N.J. Admin. Code § 10:53A-1.2 - Definitions

Current through Register Vol. 54, No. 7, April 4, 2022

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

"Benefit period" means a period of time when an individual is eligible to receive hospice services. Hospice benefit periods are for the following periods of time: 90 days; 90 days and an unlimited number of subsequent 60-day periods.

"CAP" means a limitation on the payment amount or aggregate days of inpatient care as imposed by Medicaid/NJ FamilyCare FFS program on the hospice provider. The "CAP" year begins on November 1st of one year and ends on October 31st of the next year.

"Comprehensive hospice benefits" means the covered services provided by hospices and physicians for hospice care, room and board services provided to Medicare/Medicaid/NJ FamilyCare FFS beneficiaries residing in a nursing facility, and services unrelated to the terminal illness that may be provided by Medicaid/NJ FamilyCare FFS as part of the hospice plan of care. The comprehensive hospice benefit does not include hospice services under ACCAP or any other waiver program.

"DCP&P" means the Division of Child Protection and Permanency within the New Jersey Department of Children and Families.

"Dietician" or "dietary consultant" means a person who:

1. Is registered or eligible for registration by the Commission on Dietetic Registration of the American Dietetic Association; or

2. Has a bachelor's degree from a college or university with a major in foods, nutrition, food service or institution management, or the equivalent course work for a major in the subject area; and has completed a dietetic internship accredited by the American Dietetic Association or a dietetic traineeship approved by the American Dietetic Association or has one year of full-time, or full-time equivalent, experience in nutrition and/or food service management in a health care setting; or

3. Has a master's degree plus six months of full-time, or full-time equivalent, experience in nutrition and/or food service management in a health care setting.

"Division" means the Division of Medical Assistance and Health Services within the New Jersey Department of Human Services.

"DOH" means the New Jersey Department of Health.

"Election of Hospice Benefits Statement" means a written document signed by a Medicaid/NJ FamilyCare FFS eligible individual for hospice services, indicating the following: the identification of the particular hospice that will provide care to the individual; the scope of services and conditions under which hospice services are provided; which other Medicaid/NJ FamilyCare FFS services are forfeited when choosing hospice services; the individual or his or her representative's acknowledgment that he or she has been given a full understanding of hospice care; and the effective date of the signing of the Election of Hospice Benefits Statement (FD-378) (incorporated herein by reference as Form #1 in the Appendix).

"Eligibility determining agency" means the agency responsible for determining a beneficiary's financial eligibility for hospice services. These agencies include the medical assistance customer centers, the county welfare agencies and the Division of Child Protection and Permanency. These agencies determine financial eligibility after medical necessity has been certified. See N.J.A.C. 10:53A-3 for details.

"Hospice," for the purposes of the New Jersey Medicaid/NJ FamilyCare FFS program (hereafter referred to as the Program), means a public agency or private organization (or subdivision of such organization) which is licensed by the Department of Health and Senior Services as a provider of hospice services consistent with P.L. 1997, c. 78; is Medicare-certified for hospice care; and has a valid provider agreement with the Division to provide hospice services. A hospice is primarily engaged in providing supportive or palliative care and services, as well as any other item or service, as specified in the beneficiary's plan of care, which is reimbursed by the Medicaid/NJ FamilyCare FFS program. Hospice providers in New Jersey may be hospital-based or home health agencies, or hospice agencies.

"Hospice indicator" means a unique date specific identifier in the Medicaid/NJ FamilyCare FFS eligibility record which is used in the processing of hospice claims for eligible beneficiaries.

"Hospice services," for the purposes of the Program, means services which support a philosophy and method for caring for the terminally ill emphasizing supportive and palliative rather than curative care, and includes services, such as home care, bereavement counseling, and pain control.

"Interdisciplinary group" means a group of professionals who are employed by or under contract with the hospice, that provide and/or supervise hospice services. The interdisciplinary group, at a minimum, must be composed of a physician, a registered professional nurse, a medical social worker and a pastoral or other counselor.

"Medical Director" means a physician (M.D. or D.O.) who assumes overall responsibility for the medical component of the hospice services and who is employed by or under contract with the hospice.

"Medicare-certified hospice program" means a public/private organization which provides hospice care, as described in 42 U.S.C. § 1395x(dd), in individual homes, on an outpatient basis and on a short-term inpatient basis.

"Room and board services," as referred to in this chapter, means the performance of personal care services, assistance in activities of daily living, provision of patient social activities, the administration of medications, the maintenance of the cleanliness of a resident's room, and supervision and assistance in the use of durable equipment and prescribed therapies provided to hospice beneficiaries in a nursing facility (identical to those provided to non-hospice beneficiaries in a nursing facility).

"Terminal illness," as referred to in this chapter, means having a medical prognosis of a life expectancy of six months or less as certified or recertified, in writing, by a licensed physician (M.D. or D.O.).

"Unrelated services" means services provided that are necessary for the diagnosis and treatment of diseases or illnesses that are not in and of themselves related to or are not caused primarily by the terminal condition for which hospice services are provided.


N.J. Admin. Code § 10:53A-1.2
Amended by 48 N.J.R. 134(a), effective 1/19/2016

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