N.J. Admin. Code § 10:79A-1.3 - General requirements and provisions
(a) Under the Demonstration Project, Medicaid
ACOs shall refrain from, and implement appropriate safeguards against, conduct
that may facilitate collusion among Medicaid ACO participants affecting the
commercial health care marketplace, including, but not limited to, discussions
among ACO participants about rates negotiated with commercial payers.
(b) Medicaid ACOs participating in the
Demonstration Project shall include sufficient clinical integration. Any
agreement reached by the Medicaid ACO, with the Division or a Medicaid managed
care organization for sharing of savings within the ACO, must be necessary to
improve care for Medicaid beneficiaries by incentivizing the integration of
care between multiple distinct entities. Since the Demonstration Project does
not impact the negotiated fee schedules between payers, hospitals, and
providers, it is considered pro-competitive.
(c) All approvals, exceptions, or
authorizations of any kind issued under this chapter or as part of the
Demonstration Project established under the Act are for purposes of
implementing the Act only and shall not extend beyond the Demonstration Project
or beyond the timeframes for the Demonstration Project that are established
under the Act. This specifically includes, but is not limited to, any exception
to a requirement to obtain a certificate of need.
(d) Under no circumstances shall a Medicaid
ACO negotiate reimbursement rates for clinical services provided by its
participating providers. A gainsharing plan may be negotiated and
administered.
Notes
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