Current through Register Vol. 56, No. 18, September 16, 2024
(a) The
reimbursement for mental health rehabilitation services for a psychiatric
community residence for youth, a residential child care facility, or a group
home shall be based on reasonable, negotiated, contracted costs as defined in
the Department of Human Services' Contract Reimbursement Manual and the
Contract Policy and Information Manual. Providers have access to these manuals
as indicated at
10:3-3.3(e)12.
1. These rates shall not be adjusted in the
provider's current contract year except for Department-approved adjustments
that would otherwise have been provided for under the terms of the existing
contracts if Medicaid/NJ FamilyCare reimbursement for these services had not
occurred, such as scheduled cost-of-living adjustments.
2. The total amount reimbursed by the
Division, including room and board, shall be based on the approved negotiated
contracted rates each provider receives under contract with the Division of
Mental Health and Addiction Services or the Division of Child Protection and
Permanency, with any approved Departmental adjustment.
3. All facilities, under their contract, will
receive at least a minimum per diem reimbursement rate of $ 155.00, provided
that they meet all other contractual and rule requirements.
4. This negotiated rate for DMAHS
reimbursement purposes shall be divided into two rates, one for the Title XIX
Federally reimbursable therapeutic services, and one for the non-reimbursable
Title XIX services. Non-reimbursable services shall include, but shall not be
limited to, such costs as personal needs allowances, other non-rehabilitative
services, and the cost of room and board.
i.
Reimbursement for clothing that is required as a part of a treatment regimen
and included in the plan of care shall be included in the reasonable
costs.
ii. Reimbursement for
transportation for medically necessary purposes shall be included in the Title
XIX reimbursable per diem rates. Transportation costs related to meetings and
conferences will be included in the Title XIX reimbursable per diem rates when
the primary purpose of such meetings and conferences is the dissemination of
information for the advancement of patient care or efficient operation of the
facility.
iii. The non-Title XIX
reimbursable transportation shall be included in the non-reimbursable HCPCS.
The cost of non-patient related travel, such as commuting, shall be included in
the non-Title XIX reimbursable costs.
5. To establish the rates for these two
HCPCS, the Division shall use the following Federally approved methodology,
that results in a percentage to determine the amount that is non-Title XIX
Federally reimbursable. The figure that results from this methodology shall be
developed for each class of provider and then applied to each provider within
the class.
i. The amount of reimbursement for
room and board will be determined from an analysis of the per diem rates as
follows: The costs of all the providers in each provider group in the selected
regional area shall be analyzed to determine the percentage of each provider's
total costs that are used to cover room and board and the percentage of the
total cost that is used to cover the therapeutic services. The median
percentage factor may vary depending on the provider group a provider belongs
to.
ii. The median percentage for
contracted room and board expenditures in relation to total operating
expenditures shall be applied to each provider's rates to separately determine
the reimbursement rates for the therapeutic HCPCS and room and board HCPCS
procedure codes.
iii. Each year, on
a rotating basis, a different regional area of the State shall be used to
determine the median percentage for each provider group for room and board
services and for therapeutic services.
iv. If a regional area contains too few
provider groupings to use the median-based methodology, reimbursement for room
and board will be computed for each individual facility, based on the actual
costs for the facility.
Example: When applied in the selected region of the State,
the methodology determines that the non-Title XIX reimbursable costs (room and
board) are 20 percent for Provider Type A. Based on this determination, for
provider A, whose current negotiated per diem is $ 200.00, the rate for the
Title XIX reimbursable HCPCS (therapeutic services) shall be $ 160.00 ($ 200.00
less (200 x .20)). The reimbursement for the non-Title XIX services shall be $
40.00.
For provider B, who is the same provider type as provider A,
but whose current negotiated per diem is $ 160.00, the rate for the Title XIX
reimbursable HCPCS shall be $ 128.00 ($ 160.00 less (160 x .20)). The
reimbursement for the non-Title XIX services shall be $ 32.00.
(b)
Providers shall be reimbursed on a per diem basis.
1. Providers may seek reimbursement for
services provided on the date that the child, youth or young adult is admitted
to the facility, but shall not seek reimbursement for services provided on the
child's, youth's or young adult's date of discharge.
i. On the dates that the child, youth or
young adult is listed as being under the care of the facility, but is not
physically present in the facility for the 24-hour period starting and ending
at midnight, due to therapeutic or hospital leave, the applicable HCPCS
procedure codes shall be used. See
10:77-7.2(b).
Therapeutic or hospital leave shall be authorized by appropriate medical staff
and shall be included in the plan of care.
