reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT FOR HOSPITAL SERVICES › Section 10:52-4.5 - Basis of payment and appeal procedure; out-of-State acute care general hospital services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division shall reimburse an out-of-State approved acute care general hospital (see N.J.A.C. 10:52-1.2, Definitions) for providing inpatient and outpatient hospital services to New Jersey Medicaid/NJ FamilyCare beneficiaries if the hospital meets the requirements of the Division and the services are prior authorized pursuant to N.J.A.C. 10:52-1.10. Reimbursement of inpatient hospital services is outlined in (b) and (c) below, and for outpatient services is outlined in (d) and (e) below. See (f) below for the procedure for rate appeals for out-of-State acute care general hospitals.
(b) Reimbursement for inpatient hospital services for an out-of-State acute care general hospital participating in the New Jersey Medicaid/NJ FamilyCare program and participating in the Medicaid program in the state in which the hospital is located, shall be based on the following criteria:
1. All rates in effect at the time the service is rendered shall be considered final rates by the State. Reimbursement shall be at the lesser of the established DRG payment rate for New Jersey acute care general hospitals, as described in N.J.A.C. 10:52-14(excluding add-ons), 100 percent of the claim-specific reimbursement methodology approved by the state Medicaid agency in the state in which the hospital is located, except as specified in (b)2 and (c) below, or the total charges reflected on the claim. The Division shall not reimburse out-of-State acute care general hospitals for disproportionate share hospital (DSH) payments even if the DSH payments are included in the claim-specific reimbursement methodology approved by the state Medicaid agency in the state in which the hospital is located.
2. An out-of-State acute care general hospital should provide official documentation of the Medicaid rate that has been established by the state Medicaid agency in the state in which the hospital is located. If official documentation is not provided upon request by the Division, the claim will be denied.
i. An example of acceptable documentation is a copy of the letter sent by the state Medicaid agency to the hospital specifying the Medicaid rate.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT FOR HOSPITAL SERVICES › Section 10:52-4.6 - Reimbursement for claims for which there is third-party liability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For beneficiaries for whom any third-party liability exists, claims for hospital services provided that are not the responsibility of a Medicaid/NJ FamilyCare managed care organization shall be reimbursed in accordance with 10:49-7.3 and the provisions of this chapter.
(b) For beneficiaries eligible for Medicare and Medicaid (dual eligibles), claims covered under 10:52-4.7 shall be reimbursed in accordance with the provisions of that section.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT FOR HOSPITAL SERVICES › Section 10:52-4.7 - Medicare/Medicaid or Medicare/NJ FamilyCare claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Some patients may be covered under both Medicare and Medicaid or Medicare and NJ FamilyCare. When the Medicaid/NJ FamilyCare beneficiary is covered under both programs, Item 57 on the hospital claim form shall be completed showing the Medicaid/NJ FamilyCare Eligibility Identification Number.
(b) Medicare/Medicaid and Medicare/NJ FamilyCare third-party claims for hospital services provided that are not the responsibility of a Medicaid/NJ FamilyCare managed care organization shall be reimbursed in accordance with 10:49-7.3 and the provisions of this chapter.
(c) When Medicaid/NJ FamilyCare is not the primary payer on an inpatient hospital claim, payment by Medicaid/NJ FamilyCare will be made at the lesser of:
1. The Medicaid/NJ FamilyCare allowed amount minus any other payment(s); or
2. The patient liability, including denied charges, deductible, co-insurance, copayment, and non-covered charges.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT FOR HOSPITAL SERVICES › Section 10:52-4.8 - Personal contribution to care requirements for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D

Current through Register Vol. 56, No. 14, July 15, 2024
(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D fee-for-service are set forth at N.J.A.C. 10:49-9.
(b) Personal contribution to care for NJ FamilyCare-Plan C services are $ 5.00 a visit for outpatient clinic visits and $ 10.00 for an emergency room visit that does not result in an inpatient hospital stay.
(c) Hospitals are required to collect the personal contribution to care for the above mentioned NJ FamilyCare-Plan C services if the NJ FamilyCare Identification Card indicates that a personal contribution to care is required and the beneficiary does not have a NJ FamilyCare form which indicates that the beneficiary has reached their cost share limit and no further personal contributions to care are required, until further notice. Personal contribution to care charges cannot be waived.
(d) Under NJ FamilyCare-Plan D, copayments in the amounts indicated below shall be collected by the hospital for the services as follows:
1. A $ 5.00 copayment per visit shall be required for the following services:
i. Outpatient rehabilitation services, including physical therapy, occupational therapy and speech therapy;
ii. Hospital outpatient department visits and diagnostic testing;
(1) For prenatal care, the $ 5.00 copayment shall apply only to the first visit;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT FOR HOSPITAL SERVICES › Section 10:52-4.9 - Settlement for Medicaid/NJ FamilyCare fee-for-service services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey Medicaid settlement agent for New Jersey acute care general (excluding inpatient services), special, rehabilitation, and private psychiatric and county governmental psychiatric hospitals shall determine the amount of disbursements, recoupments, and/or changes in per diem amounts and outpatient percentages, as applicable. The settlement agent shall inform the hospital and the Division of Medical Assistance and Health Services (Division/DMAHS) of the results of their review. If the settlement agent's review is accepted, DMAHS, through its fiscal agent for claims processing, shall perform the following processes:
1. For disbursements, payment shall be made to the hospital for the full amount due within 30 days from the date of settlement agent's letter.
2. The fiscal agent shall begin recoupment for the full amount of the overpayment 30 days after the date the Division receives the settlement agent's overpayment notification by withholding the Medicaid/NJ FamilyCare fee-for-service payments to the hospital.
3. If the withholding of the New Jersey Medicaid/NJ FamilyCare fee-for-service payments is not acceptable to the hospital, the hospital must submit, prior to the end of the 30-day period, a proposed repayment schedule to the Division. For a repayment schedule in excess of three months, documentation, as specified in Medicare Provider Reimbursement Manual 13-2, Section 2223, Establishing Extended Repayment, shall be submitted. If an approvable repayment schedule is not received by the Division, the withholding of Medicaid/NJ FamilyCare fee-for-service payments shall be implemented to begin recoupment.
4. The proposed repayment plans should be submitted directly to the following address:
Office of Hospital Reimbursement
Division of Medical Assistance and Health Services
PO Box 712, Mail Code #44
Trenton, New Jersey 08625-0712
5. Interest shall be charged at the maximum legal rate as of the date of the repayment agreement or 30 days from the date of the settlement agent letter to the Division, whichever is sooner.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.1 - Derivation of Preliminary Cost Base

Current through Register Vol. 56, No. 14, July 15, 2024
For general acute care hospitals, the Division of Medical Assistance and Health Services (hereafter referred to as the Division or its designee), on or before March 12, 1993 and on or before January 31 of each subsequent rate year shall implement a rate. For hospitals with a fiscal year of January 1, the rate year will be the calendar year. For hospitals on a fiscal year beginning other than January 1, but before July 1, the rate year will be the year the fiscal year begins and for hospitals on a fiscal year beginning between July 1 and December 31, the rate year will be the year the fiscal year ends.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.2 - Uniform Reporting: Current costs

Current through Register Vol. 56, No. 14, July 15, 2024
Hospitals shall be required to submit reports as required in N.J.A.C. 8:31B-4. The Director shall review the actual costs for the institutions as reported in accordance with the Financial Reporting Principles and Concepts (Subchapter 6). The review will be performed according to the methodology outlined below. Costs, so reported, shall be subject to revision due to subsequent audits.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.3 - Costs per case

Current through Register Vol. 56, No. 14, July 15, 2024
Direct and indirect care costs shall be allocated to the inpatient and outpatient services. Direct and indirect costs allocated to inpatient services shall be used to determine inpatient rates per case according to the patient diagnosis. This cost finding process is described in 10:52-5.7 through 5.11.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.4 - Development of standards

Current through Register Vol. 56, No. 14, July 15, 2024
Effective for services provided on or after October 1, 1996, the Director shall develop standard reimbursement amounts for each DRG based on the median cost per case for Medicaid/NJ FamilyCare fee-for-service beneficiaries. The standards shall be adjusted to account for significant differences in labor market areas. These standards are developed according to criteria set forth in N.J.A.C. 10:52-5.11 through 5.17. Standards so developed and issued for a rate year shall remain unaffected and no adjustments, modifications, or changes to the standards shall be made except as referenced in N.J.A.C. 10:52-5.10.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.5 - Current Cost Base

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A hospital's Current Cost Base is defined as the actual costs and revenues as identified in the Financial Elements in the base reporting period as recognized by the Division for purposes of rate setting.
(b) The Current Cost Base is used to develop the Preliminary Cost Base (PCB) and Schedule of Rates through:
1. Determination of the costs of Medicaid patients treated in the 1988 base year;
2. Identification of fixed and variable components of the Preliminary Cost Base;
3. Calculation of the economic factor cost component as defined in 10:52-5.13(a);
4. Calculation of the technology factor as described in 10:52-5.13(b);
5. The costs used to set rates for the rate year will be based on 1988 costs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.6 - Financial elements reporting/audit adjustments

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The aggregate Current Cost Base is developed from Financial Elements reported to the Division and includes:
1. Costs related to Medicaid/NJ FamilyCare direct patient care as defined in N.J.A.C. 10:52-6.14;
2. Less net income from specified sources;
3. Capital facilities allowance: Capital cash requirements (as defined in 10:52-5.14 and 6.18);
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.7 - Identification of direct and indirect costs related to Medicaid/ FamilyCare patient care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Costs related to Medicaid/NJ FamilyCare fee-for-service patient care as adjusted for price level depreciation as reported to the Division shall be classified as follows:
1. Direct patient costs:
i. Routine service costs;
ii. Ambulatory service costs; and
iii. Ancillary service costs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.8 - Patient care cost findings: direct costs per case, physician and nonphysician

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Hospital case-mix shall be determined as follows:
1. Uniform Bill-Patient Summary (UB-PS) data shall be used for determination of hospital case-mix. The appropriate patient records for the reporting period corresponding with the Financial Elements Report shall be classified into Diagnosis Related Groups (DRGs) using the following items:
i. Principal diagnosis;
ii. Secondary diagnosis;
iii. Principal and other procedures;
iv. Age;
v. Sex;
vi. Discharge status; and
vii. Birthweight (newborn).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.9 - Reasonable cost of services related to patient care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The reasonable cost of services related to patient care includes:
1. Current non-physician direct patient care costs per case as adjusted by standard costs per case for Medicaid/NJ FamilyCare fee-for-service inpatients;
2. Current physician patient service costs, as modified for physician compensation arrangements pursuant to 10:52-5.8;
3. Indirect cost pursuant to N.J.A.C 10:52-5.7 and 5.12;
4. Less a reduction for income not related to patient care, from those sources specified in 10:52-6.25 through 6.31 except all items reported as expense recovery to the Division, shall be so treated; and
5. Current major moveable equipment amount pursuant to 10:52-6.19 and 6.24.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.10 - Standard costs per case

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The standard to be used in the calculation of the proposed rates for each inpatient DRG is as follows:
1. For services provided on or after October 1, 1996, the standard to be used in the calculation of the proposed rates for each inpatient DRG is determined as the median non-physician patient care costs per Medicaid/NJ FamilyCare fee-for-service case in all hospitals whose costs are included in the data base, adjusted for labor market differentials. Standards shall be calculated across all hospitals for which current cost bases were derived from a common reporting period.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.11 - Reasonable direct cost per case

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Inpatient direct cost per case shall be determined as follows:
1. The reasonable direct cost per Medicaid/NJ FamilyCare fee-for-service case for those hospitals receiving rates in accordance with this subchapter for every DRG shall include incentives and disincentives, as appropriate, which shall be termed the boundaries of payment and are calculated as follows:
i. Effective for services provided on or after October 1, 1996, the incentive standard is multiplied by the unequalization factor and the physician mark-up.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.12 - Net income from other sources

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The net gain (loss) from Other Operating and Non Operating Revenues (as defined in 10:52-6.25 through 6.32) and expenses of the reporting period which are items considered as recoveries of or increases to the Costs Related to Patient Care (see 10:52-6.25 through 6.32) as reported to the Division is subtracted from (added to) indirect costs of the Preliminary Costs Base.
(b) Such revenue shall include all Other Operating and Non Operating Revenues and Expenses reported per Standard Hospital Accounting and Rate Evaluation (SHARE) cost center costs and "expense recoveries" as Case B and all other items reported as to their case specified in 10:52-6.25 through 6.32.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.13 - Update factors

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The economic factor is the measure of the change in prices of goods and services used by New Jersey hospitals. The economic factor will be the factor recognized under the TEFRA target limitations.
1. The hospital-specific economic factor is the weighted average of the recorded and projected change in the value of its components. The weight given to each component is its share of that hospital's total expenditure. The projection of individual components shall be based, where appropriate, on legal or regulatory changes which fix the future value of a proxy. Components which are of particular importance may be projected through the use of time series analysis or other relevant indicators.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.14 - Capital facilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Capital Facilities, as defined in 10:52-6.18, shall be included in the rate in the following manner:
1. Building and fixed equipment:
i. The yearly Capital Facilities Allowance is computed using information provided by the Share Cost Reports. For hospitals on a calendar year basis, this amount will be its 1992 depreciation and interest expense, excluding any portion associated with major moveable equipment and any interest income reported as an expense recovery. For those hospitals on a fiscal year basis, actual year's depreciation and interest applicable to rate year 1992 shall be used excluding any portion associated with major moveable equipment and any interest income reported as an expense recovery.
ii. Effective for services provided on or after October 1, 1996, all building and fixed depreciation and interest capital costs as defined in 10:52-6.18 related to GME programs shall be determined based on the 1992 audited Medicare Cost Report (HCFA-2552) and shall be excluded from the base year cost used to calculate the Medicaid DRG inpatient rates.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.15 - Division adjustments and approvals

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any modifications including any statutory or regulatory changes or changes in patient care physician compensation arrangements shall be classified as direct or indirect, and as to the financial elements affected and each element adjusted proportionately.
(b) The Division shall also approve adjustments to hospitals' Schedules of Rates for 1993 and subsequent years as necessary to subtract approved costs associated with residents not meeting the minimum requirements as defined in 10:52-5.10(b); for any costs associated with residents in programs which have lost accreditation as defined in 10:52-5.10(b); and for any costs associated with previously approved but now vacant residency positions which are unfilled as a result of a hospital's inability to recruit residents meeting these minimum standards. These costs shall include, but are not limited to, resident salaries and fringes, faculty salaries, malpractice and supplies.
(c) The Division may approve hospital appeals to transfer Division approved resident positions and associated costs between hospitals. A hospital may appeal under any option to reduce or increase the number of resident positions by transfer. An addition of resident positions by transfer may not result in a change to a higher teaching status peer group. A reduction of resident positions by transfer may result in a change to a lower teacher status peer group. The approved costs associated with a transferred resident position may not increase solely as a result of the transfer.
(d) The Division shall decide to which hospitals the approved resident positions and associated costs may be transferred.
(e) Subsections (a) through (d) above apply for dates of services provided prior to October 1, 1996. Effective for services provided on or after October 1, 1996, this section is no longer applicable.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.16 - Derivation from Preliminary Cost Base

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Apportionment of Financial Elements based on direct costs shall be as follows:
1. All other Financial Elements are added to direct Medicaid/NJ FamilyCare fee-for-service patient care costs as percentages of direct costs per Medicaid/NJ FamilyCare case. The Schedule of Rates is set such that all Medicaid/NJ FamilyCare patients' rates are based on the cost of services received by Medicaid/NJ FamilyCare fee-for-service beneficiaries, including a proportionate share of indirect financial elements requirements of operating hospital facilities.
2. In the event that a hospital is self-insured for employee health benefits, the percentage of personnel health allowance recognized in the rates shall be proportioned to the number of Medicaid/NJ FamilyCare fee-for-service beneficiaries serviced by the facility to financial elements from payers for such costs.
3. Each hospital shall receive from the Division a base rate order detailing the Schedule of Rates.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 5 - PROCEDURAL AND METHODOLOGICAL REGULATIONS › Section 10:52-5.17 - Schedule of rates-effective date

Current through Register Vol. 56, No. 14, July 15, 2024
All rates issued pursuant to this subchapter, as approved or modified, shall be effective as of October 1, 1996, of the rate year and then January 31 for subsequent years.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.1 - Reporting principles

Current through Register Vol. 56, No. 14, July 15, 2024
The reporting principles and concepts adopted by the Department of Health at N.J.A.C. 8:31B-4.1 through 4.25 shall be used for Medicaid/NJ FamilyCare fee-for-service rates.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.13 - Financial elements (generally)

Current through Register Vol. 56, No. 14, July 15, 2024
The financial elements of the rates shall include the reasonable cost of the following: direct patient care; depreciation expense and interest payments; paid taxes, excluding income taxes; education, research and training programs, not otherwise paid for by the State; and preservation, replacement and improvement of facility and equipment subject to appropriate planning requirements. All non-direct costs must be allocated based upon the proportion of Medicaid/NJ FamilyCare fee-for-service beneficiaries serviced by the hospital.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.14 - Services related to Medicaid/NJ FamilyCare fee-for-service patient care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Services related to Patient Care include Direct Patient Care; Paid Taxes excluding Income Taxes; and Educational, Research and Training Programs as further defined in 10:52-6.15 through 6.17.
(b) Services Related to Patient Care include Routine Services, Ambulatory Services, Ancillary Services, Patient Care General Services, and Institutional Services. Costs Related to Patient Care include salaries and wages, physician compensation, employee fringe benefits, medical and surgical supplies, drugs, non-medical and non-surgical supplies, purchased services and other direct expenses and major moveable equipment costs as determined in accordance with 10:52-6.20 through 6.24.
(c) All non-physician services and supplies provided to hospital inpatients, whether provided directly by the hospital or by a vendor, shall be considered services and costs related to patient care.
(d) All costs of services and supplies purchased from a vendor shall be subject to review for reasonableness by the Division.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.15 - Direct patient care

Current through Register Vol. 56, No. 14, July 15, 2024
Direct patient care is the provision by a hospital of medically necessary and appropriate health care services to a Medicaid/NJ FamilyCare fee-for-service beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.16 - Paid taxes

Current through Register Vol. 56, No. 14, July 15, 2024
Taxes are monies paid to a governmental unit for conducting business related to direct patient care within its jurisdiction. Taxes are a financial element of the Preliminary Cost Base except for Federal, State, or local income, excess profit, or franchise taxes, taxes on property not used for direct patient care, and interest and/or penalties paid thereon. Taxes related to financing of operations through the issuance of bonds, property transfers, issuance or transfer of stocks, and the like, are not classified as taxes; rather, they shall be amortized or depreciated with the cost of the security or asset. Sales and real estate taxes paid by a hospital in the provision of Services Related to Patient Care shall be included as Paid Taxes. All sales and real estate taxes for Services Related to Patient Care shall be reported in the General Administrative Services cost center and also reported separately from other classifications of expense. Employment related taxes, such as FICA, Unemployment Compensation, and Workers' Compensation, shall be classified as employee fringe benefits for all employees, including hospital-based physicians. Monies received by a hospital which chooses to self-insure in lieu of payment of Unemployment Compensation taxes and the associated administrative costs of such a self-insurance program are included as financial elements and classified as employee fringe benefits, if such monies are reasonably related to the hospital's unemployment compensation experience.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.17 - Educational, research, and training programs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Educational program costs are the costs incurred by a hospital in the provision of a formally organized, planned program of study in a health service profession approved by an organization which recognizes the professional stature of health services education programs at the national level, net of any grants, tuition, and/or donations received for this purpose. To the extent that approved residencies for primary care physicians require training in ambulatory care facilities associated with a hospital, such reasonable expenses are included. Costs incurred by a hospital for direct patient care services rendered by medical, nursing, or allied health school personnel through an approved program in the hospital are financial elements provided that such costs would be included as financial elements if directly incurred by the hospital rather than under such arrangements. If not salaried or paid a stipend by the hospital, students shall not be considered as functioning in an employee capacity and thus no dollar amount shall be imputed and reported for their services.
(b) Research program costs are those costs incurred by a hospital in systematic, intensive study directed toward a better scientific knowledge of the provision of health care services in a program of the National Institutes of Health or other program approved by the Commissioner of the Department of Health. Specific purpose grants or other funds received to offset the costs of such programs from the Federal government, New Jersey State government, New Jersey Heart Association, or other governmental or charitable organizations sponsoring such programs are applied to offset Costs Related to Patient Care.
(c) Training program costs are the costs of providing to employees orientation or other health care related training, including inservice and on-the-job training, primarily designed to benefit the hospital by helping employees better perform their assigned tasks. The costs of providing such training shall be classified as administrative expense. Costs of training and/or educational programs which primarily benefit the employee (for example, tuition reimbursement programs) rather than the hospital shall be classified as employee fringe benefits and shall be reported as such in the appropriate cost centers.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.18 - Capital facilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) With respect to Buildings and Fixed Equipment, the cost of Capital Facilities used for Services Related to Medicaid Patient Care, except for Major Moveable Equipment as defined in 10:52-6.19, are included as financial elements for all hospitals through a Capital Facilities Allowance.
(b) The amount of Revenue Related to Patient Care prospectively included for Capital Facilities in a hospital's Schedule of Rates is to be funded in the form of cash and/or investments in the Internally Generated Plant Replacement and Renovation Fund (Plant Fund).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.19 - Major moveable equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Major Moveable Equipment includes straight line depreciation costs on owned or capitalized leased Major Moveable Equipment plus a Price Level Depreciation Allowance in excess of this historical depreciation and operating lease/rent payments relative to Major Moveable Equipment utilized for Services Related to Patient Care. Leased Major Moveable Equipment is to be capitalized or reported as operating lease costs in accordance with GAAP.
1. Major Moveable Equipment Costs so determined are reported as a Natural Classification of Expense of each cost center.
2. Major Moveable Equipment utilized by more than one functional cost center must be assigned to the using cost centers based on an estimate of each center's utilization.
3. Capitalized repair and installation costs shall be included with the cost of the equipment.
4. Interest associated with capitalized financing purchases or leases shall be excluded and reported as reconciling items, since the Internally Generated Major Moveable Equipment Replacement Fund is established to provide sufficient funds to replace purchased equipment or meet installment payments for financed equipment (both principal and interest).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.20 - Natural classifications of expense

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Salaries and wages, including stipends, payable in cash, for services performed by an employee for a hospital (except a physician, including compensation for time not worked such as on call) vacation, holiday and sickpay or the monetary value assigned to direct services provided to the hospital by a person performing in an employee relationship are considered remuneration. Monetary value shall not be assigned to the services of students or other volunteer workers. All labor costs (including deferred income which qualifies as pension costs) shall be included in the accounting period during which the employee accrues the payment for their services.
(b) The following applies to the Physician Compensation--Hospital Component:
1. That portion of compensation for a physician's (M.D., D.O., D.D.S./M.D.) activities, provided through agreement with a hospital, representing services which are not directly related to an identifiable part of the medical care of an individual patient is the hospital component of physician compensation, and must be split between salaries and fees. Hospital services include teaching, research conducted in conjunction with and as part of patient care (to the extent that such costs are not met by special research funds), administration, general supervision of professional or technical personnel, laboratory quality control activities, committee work, performance of autopsies, and attending conferences as a part of the physician's hospital service activities. The allocation of physician compensation between hospital and professional components and documentation thereof is to be in accordance with Medicare HIM-15, section 2108, incorporated herein by reference, for provider component. Medicare manuals are available via the Internet from
www.cms.gov
. To obtain paper copies of the Medicare HIM-15 document or other Medicare manuals write to:
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Division of Medicare
Regional Office 2
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.21 - Medical and Surgical Supplies

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medical and Surgical Supplies are medically necessary supplies, appliances and minor moveable equipment furnished by, used at and reported by a hospital for the care and treatment of a patient during a patient's episode of hospital care. Minor moveable equipment includes, but is not limited to, such items as waste baskets, bed pans, mops and buckets. Medically necessary supplies exclude all supplies furnished by a hospital but used by a patient after his episode of care except those items where it would be medically unreasonable to limit the patient's use of the item to his episode of hospital care. The fair market value of donated Medical and Surgical Supplies is assigned to this classification if the commodity would otherwise be purchased by the hospital.
(b) Medical and Surgical Supplies include prosthetic devices, surgical supplies, anesthetic materials, oxygen and other medical gases, intravenous solutions, drugs including medically prescribed food supplements, biologicals, admission kits furnished by the hospital to inpatients not possessing such materials, and other medical care materials. The purchase cost of blood and blood components shall be excluded.
(c) The invoice/inventory cost and related revenue of all Medical and Surgical Supplies for which a separate charge is made to a patient for the use or consumption of the supply must be reported in the Medical and Surgical Supplies or Drugs Sold to Patients cost and revenue centers.
(d) Medical and Surgical Supplies issued by Central Supply Services or Pharmacy for which a separate charge is not made to a patient must be accounted for as an interdepartmental transfer at invoice/inventory cost to the cost center using the supplies and materials. The cost of reusable patient non-charge items used by more than one functional center must remain in or be transferred to the Central Supply Services cost center. The cost of reusable patient non-charged items used by one functional center should be reported in that center. The cost of other Medical and Surgical Supplies not requisitioned from Central Supply Services and for which a separate charge is not made to a patient must be reported in the functional cost center in which the supplies and/or materials are consumed.
(e) The overhead associated with the issuing of Medical and Surgical Supplies shall be reported in the Central Supply Services or Pharmacy cost centers. Except for reusable supplies in (d) above and differences between beginning and end of year inventories, no Medical and Surgical Supplies shall be reported in the Central Supply Services or Pharmacy cost centers.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.22 - Non-Medical and Non-Surgical Supplies

Current through Register Vol. 56, No. 14, July 15, 2024
Non-Medical and Non-Surgical Supplies include the invoice/inventory cost of supplies, instruments, and minor equipment (other than Medical and Surgical Supplies) required for the operation of a hospital for purposes other than the direct provision of care to a patient are reported in the using cost and revenue centers. All rebates and quantity purchase discounts shall be offset against these costs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.23 - Purchased Services

Current through Register Vol. 56, No. 14, July 15, 2024
Purchased Services include the cost of all services purchased that could be accomplished by a hospital's own employees but for which the hospital elects to contract (not necessarily with a formal contract). All physician services shall be classified as physician compensation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.24 - Major Moveable Equipment

Current through Register Vol. 56, No. 14, July 15, 2024
Major Moveable Equipment expenses are expenses to be included in the costs of each center at historical depreciation costs (for both owned and capitalized leased equipment) plus a price level replacement cost premium and operating lease expenses. Interest expense incurred through purchase or capitalized leases of Major Moveable Equipment shall not be included with Major Moveable Equipment costs since the use of price level depreciation of such equipment for the financial elements is intended to replace this financial requirement of hospitals and provide adequate funds to replace equipment at the expiration of useful life.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.25 - Reports of costs and revenues

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The financial elements shall take into account a facility's income from all sources, including specific purpose grants and other funds from governmental sources, but excluding income and principal from board or donor restricted funds, gifts and special fund raising projects. Expenses incurred and revenues generated by a hospital for items not included in the definitions of Services Related to Patient Care (that is Routine Services, Ambulatory Services, Ancillary Services, Patient Care General Services, and Institutional Services) shall be classified as either other operating expenses and revenues or non-operating revenue. These expenses and revenues shall be accounted for separately to determine if and how they shall be applied to Costs Related to Patient Care and the Capital Facilities Allowance to determine the hospital's total financial elements or the Current Cost Base. (For Preliminary Cost Bases established using data from all Other Operating and Non-Operating Revenues and Expenses reported as Standard Hospital Accounting and Rate Evaluation (SHARE) cost center costs and "expense recoveries" shall be treated as Case B, as defined in (a)2 below). There are three cases into which such reconciliations are classified:
1. Case A--Expenses and revenues related to activities which the hospital has selected to engage in but which are not an integral part of, or necessary for, the provision of patient care. Such expenses and revenues are netted against each other. Gains are applied as reductions to the Current Cost Base used to determine hospital payment rates, but any losses are not applied.
2. Case B--Expenses and revenues related to activities which the hospital has elected to engage in and which are an integral part of, or necessary for, the provision of patient care. Such expenses and revenues are netted against each other. Losses are applied as increases to the Current Cost Base and gains are applied as reductions.
3. Case C--Expenses and revenues related to activities which are specifically excluded under the State rules. Expenses and revenues shall not be netted against each other. Neither gains nor losses shall be applied in determination of the Current Cost Base.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.27 - Education and research

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Approved Education and Research Income such as grants, or contract payments, tuitions and fees received as direct support for approved educational and research programs (with the exception of those from the Graduate Medical Education Program for primary care residency programs in Family Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology) (see 10:52-6.71 ) are used to offset such expenses and treated as Case B. Transfers of Specific Purpose Fund Revenues to the Unrestricted Fund shall be reported as non-operating revenue.
(b) Non-Approved Education and Research (not approved in accordance with 10:52-6.17 ) costs and revenues up to the amount of such costs are excluded. Overhead expenses shall be included in the costs of such program as Case A.
(c) Salaried house physicians hired by the hospital to supplement house coverage of attending physicians or patient units such as residents of non-hospital programs shall be included as Case B. Coverage of emergency services and other ambulatory and ancillary services by such physicians shall be included in the cost center definition of these services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.29 - Patient convenience items

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Television and Radio provided to patients shall be excluded and net gains or losses from such services shall be treated as Case C.
(b) Telephone and Telegraph services provided to patients, including the appropriate portion of the hospital's switchboard costs shall be excluded and net gains or losses from such services treated as Case C.
(c) Luxury Meals and Items provided to patients or guests shall be excluded and treated as Case A.
(d) Non-Patient Room Rental Income generated from boarders related to or visitors of a patient shall be excluded from Revenue Related to Patient Care and treated as Case B.
(e) Private-Duty Nursing Services when provided through the hospital at the request of the patient and not prescribed by the attending physician shall be excluded and treated as Case C.
(f) Private Room Differential Income above a hospital's most common charge for a semi-private room for similar routine services, when specifically requested by the patient shall be excluded and treated as Case C. When ordered by the attending physician for medical necessity, income shall be excluded and treated as Case C. Hospitals should maintain separate revenue classifications for medically necessary and patient convenience private room revenue. Patients admitted or transferred to private rooms because of the unavailability of semi-private rooms shall be charged at the semi-private room rate, with a courtesy allowance (Policy Discount) generated for the differential. No attempt shall be made to identify private room Routine Service cost differentials.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 6 - FINANCIAL REPORTING PRINCIPLES AND CONCEPTS › Section 10:52-6.30 - Administrative items

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Administrative Expense Exclusions, as listed in this section, shall not be included in Costs Related to Patient Care and, as such, shall not be included in expenses defined as General Administrative Services (Case C);
1. Life insurance premiums for employees where the hospital is the direct beneficiary;
2. Stockholders servicing costs, such as those incurred to schedule and hold annual meetings;
3. Advertising costs, conducted by hospital personnel or agents of the hospital, which are directed at increasing utilization or medical staff membership, except where attempts to increase medical staff membership is for the procurement of a scarce medical service needed in the service area of the hospital;
4. Costs of membership in organizations not related to the development and operation of the hospital and the rendering of patient care services (for example social or fraternal organizations) shall not be included as an employee fringe benefit; and
5. Monies paid by a hospital to the home office, corporate or order headquarters for:
i. Non-patient care related enterprises;
ii. Abandoned home office planning costs for construction of a new facility; or
iii. The imputed value of services performed by non-paid workers in the case of religious orders.