N.J. Admin. Code § 10:52-14.6

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10:52-14.6 - Determination of the Statewide base rate

(a) The Division established an initial Statewide base rate, which applies to all hospitals. Those hospitals meeting the criteria for add-on amounts in accordance with N.J.A.C. 10:52-14.7have rates higher than the Statewide base rate. The initial Statewide base rate is established as follows:

1. For the initial rate year, the Division used the actual payments made for claims paid during calendar year 2006. Total payments include all DRG and outlier payments. Payments for hospital-based physicians were removed since hospital-based physician groups will bill for these services separately beginning August 3, 2009. These historical 2006 payments were inflated to the rate year by applying the excluded hospital inflation factor, also referred to as the economic factor recognized under the Center for Medicare and Medicaid Services (CMS) Tax Equity and Fiscal Responsibility Act, Pub.L. 97-248 (TEFRA) target limitations, which is published annually in the Federal Register by CMS. These adjusted payments were used to establish the total budgeted amount for inpatient acute hospital services for the rate year.

2. The amount calculated in (a) above is reduced to account for the following DRG system payments: addon amounts under N.J.A.C. 10:52-14.7, outlier payments, payments for alternate levels of care and the effect on payments where Medicaid/NJ FamilyCare is not the primary payer (that is, Medicare claims partially paid by Medicaid/NJ FamilyCare and third party liability claims). A reduction in payments was also made to remove an amount for utilization review services that were previously paid for by hospitals, which will become a State obligation, effective August 3, 2009.

i. If the Division does not have a contractor for hospital utilization review services by August 3, 2009, hospitals will receive separate payments equal to the aggregate amount of utilization review removed before establishing the Statewide base rate. Each hospital will receive a utilization review payment based on its proportional amount of Medicaid/NJ FamilyCare fee-for-service discharges from the most recent available 24 months of Medicaid/NJ FamilyCare paid claims data. The allocation of utilization review payments will account for closed hospitals in accordance with the method set forth in N.J.A.C. 10:52- 14.7(d).

(b) The Statewide base rate is increased by the hospital specific add-on amounts to determine a final rate for each hospital. The final rate for new hospitals and hospitals that had no Medicaid/NJ FamilyCare discharges in the base year are set at the Statewide base rate.

(c) The Statewide base rate will be updated annually by the excluded hospital inflation factor, also referred to as the economic factor recognized under the CMS TEFRA target limitations, which is published in the Federal Register by CMS.

(d) The initial Statewide base rate calculated in this section is $ 4,479. The Statewide base rate will not be changed, except for annual inflation as noted in (c) above, unless rebasing occurs as described in (e) below.

(e) Rebasing, which is setting the Statewide base rate using a more current year's claim payment data, will be done at the discretion of the Division with the approval of the Commissioner of DHS. Rebasing may or may not include recalibrating the DRG weights as described in 10:52-14.3(g).

N.J. Admin. Code § 10:52-14.6

Amended by 50 N.J.R. 1261(a), effective 5/21/2018