NJ Medicaid Enhanced Enrollment Requirements

The Affordable Care Act (ACA) imposed certain enhanced Medicaid enrollment requirements for State Medicaid programs to follow. Recently, the NJ Medicaid Fraud Division Unit (MFD), in consultation with the NJ Division of Medical Assistance and Health Services (DMAHS), described how it plans to comply with the ACA’s enhanced provider screening requirements.

The regulations implementing the ACA require that each State Medicaid agency screens Medicaid providers according to the level of risk — limited, moderate or high — they pose to the the Medicaid program. While states may enhance the risk level for a provider, they may not lower it.

MFD and DMAHS determined that the following providers fall into the high risk category:

  • newly enrolling durable medical equipment providers
  • pharmacies
  • prosthetic and orthotic providers
  • adult and pediatric medical day care providers
  • newly enrolling home health providers

MFD and DMAHS determined that the following providers fall into the moderate risk category:

  • ambulance providers
  • community mental health centers
  • comprehensive outpatient rehabilitation facilities
  • hospice providers
  • independent diagnostics testing facilities
  • independent clinical laboratories
  • physical therapists
  • portable x-ray providers
  • re-enrolling home health providers.

According to the 2012 workplan, MFD will begin conducting unannounced pre-enrollment visits of providers who fall into the moderate and high risk categories, and perform criminal background checks for each person with an ownership interest or who is an agent or managing employee of a provider in the moderate or high risk categories.

The 2012 workplan did not identify which providers fall into the limited risk category nor did the plan outline the verification process for this limited risk category group. We have previously discussed some of the foundational verification processes that the federal government imposes on State Medicaid Programs.

MFD has indicated that it will comply with the requirements set out in Section 6501 of the ACA, which require a state to terminate individuals or entities from the Medicaid program if they were terminated from another states Medicaid program.  According to the workplan, “[t]he federal government is establishing a portal for state to check on each other’s terminations, which MFD will continually monitor.”

Lastly, MFD’s workplan also mentioned the mandatory compliance program requirement for State Medicaid providers promulgated in Section 6401(b)(5). Although the Centers for Medicare & Medicaid has yet to issue regulations with respect to this requirement, MFD encourages providers to have a “vigorous and effective compliance program” and points providers to its website for guidance with developing and/or strengthening the provider’s compliance program. As compliance programs have to be tailored to the specific needs of an medical practice, providers and suppliers should consider obtaining advice from an experienced healthcare counsel.

If you have questions about the new New Jersey Medicaid Enrollment or Revalidation requirements, provider participation in New Jersey Medicaid or Managed Care Organizations, or have other legal needs, please contact us.