New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 53A - HOSPICE SERVICES MANUAL
Subchapter 4 - BASIS OF PAYMENT
Section 10:53A-4.4 - Limitations on reimbursement for hospice services

Universal Citation: NJ Admin Code 10:53A-4.4

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

(a) The Division limits aggregate payments to a hospice during a hospice "cap" period to the same degree, amount, and methodology as Medicare except the room and board per diem amounts reimbursed to hospice providers for services provided in a nursing facility are not subject to the "cap limitations" on the overall reimbursement to hospice providers.

1. Any payments in excess of the "cap" must be refunded by the hospice to the Division.

(b) The Division also limits payment for inpatient care according to the number of days of inpatient care furnished to hospice beneficiaries in the aggregate for that provider. The computation of the limitation is as follows:

1. During the 12-month period beginning November 1 of each year and ending October 31 of the following year, the aggregate number of inpatient days (both for general inpatient care and inpatient respite care) shall not exceed 20 percent of the aggregate total number of days of hospice care provided to all Medicaid and NJ FamilyCare FFS beneficiaries during that same period.
i. The maximum allowable number of inpatient days shall be calculated by multiplying the total number of days of Medicaid/NJ FamilyCare hospice care by 20 percent.

ii. If the total number of days of inpatient care furnished to Medicaid and NJ FamilyCare FFS hospice beneficiaries is less than or equal to the maximum, no adjustment shall be made.

iii. If the total number of days of inpatient care exceeds the maximum allowable number, the amount of the limitation will be determined by:
(1) Calculating a ratio of the maximum allowable days to the number of actual days of inpatient care, and multiplying this ratio by the total reimbursed for inpatient care (general and respite reimbursement);

(2) Multiplying the excess inpatient care days by the routine home care rate;

(3) Adding the amounts determined in the calculations of (b)1iii(1) and (2) above; and

(4) Comparing the amount in (b)1iii(3) above with interim payments made to the hospice for inpatient care during the "cap period."

(5) The aggregate number of inpatient days (both for inpatient general and inpatient respite care) shall not exceed 20 percent of the aggregate total number of days of hospice care provided to all Medicaid/NJ FamilyCare beneficiaries during that same period.

2. Any payments in excess of the "cap" must be refunded by the hospice to the Division.

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