N.J. Admin. Code § 10:79A-1.5

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

Section 10:79A-1.5 - Application process for approval of Medicaid ACOs in the Demonstration Project

(a) Certification is required in order to demonstrate that an entity seeking participation in the Demonstration Project meets the minimum governance and operational standards set forth in the Act and this chapter to carry out the Demonstration Project objectives.

(b) An entity seeking participation in the Demonstration Project must submit an application to the Department to become certified as a Medicaid ACO. In addition, a certified Medicaid ACO must obtain approval by the Department of a gainsharing plan in accordance with this chapter prior to the commencement of its second Demonstration Project year. ACO certification and gainsharing plan applications may be submitted to the Department simultaneously, or the applicant may apply for certification prior to submitting its gainsharing plan for approval. However, in no event shall a gainsharing plan be submitted more than one year following certification approval.

1. An ACOs certification application, including exhibits, is a government record subject to the Open Public Records Act, N.J.S.A. 47:1A-1 et seq., upon submission of such application to the Department for certification and approval.

2. The certification application shall be a maximum of 10 double-spaced, typed pages, 12-point font minimum.

3. The certification application must include the application checklist provided by the Department. The checklist must be signed by an individual with legal authority to bind the ACO to affirm that the applicant will function in accordance with all applicable State and Federal laws, rules, and regulations, and that the information contained in the application is complete and accurate.

4. The certification application must be submitted to the Department by July 7, 2014.

(c) An applicant must document that it meets the following minimum standards for certification in order to be certified by the Department as a Medicaid ACO eligible to participate in the Demonstration Project:

1. The applicant must be properly formed as a nonprofit corporation under the laws of the State of New Jersey. The application must include a copy of the Certificate of Incorporation as filed with the State.

2. The application must specify the applicants designated area, which shall include a municipality or defined geographic area in which no fewer than 5,000 Medicaid fee-for-service and Medicaid managed care beneficiaries reside. An applicant may propose a designated area that includes zip codes or geographic regions that are not contiguous. The designated area shall be specified by a listing of zip codes or other geographic identifiers, such as county or municipal boundaries, that allow the Department to:

i. Verify the accuracy of the proposed number of Medicaid beneficiaries to be served by the applicant;

ii. Collect and report data related to the Medicaid ACOs activities; and

iii. Administer the project.

3. The ACO must have a governing board and an established mechanism for shared governance among its members.

i. The ACO must maintain a governing board with legal authority to execute the functions of an ACO, as described within the Act and this chapter, consistent with the board members fiduciary duties of care, loyalty, and adherence to mission. The ACO shall submit the following to the Department to demonstrate its governance structure:

(1) The ACOs bylaws and other relevant materials that demonstrate the ACOs leadership and management structure and its ability to support the Demonstration Project objectives and carry out the ACOs functions.

(A) The ACOs bylaws must include a statement regarding the organizations intent to engage the public with respect to the ACOs work to have a positive impact on health access, outcomes, and costs, and to receive comments regarding the gainsharing plan.

(B) The ACOs management structure must include a quality committee, medical director, or governance structure responsible for overseeing the ACOs quality performance and its obligation to provide access to medically necessary care, as required in this chapter; a quality committee must include the ACOs medical director, primary care physicians, and at least one physician who specializes in chronic diseases.

(C) The ACOs bylaws must include an antitrust compliance policy for the organization.

(2) A list of all governing board members, including a description of their organizational affiliations and whether each member serves the governing board in an individual or organizational capacity.

ii. An ACO boards membership should balance the interests of primary and specialty care providers, hospitals, and consumer beneficiaries. The ACOs governing board must include the following types of members:

(1) Individuals representing the interests of health care providers, such as: general hospitals, clinics, private practice offices, physicians, behavioral health care providers, and dentists; specifically, the governing board must include at least one primary care physician and also include representation from other physician specialties;

(2) Individuals representing the interests of social service agencies or organizations, such as legal aid organizations, charitable and religious groups, and groups providing support for the needy and elderly;

(3) Voting representation from two or more consumer organizations capable of advocating on behalf of patients residing in the designated area;

(A) At least one of the organizations must have extensive leadership involvement by individuals residing within the designated area, such as: community organizing entities, faith-based organizations, and grassroots leadership development entities.

(B) At least one of the organizations must have an office or other physical presence in the designated area.

(C) At least one of the voting representatives must reside within the designated area.

(4) Organizations may fit the description of more than one of the categories in (c)3ii above. To ensure a balanced governing board, an organization can qualify in only one category for purposes of this requirement.

iii. The ACO shall provide with its certification application the bylaws, board membership list, and other organizing documents of the consumer organizations represented on its board to document compliance with this requirement.

4. The ACO must obtain support from providers in the designated area, as described in this paragraph.

i. The ACO must obtain the support of the following health care providers in the designated area:

(1) All of the general hospitals located in the designated area;

(2) At least 75 percent of the qualified primary care providers located in the designated area; and

(3) At least four qualified behavioral health care providers located in the designated area. The qualified behavioral health care providers must include at least one Department-licensed mental health program and at least one Department-licensed substance abuse program.

ii. The ACO must document support by providers in the designated area by providing letters of support from the entities and providers listed in (c)5i above. Each letter of support, signed by an individual with legal authority to bind the provider, shall contain the following:

(1) The providers commitment to participate in the program for the full length of the Demonstration Project (up to three years);

(2) The providers commitment to support the Demonstration Project objectives;

(3) The providers commitment to provide timely information to meet the ACOs reporting requirements, including quality measures and patient experience findings, as described in this chapter;

(4) The providers commitment to share patient medical information with participating ACO members, pursuant to necessary data sharing agreements, for the purpose of meeting the Demonstration Project objectives, including patient care, tracking, follow-up and coordination;

(5) The providers acknowledgement that, notwithstanding any Demonstration Project objectives, the provider shall retain responsibility for medically appropriate treatment and referral decisions, document the basis for such decisions, and not limit treatment and referrals to providers participating in the ACO if treatment or referral to outside providers is medically indicated;

(6) The providers acknowledgement that, consistent with the Demonstration Project objectives, the provider shall not organize his or her care delivery to reduce access to care or increase costs, but instead shall work to improve health outcomes and quality while reducing unnecessary and inefficient spending;

(7) The provider's commitment to abide by the ACOs antitrust compliance policy; and

(8) The providers commitment to cooperate with and participate in the annual evaluation.

5. The ACO must demonstrate that it has a process for engaging members of the community to develop health care goals and for receiving public comments with respect to its gainsharing plan.

i. The ACO must designate individuals in its leadership structure responsible for public engagement.

ii. Processes for engaging the public include, for example: annual public meeting(s) of the ACO board that provide a time for public comment; availability of the ACOs Certificate of Incorporation, bylaws, and gainsharing plan for public inspection and copying at a reasonable cost; availability of the ACOs reporting requirements related to gainsharing and quality measures for public inspection and copying at a reasonable cost; and other activities that engage the community and encourage community input regarding the ACOs activities. The ACO should make documents available to the public on-line where feasible.

iii. Specific public comment requirements related to the ACOs gainsharing plan are set forth in N.J.A.C. 10:79A-1.6.

6. The ACO must have processes for receiving and distributing gainsharing payments.

i. The ACO may provide its processes for receiving and distributing gainsharing payments in its bylaws or other organizational documents in addition to including the processes within its ACO certification application.

ii. Procedures for calculation, distribution, and receipt of gainsharing amounts shall be set forth in the gainsharing plan approved in accordance with N.J.A.C. 10:79A-1.6.

7. The ACO must submit the ACO Application Checklist, signed by an individual who has the ability to legally bind the ACO to the Department, which expressly affirms that the:

i. Information contained in the ACO Demonstration Project certification application is accurate, complete, and truthful, that the signatory is familiar with the laws and regulations regarding the provision of healthcare services, and that the services are to be provided in compliance with such laws and regulations;

ii. ACO will be accountable for the health outcomes, quality, cost, and access to care of Medicaid beneficiaries;

iii. ACO will participate in the Demonstration Project for at least three years following certification;

iv. ACO will comply with the Demonstration Project requirements set forth by the Act and this chapter;

v. That the ACO shall function in accordance with all applicable State and Federal laws and regulations, including, but not limited to, laws and regulations designed to protect Medicaid beneficiaries ability to access medically necessary care and HIPAA requirements protecting the privacy and security of protected health information;

vi. ACO is committed to ensuring the use of electronic prescribing and electronic medical records by health care providers located in the designated area and expressly affirms that the ACO has existing or planned infrastructure, such as information technology, that enables the ACO to collect and share data among its members;

vii. ACO acknowledges its affirmative obligation to notify the Department within 30 days of any material changes to its certification application any time during the certification process and following certification.

viii. ACO has included all necessary documents with its application, including its bylaws, Articles of Incorporation, list of members, letters of support, and relevant policies and agreements.

8. The ACO must demonstrate to the Department its capability to collect data from participants in the Demonstration Project and report quality measures, efficiency measurements, patient safety measurements, and patient satisfaction findings.

i. The ACO must provide a project plan for achieving its quality measures, efficiency, patient safety, and satisfaction measurement obligations. The ACO must also explain the policies, technical capabilities, and organizational structures it expects to develop to meet these obligations with implementation timelines, goals/objectives, and project benchmarks.

(1) Specific quality, safety, efficiency, and satisfaction measurement benchmarks and tools shall be set forth in the gainsharing plan approved pursuant to N.J.A.C. 10:79A-1.6.

(2) The ACO must explain how it expects to address any failures to meet its quality, efficiency, patient safety, and patient satisfaction measurements or to resolve other issues identified during its monitoring of patient access and care.

ii. The ACOs management structure must include a quality committee, medical director, or governance structure that is responsible for setting and evaluating standards of care, receiving and addressing patient complaints, and conducting ongoing monitoring to ensure access to quality care and to prevent inappropriate provider self-referrals, reductions in care, or limitations on services.

9. The ACO must certify that it will not negotiate rates for services provided by its participating providers with any public or private payer. Failure to comply with this requirement is grounds for decertification of the ACO.

10. The ACO must certify that it and its participants will provide the Department, the Department of Law and Public Safety, and the Department of Banking and Insurance with all data requested by any such State agency, including, but not limited to, any such data requested in order to monitor the ACOs impact on commercial rates in its designated area.

(d) The Department will independently review, evaluate, and accept or deny each certification application as follows:

1. The Department will post ACO certification applications on its website and provide a 30-day public comment period regarding each application.

2. The Department will accept and review any public comment regarding an application that is submitted within the deadline.

3. The Department will review the application materials including all attachments. The Department may request additional documentation or explanations necessary to conduct its review.

4. When the review process is completed, the Department will issue a decision in writing to accept or deny the application. The Departments decision will set forth the basis on which the decision was made. The ACO may request an administrative appeal of a denial of its application pursuant to the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq. However, any such action shall take effect immediately, or at such later date as the Department determines.

(e) If an ACO notifies the Department of a material change to its certification application materials during the certification process or following certification, the Department will advise the ACO of what action, if any, the ACO needs to take. The Department may suspend its certification review, request additional information from the ACO, decertify the ACO, require reconsideration or reapplication, or take other actions consistent with its authority under the Act or this chapter. The ACO may request an administrative appeal of a decertification action pursuant to the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq. However, any such action shall take effect immediately, or at such later date as the Department determines.

N.J. Admin. Code § 10:79A-1.5

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