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Page 162 of 202 § 10:90-13.2 Payment of medical service claims for WFNJ/GA recipients residing in a nursing facility

i. Inpatient or outpatient hospital services/care provided in a hospital either in- State or out-of-State, including, but not limited to, psychiatric hospitals, acute care hospitals, special hospitals, rehabilitation hospitals, Christian Science sanatoria and county or State hospitals; (1) Exception: Inpatient hospitalization at Mt. Carmel Guild in Newark is an eligible medical service for the WFNJ/GA program. ii. Professional services rendered to residents in public/private medical institutions; iii. Professional services to WFNJ/GA clients residing in residential treatment centers for drug or alcohol abuse; iv. Nursing facility per diem payments for individuals residing in Medicaid approved nursing facilities; (1) See N.J.A.C. 10:90-13.5 concerning per diem payments for WFNJ/GA clients residing in non-Medicaid nursing facilities on or prior to June 30, 1995; v. Early and periodic screening, diagnosis and treatment (EPSDT) services; vi. Services provided under a home and community based services waiver, in accordance with Section 1915(c) of the Social Security Act, 42 U.S.C. § 1396n; vii. Managed care services; viii. Transportation for medical services provided under contract with a vendor or through a contract with the county agency; ix. Medical services payable through other health insurance coverage, no-fault insurance benefits, or any other type of insurance/benefit coverage; (1) Medical service bills shall be submitted to the appropriate primary carrier prior to being submitted for payment consideration through the fiscal agent; x. HealthStart maternity and pediatric care services including comprehensive medical and health support service packages; xi. Hospice services provided in a nursing facility; xii. Maternity services provided by any type of provider including, but not limited to physicians, certified nurse specialists/clinical nurse practitioners, certified nurse- midwives and clinics; xiii. Medical day care services; xiv. Medical bills, which have been paid by the client or on his or her behalf; and xv. Antiretroviral prescription medications (except for a one time emergency supply pending application processing and acceptance into the AIDS Drug Distribution Program). 3. The director of the county/municipal agency may authorize payment of other medical insurance premiums.