Reimbursement Policy:

FIDE-SNP Hospital Sequestration Reimbursement

Effective Date:

July 1, 2022

Purpose:

To provide guidelines on the application of a sequestration reduction to payment rates for Hospital services for the Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP). This claims adjudication policy applies to participating hospitals.

Scope:

Products included:

• Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)

Definitions:

Sequestration is automatic spending cuts that occur through the withdrawal of funding for certain (but not all) government programs as established under the Budget Control Act of 2011 or other applicable federal laws that imposes an adjustment from CMS or other sponsors of government health care programs.

Policy:

Effective for dates of service July 1, 2022 and thereafter, Horizon NJ Health will apply a sequestration reduction to hospital payments for the Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP). The payment reduction will be equal to the then current sequestration percentage reduction applicable to federal Medicare payments to hospitals.

The reimbursement rates applicable to the FIDE-SNP product and agreed to by Horizon and hospitals in the hospital’s participation agreement are not changed.

Procedure:

Reimbursement for covered items and services for FIDE-SNP, will be reduced by a percentage commensurate to the then current sequestration percentage reduction applicable to federal Medicare payments to hospitals. The Sequestration payment adjustment will be applied at the final payment level after all other edits, rules, and adjustments have been applied.

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

History:
4/28/2022: Policy approved.