Bill Text: NJ S237 | 2010-2011 | Regular Session | Introduced
Bill Title: Revises Medicaid reimbursement methodology for certain special hospitals and specifies reimbursement methodology for certain group homes whose residents use the special hospital.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2010-01-12 - Introduced in the Senate, Referred to Senate Health, Human Services and Senior Citizens Committee [S237 Detail]
Download: New_Jersey-2010-S237-Introduced.html
STATE OF NEW JERSEY
214th LEGISLATURE
PRE-FILED FOR INTRODUCTION IN THE 2010 SESSION
Sponsored by:
Senator CHRISTOPHER "KIP" BATEMAN
District 16 (Morris and Somerset)
SYNOPSIS
Revises Medicaid reimbursement methodology for certain special hospitals and specifies reimbursement methodology for certain group homes whose residents use the special hospital.
CURRENT VERSION OF TEXT
Introduced Pending Technical Review by Legislative Counsel
An Act concerning Medicaid reimbursement to certain special hospitals and reimbursement to certain group homes and supplementing Title 30 of the Revised Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. A special hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) that has an average length of stay greater than five years:
a. Shall be reimbursed a prospective per diem rate by the State Medicaid program for Medicaid recipients. The initial prospective per diem rate shall be $695 and shall be considered the base year rate. The base year rate shall be updated each year by the economic factor specified in N.J.A.C.10:52-5.13.
The prospective per diem rate shall apply to services provided to patients admitted to the special hospital. The prospective per diem shall be considered the full reimbursement for all inpatient services provided in the special hospital to these patients. The prospective per diem rate shall not include a reimbursement component for patient educational services provided by the hospital.
(1) In the case of patients that have Medicaid as their secondary payer, the hospital shall be allowed to submit the bill to Medicaid, based on the prospective per diem rate, at the same time that the bill is submitted to the primary payer. However, the hospital shall reduce the bill submitted to Medicaid by the expected payment of the primary payer. If the payment of the primary payer is different than the expected payment as originally submitted to Medicaid, the hospital shall promptly submit a corrected bill to Medicaid.
(2) The Commissioner of Human Services shall adopt regulations to permit the special hospital to seek rate relief or to seek a new base year rate in the event the hospital has experienced an increase in its operating costs which would impact the existing per diem rate, net of capital costs, greater than 5%. The hospital shall furnish evidence of that increase in costs to the Division of Medical Assistance and Health Services in the Department of Human Services and request an adjustment to its prospective inpatient reimbursement rate.
b. Shall be: (1) reimbursed its outpatient costs based on applicable cost-based Medicare Principles of Reimbursement through the Medicare/Medicaid Cost Report, and shall not receive final reimbursement based on an outpatient prospective reimbursement methodology. If necessary, the Department of Human Services shall adopt regulations to specify an interim claims processing and payment methodology;
(2) entitled to a per diem adjustment to account for increases in its capital expenditures. Adjusted per diem payments shall begin upon project completion and facility operation. The adjustment shall be calculated based on the Medicaid share of the inpatient costs for any capital expenditures made on or after December 31, 2005. Utilizing data from the Medicare/Medicaid Cost Report, the Medicaid share shall be determined by dividing the combined total of Medicaid fee-for-service days and Medicaid managed care days by the total number of inpatient days; and the inpatient costs for capital expenditures shall be determined by dividing the hospital's inpatient costs by its total costs and multiplying that number by its total additional capital costs; and
(3) entitled to receive a per diem adjustment for its graduate medical education program, with the adjustment to be based on the Medicaid share of the costs incurred by the graduate medical education program. The Medicaid share shall be determined by dividing the Medicaid inpatient days by the total number of inpatient days and multiplying that number by the total amount of graduate medical education costs as reported on the Medicare/Medicaid Cost Report.
c. Shall not be subject to the close proximity requirements established pursuant to N.J.A.C.10:52-1.3(b)(1) for the purposes of receiving Medicaid fee-for-service reimbursement for outpatient hospital services. A special hospital that establishes an off-site location to provide outpatient services shall notify the Division of Medical Assistance and Health Services in accordance with the requirements of N.J.A.C.10:52-1.3.
2. Reimbursement by the Division of Developmental Disabilities in the Department of Human Services for residents who reside in a group home and receive services provided by a special hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.), which has an average length of stay greater than five years, shall be based on actual costs divided by actual days for each reimbursement period. This per diem amount shall be considered the final reimbursement for the room and board portion for these residents. The special hospital shall bill the services provided at the special hospital separately and shall be reimbursed according to the rules and regulations pertaining to special hospital outpatient reimbursement.
3. The Commissioner of Human Services shall adopt rules and regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), necessary to carry out the purposes of this act.
4. This act shall take effect immediately.
STATEMENT
This bill revises the Medicaid reimbursement methodology for special hospitals that have an average length of stay greater than five years. The revised methodology is similar to that applied to pediatric rehabilitation hospitals in 2004.
The bill provides that these special hospitals shall be reimbursed a prospective per diem rate by the State Medicaid program for Medicaid recipients. The initial prospective per diem rate shall be $695 and shall be considered the base year rate. The base year rate shall be updated each year by the economic factor specified in N.J.A.C.10:52-5.13.
The prospective per diem rate shall apply to services provided to patients admitted to the special hospital. The prospective per diem shall be considered the full reimbursement for all inpatient services provided in the special hospital to these patients. The prospective per diem rate shall not include a reimbursement component for patient educational services provided by the hospital.
· In the case of patients that have Medicaid as their secondary payer, the hospital shall be allowed to submit the bill to Medicaid, based on the prospective per diem rate, at the same time that the bill is submitted to the primary payer. However, the hospital shall reduce the bill submitted to Medicaid by the expected payment of the primary payer. If the payment of the primary payer is different than the expected payment as originally submitted to Medicaid, the hospital shall promptly submit a corrected bill to Medicaid.
· The Commissioner of Human Services shall adopt regulations to permit the special hospital to seek rate relief or to seek a new base year rate in the event the hospital has experienced an increase in its operating costs which would impact the existing per diem rate, net of capital costs, greater than 5%. The hospital shall furnish evidence of that increase in costs to the Division of Medical Assistance and Health Services in the Department of Human Services and request an adjustment to its prospective inpatient reimbursement rate.
With respect to outpatient costs of these special hospitals, the bill provides that they shall be reimbursed their outpatient costs based on applicable cost-based Medicare Principles of Reimbursement through the Medicare/Medicaid Cost Report, and shall not receive final reimbursement based on an outpatient prospective reimbursement methodology. If necessary, the Department of Human Services shall adopt regulations to specify an interim claims processing and payment methodology. The hospitals shall be entitled to a per diem adjustment to account for increases in their capital expenditures. Adjusted per diem payments shall begin upon project completion and facility operation. The adjustment shall be calculated based on the Medicaid share of the inpatient costs for any capital expenditures made on or after December 31, 2005.
These special hospitals also shall be entitled to receive a per diem adjustment for their graduate medical education program, with the adjustment to be based on the Medicaid share of the costs incurred by the graduate medical education program.
Also, with respect to outpatient hospital services, the bill provides that these special hospitals shall not be subject to the close proximity requirements established pursuant to N.J.A.C.10:52-1.3(b)(1) for the purposes of receiving Medicaid fee-for-service reimbursement for outpatient hospital services.
The bill also specifies the reimbursement methodology to be used by the Division of Developmental Disabilities for group home residents who receive services provided by a special hospital that has an average length of stay greater than five years. The bill provides that reimbursement shall be based on actual costs divided by actual days for each reimbursement period. The per diem amount shall be considered the final reimbursement for the room and board portion for these residents. The bill further provides that the special hospital shall bill the services provided at the special hospital separately and shall be reimbursed according to the rules and regulations pertaining to special hospital outpatient reimbursement.
