N.J. Admin. Code § 10:60-2.5

Current through Register Vol. 56, No. 17, September 3, 2024

Section 10:60-2.5 - Basis of payment for home health services

(a) Effective for services rendered on or after January 1, 1999, home health agencies shall be reimbursed the lesser of reasonable and customary charges or the service-specific unit rates described in this subsection. The following are the service-specific Statewide unit rates by each service:

Revenue	Base amount
Code	Description	Per Unit
420	Physical Therapy	$ 24.06
430	Occupational Therapy	$ 23.81
440	Speech Therapy	$ 20.27
550	Skilled Nursing	$ 29.14
560	Medical Social Services and Dietary/Nutritional Services	$ 25.90
570	Home Health Aide	$ 6.22

(b) Effective January 1, 2000, and thereafter, the reimbursement rates shall be the service-specific Statewide per unit rates found in (a) above, incrementally adjusted each January 1, beginning on January 1, 2000, using Standard and Poor's DRI Home Health Market Basket Index, published in the New Jersey Register as a notice of administrative change, in accordance with N.J.A.C. 1:30-2.7, and posted on the DMAHS' fiscal agent's website http://www.njmmis.com under "Rate and Code Information". Home health agencies shall maintain both unit and visit statistics for all services provided to Medicaid/NJ FamilyCare fee-for-service beneficiaries.

(c) Effective January 1, 1999, home health agencies shall bill the Medicaid/NJ FamilyCare fiscal agent as follows:

1. The unit of service shall be a 15 minute interval of a skilled nursing visit, a home health aide visit, a speech therapy visit, a physical therapy visit, an occupational therapy visit, a nutrition visit, or a medical social service visit, as defined at N.J.A.C. 10:60-1.2. A home health agency shall not bill when a Medicaid/NJ FamilyCare fee-for-service beneficiary is not home or cannot be found, and hands-on medical care was not provided;

2. The service-specific Statewide rate shall be billed for each full 15 minute interval of face-to-face service in which hands-on medical care was provided to a Medicaid/NJ FamilyCare fee-for-service beneficiary;

i. For instance, one unit of service shall be billed for services provided from the initial minute through 29 minutes. The second unit of service shall be billed for services provided from 30 minutes through 44 minutes. The third unit of service shall be billed for services provided from 45 minutes to 59 minutes and the fourth unit of service shall be billed for services provided from 60 minutes through 74 minutes;

3. Items including, but not limited to, nursing supervision, travel time, paperwork, and telephone contact at the home are included in the service-specific Statewide rate and, therefore, the time associated with these items is not billed directly;

4. A separate line shall be billed for each day the service is provided. A home health agency shall not "span bill" for services;

5. Routine supplies shall be considered visit overhead costs and billed as part of a unit of service. Non-routine supplies shall be billed using Revenue Code 270 on the institutional claim form and HCPCS codes in accordance with N.J.A.C. 10:59-2;

6. A home health agency shall only bill the revenue codes listed in (a) above and Revenue Code 270. No other revenue codes will be reimbursed for home health services.

(d) Home health agencies shall submit a cost report for each fiscal year to the Director, Office of Reimbursement, Division of Medical Assistance and Health Services, PO Box 712, Trenton, New Jersey 08625-0712 or the Director's designee. The cost report shall be legible and complete in order to be considered acceptable.

1. Cost reports and audited financial statements shall be due on or before the last day of the fifth month following the close of the period covered by the report.

2. A 30-day extension of the due date of a cost report may be granted by the Division for "good cause." "Good cause" means a valid reason or justifiable purpose; it is one that supplies a substantial reason, affords a legal excuse for delay, or is the result of an intervening action beyond one's control. Acts of omission and/or negligence by the home health agency, its employees, or its agents, shall not constitute "good cause."

3. To be granted the extension in (d)2 above, the provider shall submit a written request to, and obtain written approval from, the Director, Office of Reimbursement, Division of Medical Assistance and Health Services, PO Box 712, Trenton, New Jersey 08625-0712 or the Director's designee, at least 30 days before the due date of the cost report.

4. If a provider's agreement to participate in the Medicaid/NJ FamilyCare fee-for-service program terminates or the provider experiences a change of ownership, the cost report is due no later than 45 days following the effective date of the termination of the provider agreement or change of ownership. An extension of the cost report due date cannot be granted when the provider agreement is terminated or a change in ownership occurs.

5. Failure to submit an acceptable cost report on a timely basis may result in suspension of payments. Payments for claims received on or after the date of suspension may be withheld until an acceptable cost report is received.

(e) Medicare/Medicaid and Medicaid/NJ FamilyCare third-party claims for home health services provided that are not the responsibility of a Medicaid/NJ FamilyCare managed care organization shall be reimbursed in accordance with N.J.A.C. 10:49-7.3 and the provisions of this chapter.

(f) When Medicaid/NJ FamilyCare is not the primary payer on a home health services claim, payment by Medicaid/NJ FamilyCare will be made at the lesser of:

1. The Medicaid/NJ FamilyCare allowed amount minus any other payment(s); or

2. The beneficiary liability, including denied charges, deductible, coinsurance, copayment, and non-covered charges.

(g) In no event will a Medicaid/NJ FamilyCare payment for home health services exceed the total charge amount submitted on the claim.

(h) The State will perform a post-payment review of home health claims for beneficiaries eligible for both Medicare and Medicaid (dual eligibles) when Part A benefits exhaust during home health services. Based on the post-payment review, the Division will determine whether paying the beneficiary's liability for the home health services will result in a lower cost to the Division. If paying the beneficiary's liability results in a lower cost to the Division, the provider will be notified and the excess provider payments will be recouped by the Division.

1. Where benefits have been exhausted under Medicare Part A, the charges to be billed to the Medicaid/NJ FamilyCare Program must be itemized for the Medicare Part A non-covered services in order to determine the liability of Medicare Part B and other third-party payers.

(i) If prior authorization is required for Medicaid/NJ FamilyCare program purposes, it shall be obtained and shall be submitted with the institutional claim form.

N.J. Admin. Code § 10:60-2.5

Amended by 50 N.J.R. 1992(b), effective 9/17/2018

Amended by 54 N.J.R. 1721(a), effective 9/6/2022