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.
