N.J. Admin. Code § 10:164-1.6

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:164-1.6 - Basis of payment

(a) The facility providing adult day health services shall agree to accept the reimbursement rates established by the Department as the total reimbursement for services provided to eligible Medicaid beneficiaries and to eligible beneficiaries enrolled in the HCEP or in the JACC.

1. In a nursing facility-based program, the adult day health services per diem rate is 45 percent of that nursing facility's per diem rate.

2. In freestanding facilities, the adult day health services per diem rate is based on an average of the rates paid to nursing facility adult day health services providers in effect as of July 1 each year.

3. For hospital-affiliated facilities, the adult day health services rate is a negotiated per diem rate, which shall not exceed the maximum adult day health services per diem rate paid to nursing facility-based providers.

4. The reimbursement rate set for any Medicaid beneficiary or any JACC or HCEP beneficiary in an adult day health services facility shall not exceed the rate charged by the facility to individuals who are not enrolled in the Medicaid, JACC or HCEP programs.

5. The per diem reimbursement shall cover the cost of all services required as a condition of licensure at N.J.A.C. 8:43F, except as noted below:

i. Physical therapy, occupational therapy and speech-language pathology services shall not be included in the per diem rate reimbursed for adult day health services. These therapies, when provided by the facility, shall be billed separately using the Health Insurance Claim Form, CMS-1500 established by CMS, incorporated herein by reference as amended and supplemented, available upon request from the US Government Printing Office at (202) 512-1800, or third-party insurance form, as applicable.

ii. It is only in the role of attending physician that the medical consultant may bill the New Jersey Medicaid Program on the Health Insurance Claim Form, CMS-1500, for services provided to a Medicaid beneficiary. The medical consultant shall not bill the New Jersey Medicaid Program separately for any service performed for any Medicaid beneficiary in an adult day health services facility while serving solely in his or her capacity as medical consultant.

(b) The cost of transportation services provided by the facility shall be included in the per diem reimbursement rate for adult day health services. The Department shall not reimburse transportation as a separate service.

(c) Physician services for Community Care Program for the Elderly and Disabled beneficiaries or Home Care Expansion Program or Jersey Assistance for Community Caregiving Program participants shall not be reimbursed by those programs.

(d) The Department shall not reimburse for adult day health services when partial care/partial hospitalization program services are provided to a beneficiary on the same day.

(e) For Medicare coverage, the only services that are considered for payment under Medicare are physical therapy and speech-language pathology services since adult day health services is not a covered Medicare service. When the beneficiary is covered under Medicare, only the Medicare Form UB-92/CMS-1450 shall be completed for physical therapy and speech-language pathology services showing the Eligibility Identification Number.

(f) For third-party liability, some insurance companies currently offer adult day health services as a benefit. The facility shall review the beneficiary's and family's insurance plans before submitting claims to assure that insurance companies are billed before submitting to the fiscal agent.

(g) The facility administrator shall verify that a beneficiary has valid financial coverage as of the time services are rendered to the beneficiary.

1. The facility administrator shall verify coverage for Medicaid beneficiaries and HCEP participants by using one of the eligibility verification systems or tools identified at N.J.A.C. 10:49-2.11, such as the Recipient Eligibility Verification System.

2. The facility administrator shall verify coverage for beneficiaries who participate in a program listed at N.J.A.C. 10:164-1.1(b), which requires case or care management, with the exception of JACC participants, by using the Recipient Eligibility Verification System and by contacting the beneficiary's case or care manager for verification of the beneficiary's financial coverage.

3. The facility administrator shall verify coverage for JACC participants by contacting the beneficiary's case or care manager for verification of the beneficiary's financial coverage.

(h) Distributions of assessments collected pursuant to the Nursing Home Quality of Care Improvement Fund Act, N.J.S.A. 26:2H-92 through 101, shall not be included in the calculation of adult day health services facility reimbursement rates pursuant to (a) above.

(i) Facilities shall be reimbursed for no more than a combined total of five days of treatment per week per beneficiary, even if the beneficiary receives services from multiple adult day health services facilities during the same week.

1. For the purposes of this subsection, "week" means seven calendar days, starting on Sunday and continuing through Saturday.

N.J. Admin. Code § 10:164-1.6

Amended by R.1994 d.427, effective August 15, 1994.
See: 26 N.J.R. 1427(a), 26 N.J.R. 3474(a).
Amended by R.1996 d.6, effective January 2, 1996.
See: 27 N.J.R. 3540(a), 28 N.J.R. 184(b).
Amended by R.2001 d.5, effective January 2, 2001.
See: 32 N.J.R. 3053(a), 33 N.J.R. 55(a).
In (a), amended N.J.A.C. reference in the introductory paragraph.
Recodified from N.J.A.C. 8:86-1.8 by R.2005 d.390, effective December 19, 2005 (operative February 1, 2006).
See: 36 N.J.R. 5262(a), 37 N.J.R. 385(b), 4968(a).
Former N.J.A.C. 8:86-1.6, Recipient review, evaluation and identification, repealed.
Amended by R.2008 d.1, effective January 7, 2008.
See: 39 N.J.R. 2424(a), 40 N.J.R. 177(a).
Rewrote (g).
Amended by R.2009 d.346, effective November 16, 2009 (operative April 1, 2010).
See: 40 N.J.R. 6328(a), 41 N.J.R. 4257(a).
Rewrote (a); in (b), deleted "or pediatric" following "adult" and "by the Department" from the end and substituted "The Department" for "Transportation" and "reimburse transportation" for "be reimbursed"; in (f), substituted "third-party" for "third party" and deleted "or pediatric" following "adult"; in (h), substituted "26:2H-92 through 101" for "26:2H-92 to 101" and deleted "or pediatric" preceding "day health services"; in the introductory paragraph of (i), deleted "or pediatric" following "adult" and recodified the former last sentence of (i) as (i)1.