N.J. Admin. Code § 8:85-1.18

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:85-1.18 - Medicaid/Medicare

(a) The New Jersey Medicaid Program will reimburse for NF services provided to combination Medicare/Medicaid beneficiaries only after Medicare covered benefits have been fully utilized or when medically necessary services are not covered by the Medicare Program. (Exceptions--see (f)1i below.)

1. A facility shall begin to bill Medicare for eligible residents immediately upon receipt of Medicare certification.

2. Failure by a facility to bill Medicare for Medicare/Medicaid eligible residents who meet the criteria for Medicare reimbursement for long-term care services, and who occupy Medicare certified beds may result in the termination of a facility's Medicaid provider agreement.

(b) Only skilled nursing facilities (SNFs), as defined in 8:85-1.2, certified by the Centers for Medicare & Medicaid Services (CMS) and the New Jersey Department of Health and Senior Services are eligible to be reimbursed by Medicare for services rendered consistent with all Medicare requirements.

(c) Medicare covers eligible beneficiaries needing post-hospital skilled nursing care when they are placed in Medicare certified facilities.

(d) Medicare-eligible residents shall be placed in Medicare certified beds. If no Medicare certified beds are vacant at the time a Medicare-eligible person is admitted, a nursing facility patient who is occupying a Medicare certified bed but who is not eligible for Medicare reimbursement, may be relocated to allow the newly admitted patient to occupy a Medicare certified bed. In accordance with 42 C.F.R. 483.10 (o), such relocation shall only occur when the individual agrees to the relocation. The nursing facility shall provide sufficient preparation and orientation to the resident to ensure a safe and orderly transfer. If consent is not granted, Medicaid shall reimburse the nursing facility for a timely submitted claim reimbursable under Medicaid rules.

(e) When Medicare benefits are denied, terminated or exhausted, because of coverage limitations, Medicaid may be billed on behalf of eligible beneficiaries, provided that:

1. The services are allowable and provided within the standards and procedures established by the New Jersey Medicaid program as described in this manual. Medicaid shall reimburse a nursing facility if Medicare does not pay the claim and the claim is Medicaid reimbursable.

2. The certified facility provides written documentation of a denial of Medicare coverage:

i. The certified facility shall indicate for all Medicare eligible beneficiaries through status reports, that the effort was made to apply for Medicare reimbursement prior to Medicaid billing. Status reports affirming denial shall be obtained from the Medicare Fiscal Intermediary. Status reports shall consist of:

(1) A copy of form Inpatient Hospital and Skilled Nursing Facility Admission and Billing SSA-1453; or

(2) A notice of denial of coverage form Notice of Medicare Claim Determination SSA-1954 or form Notice of Medicare Claim Determination SSA-1955; or

(3) The facility statement of non-coverage, signed by an administrator or officer, which shall be accepted only under the limitation of benefits.

(f) Medicare Part A coinsurance may be paid by the New Jersey Medicaid Program, but the total combined Medicare/Medicaid reimbursement may never exceed the facility's Medicaid Nursing Facility rate. If the Medicaid beneficiary has available income during the coinsurance period of Medicare eligibility, it shall be used to offset the coinsurance charges, prior to billing Medicaid. New Jersey Medicaid will pay Part B Medicare insurance premiums for all eligible Medicare-Medicaid beneficiaries. Claims for Part B services shall be billed to Medicaid only after Medicare benefits have been exhausted. Medicare timely filing requirements shall be met prior to the reimbursement of coinsurance by Medicaid.

1. Coinsurance and deductible payment shall be made as follows:

i. Medicaid will not assume responsibility for payment of coinsurance for certain services under Part B Medical Insurance when the basis of payment is fee for service (for example, physicians or podiatrists). However, coinsurance is paid for certain other Part B Provider services where the basis for payment is not fee for service (for example, durable medical equipment), but only in those instances where the Medicare allowable reimbursement is less than the Medicaid established reimbursement for those items.

ii. Medicaid will assume responsibility for deductible payments for Part B Medical Insurance services.

N.J. Admin. Code § 8:85-1.18

Amended by R.1998 d.177, effective 4/6/1998.
See: 29 New Jersey Register 4614(a), 30 New Jersey Register 1284(b).
In (a), made an internal reference change in the introductory paragraph, and added 1 and 2; inserted a new (d); recodified former (d) as (e), inserted a reference to denial of benefits in the introductory paragraph, and added a second sentence in 1; and recodified former (e) as (f).
Recodified from N.J.A.C. 10:63-1.18 and amended by R.2005 d.389, effective 1/17/2006.
See: 36 New Jersey Register 4700(a), 37 New Jersey Register 1185(a), 38 New Jersey Register 674(a).
Substituted "beneficiary" for "recipient" throughout; rewrote (b).