N.J. Admin. Code § 10:79A-1.7 - Annual ACO reporting requirements

(a) An ACO shall provide information to the Department to document its activities and the Department shall review and evaluate information provided by the ACO to ensure the Demonstration Project is being administered in a way that achieves the Demonstration Project objectives while protecting patient safety and safeguarding the use of public funds.

(b) With the exception of any commercial rate data provided pursuant to (c)8 below, the ACOs annual report will be considered a government record subject to the Open Public Records Act, N.J.S.A. 47:1A-1 et seq., upon submission to the Department.

(c) To enable the Department to carry out its monitoring, oversight, and evaluation responsibilities, the ACO shall report annually to the Department as follows:

1. The total savings achieved pursuant to the savings calculation methodology in this chapter. The annual savings achieved report must provide the benchmark payment calculation and the expenditures made during that year of the Demonstration Project and must be reported within 30 days of savings distribution;

2. The amount of savings distributed to each participating ACO member pursuant to the distribution of savings methodology contained in the ACOs gainsharing plan;

3. How each participating ACO member spent its savings distribution;

4. Quality performance at the practice level and for the ACO as a whole;

5. Patient experience findings at the practice level and for the ACO as a whole;

6. The cumulative and categorical number of complaints received at a practice level, the types of complaints received, and the resolutions implemented.

i. The ACO must collect and respond in a timely manner to patients and consumers comments and complaints and ensure compliance with all State and Federal laws affecting patient access to appropriate care and services. If the ACO learns of a material concern regarding patient safety and/or satisfaction, the ACO shall promptly report such concern to the Department within three business days independent of the annual reporting requirements so that such concern can be properly addressed;

7. The ACO must renew its certification that it will not negotiate rates for participants services with any public or private payer and attest that it has not done so in the previous year. Failure to comply with this requirement is grounds for decertification of the ACO; and

8. The ACO shall certify that it and its participants have complied with any request to provide the Department and the Department of Banking and Insurance with all data necessary for the State to monitor the ACOs impact on commercial rates in its designated area.

(d) The Department will review and analyze the ACO annual reports to ensure the data provided is complete and accurate and that the ACO is achieving the Demonstration Project objectives per the ACOs gainsharing plan. The Department will independently review, evaluate, and accept or reject the ACOs annual report as follows:

1. Upon receipt of an ACOs annual report, the Department shall post the report on its website and provide for public comment within 45 days.

i. The Department shall review any public comment regarding the report that is submitted by the deadline.

2. The Department shall review, analyze and, as needed, verify the annual report. The Department may request additional documentation or explanations necessary to conduct its review.

3. The Department shall issue a decision in writing to accept or deny the report. The Departments decision shall set forth the basis, including the factual record compiled by the Department, on which the decision was made, including, but not limited to, the following:

i. The annual report demonstrates that the ACO has been carrying out the Demonstration Project objectives.

ii. The annual report demonstrates that the ACO has been in compliance with all Demonstration Project requirements and State and Federal laws, in particular laws designed to protect Medicaid beneficiaries ability to access medically necessary care.

4. If the annual report is rejected, the ACO must seek reconsideration by submitting corrections or amendments to the Department within 15 days of the rejection, and the Department shall thereafter issue a final decision.

i. The Department will review its decision to reject the annual report with the ACO, in person or by conference call, to explain the rationale for its decision and to provide guidance to assist the ACOs resubmission of its report.

5. If the ACO fails to provide the annual report in a timely manner, the Department may place it on a remediation plan, suspend its participation in the project, or take other appropriate action. The ACO may request an administrative appeal of a suspension action pursuant to the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq. However, any such action shall take effect immediately, or at such later date as the Department determines.

6. If the Department discovers material issues with an ACOs performance during its review and evaluation of the ACOs annual report or at any other time, the Department has the authority to request additional information from the ACO, require reconsideration or resubmission of the annual report, decertify the ACO, or take other actions consistent with its obligations under the Act and this chapter. The ACO may request an administrative appeal of a decertification action pursuant to the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq. However, any such action shall take effect immediately, or at such later date as the Department determines.

Notes

N.J. Admin. Code § 10:79A-1.7

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