New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 52 - HOSPITAL SERVICES MANUAL
Subchapter 13 - ELIGIBILITY FOR AND BASIS OF PAYMENT FOR DISPROPORTIONATE SHARE HOSPITALS
Section 10:52-13.5 - Eligibility for and payment of Hospital Relief Subsidy Fund DSH

Universal Citation: NJ Admin Code 10:52-13.5

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Hospitals eligible for additional disproportionate share payments may receive an additional payment determined by the Commissioner of the Department of Human Services from the Hospital Relief Subsidy Fund. This additional payment shall be based upon the facility's percentage of clients with HIV, mental health, tuberculosis, substance abuse and addiction, complex neonates, HIV as a secondary diagnosis, and mothers with substance abuse.

1. Effective for periods after State Fiscal Year 1999, payments from the Hospital Relief Subsidy Fund shall be calculated and distributed to eligible disproportionate share hospitals, if funds are available, using the most recent calendar year hospital data available as of February 1 of each State fiscal year preceding the distribution year. For the purpose of pricing the problem billed cases listed at (a)1ii(1) below effective on or after July 6, 1998, the Medicaid/NJ FamilyCare rate shall be defined as the rate in effect as of February 1 of each State fiscal year preceding the distribution year. Effective for payments on or after July 6, 1998, this payment shall no longer be distributed over a Calendar Year. Instead, it shall be distributed over the State Fiscal Year, July through June.
i. For purposes of determining which hospitals are eligible for payment from the HRSF, a hospital shall satisfy both of the two following independent criteria:
(1) The hospital's cases for the seven categories listed at (a)1ii(1) below, priced at the Medicaid/NJ FamilyCare rate, divided by the hospital's Total Operating Revenue, expressed as a percentage, shall be equal to or greater than the median percentage for New Jersey Hospitals receiving Medicaid/NJ FamilyCare payments. For periods in which the data source excludes GME and IME in the rate, the Medicaid rate shall be adjusted by a hospital-specific GME and IME add-ons. The hospital-specific GME and IME add-ons shall be calculated as defined in (a)1iv below; and

(2) The hospital's charity care days plus the hospital's Medicaid/NJ FamilyCare-Plan A days, divided by the hospital's total days, expressed as a percentage, shall be equal to or greater than the median percentage for New Jersey hospitals receiving Medicaid/NJ FamilyCare-Plan A payments. For payments distributed in State Fiscal Years after State Fiscal Year 1999, the hospital's Medicaid days shall include Medicaid FamilyCare-Plan A managed care days if the data is available by February 1 prior to the State fiscal year of distribution.

ii. The subsidy shall be an amount allocated by the Commissioner during the fiscal year for this purpose and shall be distributed in the following manner:
(1) The payments for admissions for the following categories are taken from the same calendar year hospital data as defined in (a)4i above maintained by the New Jersey Department of Health:
(A) HIV (MDC 24);

(B) Mental Health (MDC 19);

(C) Substance Abuse (MDC 20);

(D) Complex Neonates (DRG 600 through 618, 622, 623, 626, or 627);

(E) Tuberculosis as a major or minor diagnosis (ICD-10-CM; 010.0 through 018.9);

(F) Mothers with substance abuse (MDC 14 with the following codes: (ICD-10-CM; 6483, 6555, 304, and 305); and

(G) HIV as a secondary diagnosis (excluding MDC 24; including ICD-10-CM; 0420 through 0422, 0429 through 0433, 0439, 0440, and 0449).

iii. The funding for the subsidy shall be distributed among eligible facilities based upon the hospital's percentage of payments, priced at the Medicaid/NJ FamilyCare rate, including the relevant GME and IME add-ons as defined in (a)1iv below, for patient with the categories in (a)1ii(1) above as a percentage of all payments, priced at the Medicaid/NJ FamilyCare rate, including the relevant GME and IME add-ons as defined in (a)1iv below, for patients in these categories in eligible hospitals.

iv. For periods in which the data source excludes GME and IME costs in the Medicaid/NJ FamilyCare-Plan A fee-for-service rate, the rate shall be adjusted by hospital-specific GME and IME add-ons. Unless otherwise specified in this section, effective for periods after State Fiscal Year 1999, the hospital-specific GME and IME add-on shall be calculated using the most recent hospital data as of February 1 of each State fiscal year preceding the distribution year. GME and IME add-ons shall not be revised as a result of any subsequent settlement and/or retrospective Medicaid/NJ FamilyCare-Plan A rate. The add-ons shall be calculated as follows:
(1) A hospital-specific GME add-on shall be calculated based on the hospital-specific GME per discharge multiplied by the number of cases of the categories defined in (a)1ii(1) above. The hospital-specific GME per discharge shall be calculated on the inpatient share of the aggregate approved GME amount from Worksheet E-3 Part IV of the Medicare submitted cost report divided by the hospital-specific total hospital discharges from Worksheet S-3 Part I of the Medicare submitted cost report.

(2) The hospital-specific IME add-on shall be calculated based on Medicare's IME formula, at 42 CFR 412.105, incorporated herein by reference, as amended and supplemented. The teaching hospital's IME factor, as calculated by the Medicare IME calculation, shall be multiplied by the number of cases of the categories defined in (a)1ii(1) above, priced at the current available Medicaid/NJ FamilyCare inpatient rates. The components of the IME formula, IME intern and resident FTEs, and maintained beds shall be taken from the Medicare submitted cost report. The IME formula used shall be the Medicare formula approved for the Medicare submitted cost report used in the calculation.

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