N.J. Admin. Code § 8:85-3.1

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

Section 8:85-3.1 - Purpose and scope

(a) These rules describe the methodology to be used by the State of New Jersey, Department of Health and Senior Services (Department), to establish prospective per diem rates for the provision of nursing facility services to residents under the State's Medicaid program.

(b) The Department believes that the strict application of these rules will generally produce equitable rates for the payment of nursing facilities (NFs) for the reasonable cost of providing routine patient care services. The Department recognizes, however, that no rules can be developed which might not result in some inequities if applied rigidly and indiscriminately in all situations. Inequities could be in the form of rates that are unduly low or rates that are unduly high.

(c) Accordingly, in the case where a NF believes that, owing to an unusual situation, the application of these rules results in an inequity, the Department is prepared to review the particular circumstances with the NF. Appeals on the grounds of inequity should be limited to circumstances peculiar to the NF affected. They should not address the broader aspects of the rules themselves.

(d) On the other hand, these rules are not purported to be an exhaustive list of unreasonable costs. Accordingly, notwithstanding any inference one may derive from these guidelines, the Department reserves the right to question and exclude any unreasonable costs, consistent with the provision of 30:4D-1 et seq.

(e) All rates established pursuant to these rules will be subject to onsite audit verification of costs and statistics reported by NFs.

(f) The nursing facility rate formulae contained in this subchapter have been developed to meet the following overall goals:

1. To comply with Federal requirements that rates are reasonable and adequate to meet the cost that efficiently and economically operated facilities must incur to provide care in conformity with applicable State and Federal laws, rules, regulations and quality and safety standards;

2. To provide rates that are sufficient for facilities to meet the needs of their Medicaid beneficiaries through a rate setting system based on the average needs of individuals in their care; and

3. To control unnecessary costs, avoid duplicative cost reporting requirements and prevent fraud and abuse.

(g) For dates of service on or after July 1, 2010, the rates for Class I proprietary and voluntary NFs and Class II governmental NFs shall be based on the prospective case mix system required by this chapter.

N.J. Admin. Code § 8:85-3.1

Amended by R.1985 d.705, effective 1/21/1986.
See: 17 N.J.R. 2331(a), 18 N.J.R. 189(a).
Old 1 and 2 deleted; new 1 added; old 3 and 4 recodified to 2 and 3.
Petition for Rulemaking: Notice of receipt of petition on Medicaid reimbursement system for long-term care facilities.
See: 22 N.J.R. 672(d).
Recodified from Subchapter Foreword and amended by R.1994 d.624, effective 1/3/1995.
See: 26 N.J.R. 3614(a), 27 N.J.R. 156(a).
Amended by R.1996 d.147, effective 3/18/1996.
See: 27 N.J.R. 3314(a), 28 N.J.R. 1535(a).
Recodified from N.J.A.C. 10:63-3.1 and amended by R.2005 d.389, effective 1/17/2006.
See: 36 N.J.R. 4700(a), 37 N.J.R. 1185(a), 38 N.J.R. 674(a).
Rewrote (a) and made technical changes in (b) through (d).
Amended by R.2011 d.121, effective 4/18/2011.
See: 42 N.J.R. 1793(a), 43 N.J.R. 961(c).
In the introductory paragraph of (f), substituted "rate" for "reimbursement"; in (f)1, substituted a semicolon for a period at the end; rewrote (f)2 and (f)3; and added (g).