N.J. Admin. Code § 10:60A-4.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:60A-4.1 - Reimbursement rate

(a) In accordance with P.L. 2016, c. 10, the per diem reimbursement rate for PMDC for fiscal year 2017 is $ 330.81 (base reimbursement rate), as amended and supplemented by subsequent State appropriations acts.

1. The Department shall rebase the base reimbursement rate every three years using data regarding median allowable costs the Department collects in PMDC facility cost reports and financial statements.

2. In years during which the Department does not rebase the base reimbursement rate, the Department shall calculate the per diem reimbursement rate payable to all PMDC facilities by multiplying the base reimbursement rate by the inflation adjustment factor.

3. The Department shall develop the inflation adjustment factor upon consideration of:

i. The average hourly earnings of manufacturing employees in New Jersey as published by the United States Department of Labor, Bureau of Labor Statistics;

ii. The Consumer Price Index as published by the United States Department of Labor, Bureau of Labor Statistics; and

iii. Other standards imposed by law or regulation governing rate-setting methodology in Medicaid/NJ FamilyCare programs.

4. The Department shall publish a notice of revisions to the PMDC base reimbursement rate, per diem reimbursement rate, and/or inflation adjustment factor in the New Jersey Register by no later than February 1 of the fiscal year immediately preceding the fiscal year for which the revision is to be in effect.

5. The requirements of (a)1 through 4 above shall not apply in any State fiscal year for which the PMDC rate is established in the State appropriations act.

(b) Pursuant to the Medicaid Administration Manual at N.J.A.C. 10:49-9.8(b)6, a PMDC facility shall accept the Medicaid/NJ FamilyCare reimbursement rates the Department establishes, and shall accept payments the Department makes on behalf of PMDC beneficiaries to PMDC facilities as payment in full for services so provided, subject to any applicable deductible, coinsurance, or co-payment for which a Medicaid/NJ FamilyCare beneficiary may be responsible.

(c) A medical director may bill the New Jersey Medicaid/NJ FamilyCare Program using the Health Insurance Claim Form, CMS-1500, only for services provided to a PMDC beneficiary for whom the medical director is a designated primary health care provider.

1. A medical director shall not bill the New Jersey Medicaid/NJ FamilyCare Program separately for any service performed for any PMDC beneficiary in a PMDC facility while serving solely in the role of a medical director.

(d) Transportation services a PMDC facility provides are included in the per diem reimbursement rate for PMDC and are not reimbursable as a separate service.

(e) All prescribed therapies identified in the PMDC beneficiary's initial and/or interdisciplinary plan of care are included in the per diem reimbursement rate and neither the PMDC facility nor the individuals providing the prescribed therapies shall bill the New Jersey Medicaid/NJ FamilyCare Program separately for these therapies.

(f) The PMDC facility administrator shall make inquiry of the child's parent respecting the existence of any private health insurance plan that provides a payment benefit for PMDC on behalf of the child and shall ensure that the PMDC facility bills any such private health insurance plan for covered services provided to the child prior to the facility submitting claims for Medicaid/NJ FamilyCare reimbursement to the fiscal agent.

(g) The PMDC facility administrator shall verify each child's Medicaid/NJ FamilyCare financial eligibility, prior to submitting a prior authorization request form, and monthly thereafter, using the Recipient Eligibility Verification System pursuant to N.J.A.C. 10:49-2.11.

(h) The Department shall reimburse PMDC facilities for no more than a combined total of five units of service per week per PMDC beneficiary, even if the PMDC beneficiary receives services from multiple PMDC facilities during the same week.

N.J. Admin. Code § 10:60A-4.1

Amended and Recodified from 10:166-4.1 by 56 N.J.R. 262(a), effective 2/20/2024