Medicaid

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Amortization Rate
Under a screened cost approach for the calculation of a reimbursement rate, an amortization rate in accordance with a petitioner's lower actual interest rate may be used. Decision: 4 N.J.A.R. 026
Capital Facilities Allowance
The Capital Facilities Allowance rate is a screen for reasonableness taking into account all regulatory rate components. Decision: 9 N.J.A.R. 045
Care Guidelines
Care Guidelines attempt to ensure that the State Medicaid agency only reimburses providers for the reasonable cost of services related to patient care, not the actual costs of care. Decision: 8 N.J.A.R. 283 Decision: 9 N.J.A.R. 045
Medicaid program should not alter its regulations for a provider who decides, as a management decision, to enter into a financing arrangement known to be inconsistent with the laws. Decision: 9 N.J.A.R. 045
States are to be given maximum flexibility in developing rate methodologies in compliance with a reasonable cost-related basis requirement. Decision: 9 N.J.A.R. 045
Claim Submission
Division of Medical Assistance and Health Services was correct in denying payment for the billing of a patient in a long-term care facility where the claim was not submitted within the prescribed time period and an opportunity was given to present arguments for the waiver of the time period restriction. Decision: 1 N.J.A.R. 193
Failure to re-submit a prescription claim originally rejected for incomplete information within the required 180-day time period results in the denial of reimbursement. Decision: 2 N.J.A.R. 369
Although regulations require the submission of claims within a proscribed time period, denial of claims not submitted within that time period is arbitrary and unreasonable where the time limitations had never been previously enforced. Decision: 2 N.J.A.R. 196
Estoppel
Recovery of Medicaidoverpayments with interests will not be barred by equitable estoppel where no showing was made that an officer of the State, conscious of the State's true interest and aware of petitioner's misapprehension stood by while the other party acted in detrimental reliance. Decision: 8 N.J.A.R. 217
Equitable estoppel may only be applied against the State to prevent a manifest wrong or injustice. Decision: 8 N.J.A.R. 217
Historical Rate
Historical rate costs are simply a facility's own actual costs for a base period. Decision: 9 N.J.A.R. 045
Home Health Care
An agency's action reducing homemaker services due to severe fiscal constraints on the agency's funding was reversed where the agency failed to establish that any equitable plan had been formulated for the proposed reduction in services and did not present any financial data to substantiate the claim of insufficient funds. Decision: 2 N.J.A.R. 024
Where evidence established that an individual is eligible for homemaker services but the local agency is unable to provide such services due to fiscal constraints, reduction of services is proper where all individuals in a similar situation have had their services reduced. Decision: 3 N.J.A.R. 216
Income Eligibility
An individual whose monthly income level is exactly equal to the applicable Medicaid eligibility income standard is eligible for Medicaid. Decision: 1 N.J.A.R. 047
Medical Equipment
An "easy lift" chair is excluded from Medicaid coverage since the item is not medically necessary for diagnosis or treatment of a disease or injury; the chair is required only for family convenience and is environmental equipment for which there is no reimbursement. Decision: 2 N.J.A.R. 145
Reasonable Charges
Both State and Federal Law require that the State's plan for medical assistance provide such methods and charges as may be necessary to as- sure that payments for all services under the plan are not in excess of reasonable charges consistent with efficiency, economy and quality of care. Decision: 9 N.J.A.R. 045
Reimbursement Freeze
A freeze on Medicaid reimbursement rates is invalid where it had not been submitted for prior approval to the required federal officials, nor had it been given the notice required by the State's Administrative Procedure Act. Decision: 6 N.J.A.R. 127
Reimbursement Rate
Reimbursement rates for long-term nursing care facilities may be determined either by the basis of actual additional cost with a factor for a return on net equity or on the basis of a screening formula. Decision: 4 N.J.A.R. 026
Travel Costs
Denial of reimbursement of travel costs to an out-of-state site for recreation and socialization therapy is improper where evidence shows that petitioner receives medical and psychological care at the site and no evidence was presented to show a suitable alternative site was available. Decision: 4 N.J.A.R. 237