Current through Register Vol. 54, No. 7, April 4, 2022
Division limits aggregate payments to a hospice during a hospice "cap" period
to the same degree, amount, and methodology as Medicare except the room and
board per diem amounts reimbursed to hospice providers for services provided in
a nursing facility are not subject to the "cap limitations" on the overall
reimbursement to hospice providers.
payments in excess of the "cap" must be refunded by the hospice to the
Division also limits payment for inpatient care according to the number of days
of inpatient care furnished to hospice beneficiaries in the aggregate for that
provider. The computation of the limitation is as follows:
During the 12-month period beginning
November 1 of each year and ending October 31 of the following year, the
aggregate number of inpatient days (both for general inpatient care and
inpatient respite care) shall not exceed 20 percent of the aggregate total
number of days of hospice care provided to all Medicaid and NJ FamilyCare FFS
beneficiaries during that same period.
maximum allowable number of inpatient days shall be calculated by multiplying
the total number of days of Medicaid/NJ FamilyCare hospice care by 20
ii. If the total number of
days of inpatient care furnished to Medicaid and NJ FamilyCare FFS hospice
beneficiaries is less than or equal to the maximum, no adjustment shall be
If the total number of
days of inpatient care exceeds the maximum allowable number, the amount of the
limitation will be determined by:
Calculating a ratio of the maximum allowable days to the number of actual days
of inpatient care, and multiplying this ratio by the total reimbursed for
inpatient care (general and respite reimbursement);
(2) Multiplying the excess inpatient care
days by the routine home care rate;
(3) Adding the amounts determined in the
calculations of (b)1iii(1) and (2) above; and
(4) Comparing the amount in (b)1iii(3) above
with interim payments made to the hospice for inpatient care during the "cap
(5) The aggregate number
of inpatient days (both for inpatient general and inpatient respite care) shall
not exceed 20 percent of the aggregate total number of days of hospice care
provided to all Medicaid/NJ FamilyCare beneficiaries during that same
Any payments in excess of the "cap" must be refunded by the hospice to the
N.J. Admin. Code §
Amended by R.1997 d.479,
See: 29 N.J.R. 3441(a), 29 N.J.R. 4853(a).
Amended by R.2003 d.320, effective
N.J.R. 2899(a), 35 N.J.R. 3568(a).
Rewrote the section.
See: 42 N.J.R.