N.J. Admin. Code § 10:49A-3.1 - Calculating and providing the rebate

(a) A facility must provide a rebate to the Department if the facility has a PCR of less than 90 percent.

1. For the sole purpose of determining if the facility has a PCR of less than 90 percent, the Department is entitled to receive a rebate pursuant to this subchapter, the term "payer" means the Department, as the administrator of the New Jersey Medicaid/NJ FamilyCare fee-for-service and Managed Care programs.

(b) Each percentage calculation in this section shall be rounded to three decimal places. The amount shall be rounded up if the number in the fourth decimal place is greater than or equal to five, and otherwise rounded down. For example, 0.79881 shall be rounded up to 0.799 or 79.9 percent, and 0.82549 shall be rounded down to 0.825 or 82.5 percent.

(c) Each dollar amount calculation in this section shall be rounded to two decimal places, except for the final rebate amount, which is defined separately. The amount shall be rounded up if the number in the third decimal place is greater than or equal to five, and otherwise rounded down. For example, $ 7.9881 shall be rounded up to $ 7.99, and $ 8.2549 shall be rounded down to $ 8.25.

(d) The payer's Cost Share Percentage is the ratio of the reported number of Medicaid/NJ FamilyCare Bed Days (numerator) to the reported number of Total Bed Days (denominator). The payer's Cost Share Percentage shall be rounded as defined at (b) above.

(e) The payer's Share of Expenses is the dollar amount calculated by multiplying the payer's Cost Share Percentage by the sum of all reported expenses, as described in this section. The payer's Share of Expenses shall be rounded as defined at (c) above.

(f) A facility's PCR is the ratio of the payer's Share of Expenses to the payer's reported Medicaid/NJ FamilyCare Revenue (denominator). A facility's PCR shall be rounded as defined at (b) above.

(g) For each PCR reporting year, a facility must provide a rebate to the payer if the facility's PCR does not meet or exceed 90 percent.

1. If a facility's PCR is 90 percent or higher, the Rebate Percentage is zero.

2. If a facility's PCR is below 90 percent, the Rebate Percentage is 90 percent minus the facility's rounded PCR.

(h) If a rebate is required, the amount is calculated by multiplying the facility's Rebate Percentage by the reported Medicaid/NJ FamilyCare Revenue.

1. A facility's final rebate shall be rounded to the one-dollar position. The amount shall be rounded up if the number in the first decimal place is greater than or equal to five. For example, $ 8,254.91 shall be rounded up to $ 8,255.00 and $ 7,988.16 shall be rounded down to $ 7,988.00.

2. A facility must pay any rebate owing no later than the first day of the seventh month following the end of the PCR reporting year.

3. A facility must provide any rebates owed in the form of a lump-sum check unless the payer provides written instructions for a revenue credit.

4. If a rebate from any facility is not paid by the required date, the amount will be withheld from all other State and Medicaid/NJ FamilyCare fee-for-service and Managed Care payments due to the facility owner, as identified by a Tax Identification Number, including offset against prospective payments, any other amounts due, and referral to the Department of the Treasury's program for debt collection.

5. A facility is not required to provide a rebate to the payer if the calculated rebate owed to the payer is de minimis, meaning less than $ 1,000.

(i) As an example of the calculations in this section, assume a facility reports 100 total bed days, 50 Medicaid/NJ FamilyCare bed days, $ 1,000 of total expenses, and $ 570.00 of Medicaid/NJ FamilyCare revenue.

1. The payer's Cost Share Percentage is 50 percent (50/100).

2. The payer's Share of Expenditures is $ 500.00 (50% $ 1,000).

3. The payer's PCR is 87.7 percent ($ 500/$ 570).

4. The payer's Rebate Percentage is 2.3 percent (90.0% - 87.7%).

5. The payer's Rebate is $ 13.00 (2.3% $ 570). This example does not apply the de minimis rule due to illustrative small dollar amounts.

6. The payer's Share of Expenditures plus Rebate is $ 513.00, which is 90 percent of the payer's Revenue ($ 513/$ 570).

(j) If a State entity with financial audit and/or investigatory authority determines that the payment of rebates by a facility will cause the facility's cash balance to fall below the amount needed to operate as a going concern, the facility may request that the Department defer all, or a portion of, the rebate payments owed by the facility. The Department may permit a deferral of all, or a portion of, the rebates owed, but only for a period determined by the Department in consultation with the auditing entity. Upon receipt of notice that a rebate is due, a facility may request a deferral by filing a written request, including a copy of the State entity's finding, with the Division of Medical Assistance and Health Services, Office of Legal and Regulatory Affairs, PO Box 712, Mail Code #26, Trenton, NJ 08625-0712. The written request must be filed within 60 days of receipt of notification of the rebate.

(k) The Department requires, at a minimum, that all reports shall be submitted timely, as described above, and that all data used in reports shall comply with the definitions, criteria, and other requirements as set forth in this chapter. If a facility fails to submit a timely report, fee-for-service and Managed Care claims will be held in pending status and no payments will be made until the facility is in compliance with the requirements in this chapter.

Notes

N.J. Admin. Code § 10:49A-3.1

Adopted by 53 N.J.R. 1783(a), effective 10/18/2021