N.J. Admin. Code § 10:79A-1.4 - Review and oversight

(a) In accordance with the Act, this chapter, and the Departments ongoing authority to oversee and regulate the Medicaid ACOs, the Department, in consultation with the Office of the Attorney General, shall:

1. Review each submitted ACO certification application and issue a written decision on the determination to approve or deny the application, specifying the reason(s) for approval or denial;

2. Review each gainsharing plan submitted by a certified Medicaid ACO or by a Medicaid ACO applicant and issue a written decision on the determination to approve or deny the gainsharing plan;

3. Review each Medicaid ACOs annual report and issue a written acceptance or rejection of the annual report;

4. Evaluate the Demonstration Project annually to assess whether cost savings are achieved and whether there is an improvement in outcomes including health screenings, emergency room visits, hospitalization, and inpatient recidivism rates;

5. In consultation with the Department of Banking and Insurance, evaluate the Demonstration Project annually to assess potential anticompetitive effects on commercial rates for clinical services in the ACOs designated area. The evaluation should take the form of a written report and should recommend terminating the ACO if information available on commercial rates in the designated area supports a conclusion that the ACO is causing rates to rise more quickly than they do in comparable markets that do not have an ACO; and

6. Provide a mechanism whereby payors, non-ACO providers, or other potentially affected parties in the designated area can lodge complaints about any anticompetitive activity by ACOs and their participants.

(b) The Department, in consultation with the Department of Health and the Office of the Attorney General, shall:

1. Design and implement the application process for approval of participating ACOs in the Demonstration Project;

2. Collect data from participants in the Demonstration Project; and

3. Approve a methodology proposed by the Medicaid ACO applicant for calculation of cost savings and for monitoring of health outcomes and quality of care under the Demonstration Project.

(c) The Department, in consultation with the Department of Health, will evaluate the Demonstration Project annually to assess whether cost savings, including savings in administrative costs and savings due to improved health outcomes, is achieved through implementation of the Demonstration Project. The Department also will evaluate the Demonstration Project annually to assess whether there is improvement in the rates of health screening, the health outcomes, and hospitalization rates for persons with chronic illnesses, and the hospitalization and readmission rates for patients residing in the designated areas served by the ACOs.

Notes

N.J. Admin. Code § 10:79A-1.4

Amended by 46 N.J.R. 791(a), effective 5/5/2014.