HCPCS Code," "DESCRIPTION" and "MAXIMUM FEE ALLOWANCE." The information given under each column is summarized below:

1. (No change.)

2. "DESCRIPTION"–Code narrative: [Narratives] Complete narratives for [Level III] the codes are found at N.J.A.C. 10:77A-2.2;

3. (No change.)

(d) Alphabetic and numeric symbols under "IND" and "MOD": These symbols, when listed under the "IND" and "MOD" columns, are elements of the HCPCS coding system used as qualifiers or indicators ("IND" column) and as modifiers ("MOD" column). They assist the provider in determining the appropriate procedure codes to be used, the area to be covered, the minimum requirements needed and any additional parameters required for reimbursement purposes.

1. Providers shall consider these symbols and/or letters when billing because the symbols/letters reflect requirements, in addition to the narrative that accompanies the CPT/HCPCS procedure code, for which the provider is liable. These additional requirements shall be fulfilled before reimbursement is requested.

i. “52” Reduced Services: Under certain circumstances a service or procedure is partially reduced or modified. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier '52', signifying that the service is reduced or modified. This provides a means of reporting reduced services without disturbing the identification of the basic service. In this chapter, the “52” modifier indicates that AMHR services are rendered in a supervised apartment setting rather than in a group home setting.

(e) (No change.)

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