N.J. Admin. Code § 10:77-3.6

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:77-3.6 - Basis of reimbursement

(a) The reimbursement for mental health rehabilitation services for a psychiatric community residence for youth, a residential child care facility, or a group home shall be based on reasonable, negotiated, contracted costs as defined in the Department of Human Services' Contract Reimbursement Manual and the Contract Policy and Information Manual. Providers have access to these manuals as indicated at N.J.A.C. 10:3-3.3(e)12.

1. These rates shall not be adjusted in the provider's current contract year except for Department-approved adjustments that would otherwise have been provided for under the terms of the existing contracts if Medicaid/NJ FamilyCare reimbursement for these services had not occurred, such as scheduled cost-of-living adjustments.

2. The total amount reimbursed by the Division, including room and board, shall be based on the approved negotiated contracted rates each provider receives under contract with the Division of Mental Health and Addiction Services or the Division of Child Protection and Permanency, with any approved Departmental adjustment.

3. All facilities, under their contract, will receive at least a minimum per diem reimbursement rate of $ 155.00, provided that they meet all other contractual and rule requirements.

4. This negotiated rate for DMAHS reimbursement purposes shall be divided into two rates, one for the Title XIX Federally reimbursable therapeutic services, and one for the non-reimbursable Title XIX services. Non-reimbursable services shall include, but shall not be limited to, such costs as personal needs allowances, other non-rehabilitative services, and the cost of room and board.

i. Reimbursement for clothing that is required as a part of a treatment regimen and included in the plan of care shall be included in the reasonable costs.

ii. Reimbursement for transportation for medically necessary purposes shall be included in the Title XIX reimbursable per diem rates. Transportation costs related to meetings and conferences will be included in the Title XIX reimbursable per diem rates when the primary purpose of such meetings and conferences is the dissemination of information for the advancement of patient care or efficient operation of the facility.

iii. The non-Title XIX reimbursable transportation shall be included in the non-reimbursable HCPCS. The cost of non-patient related travel, such as commuting, shall be included in the non-Title XIX reimbursable costs.

5. To establish the rates for these two HCPCS, the Division shall use the following Federally approved methodology, that results in a percentage to determine the amount that is non-Title XIX Federally reimbursable. The figure that results from this methodology shall be developed for each class of provider and then applied to each provider within the class.

i. The amount of reimbursement for room and board will be determined from an analysis of the per diem rates as follows: The costs of all the providers in each provider group in the selected regional area shall be analyzed to determine the percentage of each provider's total costs that are used to cover room and board and the percentage of the total cost that is used to cover the therapeutic services. The median percentage factor may vary depending on the provider group a provider belongs to.

ii. The median percentage for contracted room and board expenditures in relation to total operating expenditures shall be applied to each provider's rates to separately determine the reimbursement rates for the therapeutic HCPCS and room and board HCPCS procedure codes.

iii. Each year, on a rotating basis, a different regional area of the State shall be used to determine the median percentage for each provider group for room and board services and for therapeutic services.

iv. If a regional area contains too few provider groupings to use the median-based methodology, reimbursement for room and board will be computed for each individual facility, based on the actual costs for the facility.

Example: When applied in the selected region of the State, the methodology determines that the non-Title XIX reimbursable costs (room and board) are 20 percent for Provider Type A. Based on this determination, for provider A, whose current negotiated per diem is $ 200.00, the rate for the Title XIX reimbursable HCPCS (therapeutic services) shall be $ 160.00 ($ 200.00 less (200 x .20)). The reimbursement for the non-Title XIX services shall be $ 40.00.

For provider B, who is the same provider type as provider A, but whose current negotiated per diem is $ 160.00, the rate for the Title XIX reimbursable HCPCS shall be $ 128.00 ($ 160.00 less (160 x .20)). The reimbursement for the non-Title XIX services shall be $ 32.00.

(b) Providers shall be reimbursed on a per diem basis.

1. Providers may seek reimbursement for services provided on the date that the child, youth or young adult is admitted to the facility, but shall not seek reimbursement for services provided on the child's, youth's or young adult's date of discharge.

i. On the dates that the child, youth or young adult is listed as being under the care of the facility, but is not physically present in the facility for the 24-hour period starting and ending at midnight, due to therapeutic or hospital leave, the applicable HCPCS procedure codes shall be used. See N.J.A.C. 10:77-7.2(b). Therapeutic or hospital leave shall be authorized by appropriate medical staff and shall be included in the plan of care.

N.J. Admin. Code § 10:77-3.6

Amended by 48 N.J.R. 81(a), effective 1/4/2016