MedicaidCoverageMedium impact
Newsletter Vol. 2, No. 62
New Jersey Medicaid·NJ · Geriatrics, Palliative Care·Provider Notice
Effective date
Nov 1, 2024
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid now allows increased Personal Care Assistant (PCA) services beyond standard limits when medically indicated for specific circumstances (caregiver unavailability, recipient living alone, severe functional limitations, or acute medical deterioration). Providers must notify the Medicaid District Office when PCA services exceed the standard threshold to ensure reimbursement; failure to notify may result in non-payment of excess hours.
Action Required
By November 2024 (immediately): (1) Billing team and providers must update protocols to document and track when PCA services exceed standard limits, including the specific medical justification (caregiver illness/absence, recipient living alone, severe ADL limitations, or acute medical deterioration). (2) Designate staff responsible for notifying the Medicaid District Office in writing or by telephone whenever a Medicaid recipient receives more than the standard hours of PCA services—this notification must be completed before or concurrent with claim submission to avoid non-payment. (3) Update home care agency documentation templates and EMR systems to capture the qualifying condition for increased hours. (4) Train providers on the four qualifying criteria and ensure all claims for increased PCA hours include specific medical justification tied to these criteria. (5) Implement a quality assurance checklist to verify MDO notification was completed before processing reimbursement. Consequence: Claims for PCA hours exceeding the standard amount will not be reimbursed if MDO notification is not documented, and claims are subject to post-payment quality assurance review.