N.J. Admin. Code § 10:79A-1.3

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

Section 10:79A-1.3 - General requirements and provisions

(a) Under the Demonstration Project, Medicaid ACOs shall refrain from, and implement appropriate safeguards against, conduct that may facilitate collusion among Medicaid ACO participants affecting the commercial health care marketplace, including, but not limited to, discussions among ACO participants about rates negotiated with commercial payers.

(b) Medicaid ACOs participating in the Demonstration Project shall include sufficient clinical integration. Any agreement reached by the Medicaid ACO, with the Division or a Medicaid managed care organization for sharing of savings within the ACO, must be necessary to improve care for Medicaid beneficiaries by incentivizing the integration of care between multiple distinct entities. Since the Demonstration Project does not impact the negotiated fee schedules between payers, hospitals, and providers, it is considered pro-competitive.

(c) All approvals, exceptions, or authorizations of any kind issued under this chapter or as part of the Demonstration Project established under the Act are for purposes of implementing the Act only and shall not extend beyond the Demonstration Project or beyond the timeframes for the Demonstration Project that are established under the Act. This specifically includes, but is not limited to, any exception to a requirement to obtain a certificate of need.

(d) Under no circumstances shall a Medicaid ACO negotiate reimbursement rates for clinical services provided by its participating providers. A gainsharing plan may be negotiated and administered.

N.J. Admin. Code § 10:79A-1.3

Amended by 46 N.J.R. 791(a), effective 5/5/2014.