New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79A - ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION PROJECT › Subchapter 1 - GENERAL PROVISIONS › Section 10:79A-1.1 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter,
				  shall have the following meanings, unless the context clearly indicates
				  otherwise:
"ACO" means an accountable care organization, a legal entity
				  that is recognized and authorized under applicable State law, as identified by
				  a Taxpayer Identification number and comprised of an eligible group of ACO
				  participants that work together to manage and coordinate care for Medicaid
				  beneficiaries and have established a mechanism for shared governance that
				  provides all ACO participants with an appropriate proportionate control over
				  the ACOs decision-making processes.
"ACO participant" means a provider or a supplier as
				  identified by a Taxpayer Identification number.
"Access to care" means the timely use of affordable personal
				  health services to achieve the best possible health outcomes.
"Act" means
				  P.L.
				  2011, c. 114, an act
				  establishing a Medicaid accountable care demonstration project.
"Behavioral healthcare provider" means a provider licensed or
				  designated by an authorized State agency or licensed or approved by the
				  Department of Human Services to render behavioral healthcare (mental health
				  and/or substance use disorder) services to New Jersey residents with mental
				  illnesses, substance use, or co-occurring disorders.
"Consumer organization" means a formally organized entity
				  that is capable of advocating on behalf of people who reside in the designated
				  area who need medical care.
"Designated area" means a municipality or defined geographic
				  area in which no fewer than 5,000 Medicaid beneficiaries reside.
"Demonstration Project objectives" means increasing access to
				  primary care, behavioral health care, pharmaceuticals, and dental care and
				  improving health outcomes and quality as measured by objective metrics and
				  patient experience of care for vulnerable populations in a designated area
				  while reducing unnecessary and inefficient spending of public Medicaid
				  funds.
"Demonstration Project year" means an annual 12-month period
				  specified in an approved gainsharing plan during which health care
				  expenditures, quality improvements, and health outcomes are identified and
				  compared with a benchmark period in order to determine whether savings were
				  achieved and quality and health outcomes were improved.
"Department" means the New Jersey Department of Human
				  Services.
"Disproportionate share hospital" means a hospital designated
				  by the Commissioner of Human Services pursuant to Title XIX of the Social
				  Security Act (
				  42 U.S.C. §§
										1396a et seq.).
"Division or DMAHS" means the New Jersey Division of Medical
				  Assistance and Health Services.
"Gainsharing" means the sharing of savings achieved by an ACO
				  in the Medicaid ACO Demonstration Project established pursuant to
				  P.L.
				  2011, c. 114, as
				  calculated in accordance with a gainsharing plan approved by the Division.
				  Gainsharing shall not mean the splitting of profits or the payment or sharing
				  of revenue in a manner not identified in an approved gainsharing plan.
"General hospital" means a health care facility licensed as a
				  general hospital pursuant to rules promulgated by the Department of
				  Health.
"Health outcomes" means outcomes measured by objective
				  metrics and patient experience of care.
"HIPAA" means Health Insurance Portability and Accountability
				  Act of 1996, P.L.
				  104-191, as amended and supplemented.
"Medicaid" means the Medicaid program established pursuant to
				  30:4D-1 et seq..
"Medicaid ACO Demonstration Project" or "Demonstration
				  Project" means the three-year demonstration project established pursuant to
				  P.L.
				  2011, c. 114.
"Primary care provider" includes the following licensed
				  individuals: physicians, physician assistants, advanced practice nurses, and
				  certified nurse midwives, whose professional practice involves the provision of
				  primary care, including internal medicine, family medicine, geriatric care,
				  pediatric care, and/or obstetrical/gynecological care.
"Protected health information" has the same meaning as set
				  forth at
				  45
				  CFR 160.103.
"Qualified behavioral healthcare provider" means a licensed
				  behavioral health care provider who participates in the Medicaid program and
				  renders clinic-based and home-based services to individuals residing in the
				  designated area served by the Medicaid ACO. Qualified behavioral healthcare
				  provider includes all services and providers referenced in the definition of
				  behavioral healthcare provider.
"Qualified primary care provider" means a primary care
				  provider who participates in the Medicaid program and who spends at least 25
				  percent of his or her professional time or 10 hours per seven-day week,
				  whichever is less, rendering clinical or clinical supervision services at an
				  office or clinic setting located within the designated area served by the
				  Medicaid ACO.
"Quality measures" means measures to assess the quality of
				  care furnished by an ACO, as measured by objective metrics and patient
				  experience of care and utilization.
"Taxpayer Identification number (TIN)" means a Federal
				  taxpayer identification number or employer identification number as described
				  at
				  26 CFR
				  301.6109-1.