New Jersey 2022-2023 Regular Session

New Jersey Senate Bill S4179 Compare Versions

Only one version of the bill is available at this time.

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1	1	SENATE, No. 4179 STATE OF NEW JERSEY 220th LEGISLATURE INTRODUCED DECEMBER 4, 2023
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3	3	SENATE, No. 4179
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7	7	STATE OF NEW JERSEY
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9	9	220th LEGISLATURE
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13	13	INTRODUCED DECEMBER 4, 2023
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17	17	Sponsored by: Senator ANTHONY M. BUCCO District 25 (Morris and Somerset) SYNOPSIS Provides for certain pediatric NJ FamilyCare beneficiaries to maintain private duty nursing hours when transitioning to Managed Long Term Services and Supports; codifies and expands appeals provisions for private duty nursing services. CURRENT VERSION OF TEXT As introduced.
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21	21	Sponsored by:
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23	23	Senator ANTHONY M. BUCCO
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25	25	District 25 (Morris and Somerset)
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35	35	SYNOPSIS
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37	37	Provides for certain pediatric NJ FamilyCare beneficiaries to maintain private duty nursing hours when transitioning to Managed Long Term Services and Supports; codifies and expands appeals provisions for private duty nursing services.
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41	41	CURRENT VERSION OF TEXT
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43	43	As introduced.
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47	47	An Act concerning private duty nursing services covered under NJ FamilyCare and supplementing P.L.1968, c.413 (C.30:4D-1 et seq.). Be It Enacted by the Senate and General Assembly of the State of New Jersey: 1. a. Notwithstanding the provisions of N.J.A.C.10:60-5.1 et seq. or any law or regulation to the contrary, a NJ FamilyCare beneficiary transitioning from the Early and Periodic Screening, Diagnosis, and Treatment program to the Managed Long Term Services and Supports program shall: (1) automatically receive coverage under the Managed Long Term Services and Supports program for no less than the number of weekly private duty nursing service hours the beneficiary was eligible to receive pursuant to the most recent nursing assessment completed under the Early and Periodic Screening, Diagnosis, and Treatment program; and (2) be allowed to carry forward unused private duty nursing service hours from week to week. b. The managed care organization responsible for a beneficiary's NJ FamilyCare benefits under the Managed Long Term Services and Supports program shall be authorized to decrease the number of covered private duty nursing service hours authorized for a beneficiary under paragraph (1) of subsection a. of this section, if the managed care organization, upon consultation with the beneficiary's primary care physician and other relevant members of the beneficiary's medical team, can demonstrate that the beneficiary's medical need for private duty nursing services has changed since the beneficiary's most recent nursing assessment under the Early and Periodic Screening, Diagnosis, and Treatment program. Under no circumstances shall a managed care organization be authorized to justify a decrease in the number of a beneficiary's covered private duty nursing service hours, as authorized in paragraph (1) of subsection a. of this section, based on anything other than a change in medical necessity. A beneficiary shall have the right to a continuation of benefits, as outlined in section 2 of this act, during an appeal of any decrease in the number of the beneficiary's covered private duty nursing service hours determined by a managed care organization pursuant to this section. c. Upon the effective date of this act, the Department of Human Services shall review the records of all beneficiaries who have transitioned from the Early and Periodic Screening, Diagnosis, and Treatment program to the Managed Long Term Services and Supports program in the preceding five years to determine if any beneficiaries may be eligible for coverage of an increased number of private duty nursing services hours pursuant to the provisions of this section. Upon identifying a beneficiary eligible for coverage of an increased number of private duty nursing service hours pursuant to this section, the department shall notify the beneficiary and the beneficiary's managed care organization, and direct the managed care organization to implement the coverage change, provided that the beneficiary consents. 2. Notwithstanding the provisions of any law or regulation to the contrary, a managed care organization contracted with the Division of Medical Assistance and Health Services in the Department of Human Services shall: a. automatically continue a beneficiary's private duty nursing services benefits during an appeal of an adverse benefit determination, provided that: (1) the appeal involves the termination, suspension, or reduction of previously authorized private duty nursing services; (2) the private duty nursing services were ordered by an authorized provider; and (3) the appeal request is made by the beneficiary, provider, or the beneficiary's authorized representative within 30 calendar days of the date of the notification of adverse benefit determination; and b. continue the beneficiary's private duty nursing services benefits while an appeal of an adverse benefit determination is pending until 30 calendar days after one of the following occurs: (1) the beneficiary withdraws the appeal; or (2) the appeal results in a decision adverse to the beneficiary. 3. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this act and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program. 4. The Commissioner of Human Services, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt rules and regulations necessary to implement the provisions of this act. 5. This act shall take effect immediately. STATEMENT This bill provides that a NJ FamilyCare beneficiary transitioning from the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for children under age 21 to the Managed Long Term Services and Supports (MLTSS) program for people of all ages with long-term care needs will automatically receive coverage under the MLTSS program for no less than the number of weekly private duty nursing service hours that the beneficiary was eligible to receive pursuant to the most recent nursing assessment completed under the EPSDT program. Moreover, the bill requires that such beneficiaries will be allowed to carry forward unused private duty nursing service hours from week to week. A managed care organization may decrease the number of covered private duty nursing service hours for such a beneficiary only based on a change in medical necessity, as determined by an authorized provider. The MLTSS program currently limits the number of weekly private duty nursing hours to 16. By contrast, there is no cap on such services under the EPSDT program. Furthermore, the bill directs the Department of Human Services to review the records of all beneficiaries who have transitioned from the EPSDT program to the MLTSS program in the five years preceding the bill's enactment to determine if any beneficiaries may be eligible for coverage of an increased number of private duty nursing services hours pursuant to the provisions of the bill. The bill also codifies and expands certain provisions in the contract between the Medicaid managed care organizations and the State for all private duty nursing services appeals. Under the bill, a managed care organization is required to automatically continue a beneficiary's provider-authorized private duty nursing services benefits during an appeal of a change of previously authorized private duty nursing services, provided that the appeal request is made by an eligible entity within 30 calendar days of the date of notification of the adverse benefit determination. These provisions reflect existing contract elements, except that currently an appeal request must be made within 10 calendar days, rather than 30. The bill also requires managed care organizations to continue the beneficiary's private duty nursing services benefits while an appeal is pending until 30 days after either the beneficiary withdraws the appeal or the appeal results in a decision adverse to the beneficiary. Currently, the managed care organizations can discontinue benefits upon the date of either of these two events.
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49	49	An Act concerning private duty nursing services covered under NJ FamilyCare and supplementing P.L.1968, c.413 (C.30:4D-1 et seq.).
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53	53	Be It Enacted by the Senate and General Assembly of the State of New Jersey:
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57	57	1. a. Notwithstanding the provisions of N.J.A.C.10:60-5.1 et seq. or any law or regulation to the contrary, a NJ FamilyCare beneficiary transitioning from the Early and Periodic Screening, Diagnosis, and Treatment program to the Managed Long Term Services and Supports program shall:
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59	59	(1) automatically receive coverage under the Managed Long Term Services and Supports program for no less than the number of weekly private duty nursing service hours the beneficiary was eligible to receive pursuant to the most recent nursing assessment completed under the Early and Periodic Screening, Diagnosis, and Treatment program; and
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61	61	(2) be allowed to carry forward unused private duty nursing service hours from week to week.
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63	63	b. The managed care organization responsible for a beneficiary's NJ FamilyCare benefits under the Managed Long Term Services and Supports program shall be authorized to decrease the number of covered private duty nursing service hours authorized for a beneficiary under paragraph (1) of subsection a. of this section, if the managed care organization, upon consultation with the beneficiary's primary care physician and other relevant members of the beneficiary's medical team, can demonstrate that the beneficiary's medical need for private duty nursing services has changed since the beneficiary's most recent nursing assessment under the Early and Periodic Screening, Diagnosis, and Treatment program. Under no circumstances shall a managed care organization be authorized to justify a decrease in the number of a beneficiary's covered private duty nursing service hours, as authorized in paragraph (1) of subsection a. of this section, based on anything other than a change in medical necessity. A beneficiary shall have the right to a continuation of benefits, as outlined in section 2 of this act, during an appeal of any decrease in the number of the beneficiary's covered private duty nursing service hours determined by a managed care organization pursuant to this section.
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65	65	c. Upon the effective date of this act, the Department of Human Services shall review the records of all beneficiaries who have transitioned from the Early and Periodic Screening, Diagnosis, and Treatment program to the Managed Long Term Services and Supports program in the preceding five years to determine if any beneficiaries may be eligible for coverage of an increased number of private duty nursing services hours pursuant to the provisions of this section. Upon identifying a beneficiary eligible for coverage of an increased number of private duty nursing service hours pursuant to this section, the department shall notify the beneficiary and the beneficiary's managed care organization, and direct the managed care organization to implement the coverage change, provided that the beneficiary consents.
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69	69	2. Notwithstanding the provisions of any law or regulation to the contrary, a managed care organization contracted with the Division of Medical Assistance and Health Services in the Department of Human Services shall:
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71	71	a. automatically continue a beneficiary's private duty nursing services benefits during an appeal of an adverse benefit determination, provided that:
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73	73	(1) the appeal involves the termination, suspension, or reduction of previously authorized private duty nursing services;
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75	75	(2) the private duty nursing services were ordered by an authorized provider; and
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77	77	(3) the appeal request is made by the beneficiary, provider, or the beneficiary's authorized representative within 30 calendar days of the date of the notification of adverse benefit determination; and
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79	79	b. continue the beneficiary's private duty nursing services benefits while an appeal of an adverse benefit determination is pending until 30 calendar days after one of the following occurs:
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81	81	(1) the beneficiary withdraws the appeal; or
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83	83	(2) the appeal results in a decision adverse to the beneficiary.
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87	87	3. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this act and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program.
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91	91	4. The Commissioner of Human Services, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt rules and regulations necessary to implement the provisions of this act.
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95	95	5. This act shall take effect immediately.
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101	101	STATEMENT
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105	105	This bill provides that a NJ FamilyCare beneficiary transitioning from the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for children under age 21 to the Managed Long Term Services and Supports (MLTSS) program for people of all ages with long-term care needs will automatically receive coverage under the MLTSS program for no less than the number of weekly private duty nursing service hours that the beneficiary was eligible to receive pursuant to the most recent nursing assessment completed under the EPSDT program. Moreover, the bill requires that such beneficiaries will be allowed to carry forward unused private duty nursing service hours from week to week. A managed care organization may decrease the number of covered private duty nursing service hours for such a beneficiary only based on a change in medical necessity, as determined by an authorized provider. The MLTSS program currently limits the number of weekly private duty nursing hours to 16. By contrast, there is no cap on such services under the EPSDT program.
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107	107	Furthermore, the bill directs the Department of Human Services to review the records of all beneficiaries who have transitioned from the EPSDT program to the MLTSS program in the five years preceding the bill's enactment to determine if any beneficiaries may be eligible for coverage of an increased number of private duty nursing services hours pursuant to the provisions of the bill.
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109	109	The bill also codifies and expands certain provisions in the contract between the Medicaid managed care organizations and the State for all private duty nursing services appeals. Under the bill, a managed care organization is required to automatically continue a beneficiary's provider-authorized private duty nursing services benefits during an appeal of a change of previously authorized private duty nursing services, provided that the appeal request is made by an eligible entity within 30 calendar days of the date of notification of the adverse benefit determination. These provisions reflect existing contract elements, except that currently an appeal request must be made within 10 calendar days, rather than 30.
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111	111	The bill also requires managed care organizations to continue the beneficiary's private duty nursing services benefits while an appeal is pending until 30 days after either the beneficiary withdraws the appeal or the appeal results in a decision adverse to the beneficiary. Currently, the managed care organizations can discontinue benefits upon the date of either of these two events.