N.J.S.A. 30:4D-6 — Medical assistance for qualified applicants.

30:4D-6 Medical assistance for qualified applicants. 6. a. Subject to the requirements of Title XIX of the federal Social Security Act, the limitations imposed by this act, and by the rules and regulations promulgated pursuant thereto, the department shall provide medical assistance to qualified applicants, including authorized services within each of the following classifications: (1) Inpatient hospital services; (2) Outpatient hospital services; (3) Other laboratory and X-ray services; (4) (a) Skilled nursing or intermediate care facility services; (b) Early and periodic screening and diagnosis of individuals who are eligible under the program and are under age 21, to ascertain their physical or mental health status and the health care, treatment, and other measures to correct or ameliorate defects and chronic conditions discovered thereby, as may be provided in regulation of the Secretary of the federal Department of Health and Human Services and approved by the commissioner; (5) Physician's services furnished in the office, the patient's home, a hospital, a skilled nursing or intermediate care facility, or elsewhere. As used in this subsection, "laboratory and X-ray services" include HIV drug resistance testing, including, but not limited to, genotype assays that have been cleared or approved by the federal Food and Drug Administration, laboratory-developed genotype assays, phenotype assays, and other assays using phenotype prediction with genotype comparison, for persons diagnosed with HIV infection or AIDS. b. Subject to the limitations imposed by federal law, by this act, and by the rules and regulations promulgated pursuant thereto, the medical assistance program may be expanded to include authorized services within each of the following classifications: (1) Medical care not included in subsection a.(5) above, or any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice, as defined by State law; (2) Home health care services; (3) Clinic services; (4) Dental services; (5) Physical therapy and related services; (6) Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist, whichever the individual may select; (7) Optometric services; (8) Podiatric services; (9) Chiropractic services; (10) Psychological services; (11) Inpatient psychiatric hospital services for individuals under 21 years of age, or under age 22 if they are receiving such services immediately before attaining age 21; (12) Other diagnostic, screening, preventative, and rehabilitative services, and other remedial care; (13) Inpatient hospital services, nursing facility services, and immediate care facility services for individuals 65 years of age or over in an institution for mental diseases; (14) Intermediate care facility services; (15) Transportation services; (16) Services in connection with the inpatient or outpatient treatment or care of substance use disorder, when the treatment is prescribed by a physician and provided in a licensed hospital or in a narcotic and substance use disorder treatment center approved by the Department of Health pursuant to P.L.1970, c.334 (C.26:2G-21 et. seq.) and whose staff includes a medical director, and limited those services eligible for federal financial participation under Title XIX of the federal Social Security Act; (17) Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary of the federal Department of Health and Human Services, and approved by the commissioner; (18) Comprehensive maternity care, which may include: the basic number of prenatal and postpartum visits recommended by the American College of Obstetrics and Gynecology; additional prenatal and postpartum visits that are medically necessary; necessary laboratory, nutritional assessment and counseling, health education, personal counseling, managed care, outreach, and follow-up services; treatment of conditions which may complicate pregnancy; doula care; and physician or certified nurse midwife delivery services. For the purposes of this paragraph, "doula" means a trained professional who provides continuous physical, emotional, and informational support to a mother before, during, and shortly after childbirth, to help her to achieve the healthiest, most satisfying experience possible; (19) Comprehensive pediatric care, which may include: ambulatory, preventive, and primary care health services. The preventive services shall include, at a minimum, the basic number of preventive visits recommended by the American Academy of Pediatrics; (20) Services provided by a hospice which is participating in the Medicare program established pursuant to Title XVIII of the Social Security Act, Pub.L.89-97 (42 U.S.C. s.1395 et seq.). Hospice services shall be provided subject to approval of the Secretary of the federal Department of Health and Human Services for federal reimbursement; (21) Mammograms, subject to approval of the Secretary of the federal Department of Health and Human Services for federal reimbursement, including one baseline mammogram for women who are at least 35 but less than 40 years of age; one mammogram examination every two years or more frequently, if recommended by a physician, for women who are at least 40 but less than 50 years of age; and one mammogram examination every year for women age 50 and over; (22) Upon referral by a physician, advanced practice nurse, or physician assistant of a person who has been diagnosed with diabetes, gestational diabetes, or pre-diabetes, in accordance with standards adopted by the American Diabetes Association: (a) Expenses for diabetes self-management education or training to ensure that a person with diabetes, gestational diabetes, or pre-diabetes can optimize metabolic control, prevent and manage complications, and maximize quality of life. Diabetes self-management education shall be provided by an in-State provider who is: (i) a licensed, registered, or certified health care professional who is certified by the National Certification Board of Diabetes Educators as a Certified Diabetes Educator, or certified by the American Association of Diabetes Educators with a Board Certified-Advanced Diabetes Management credential, including, but not limited to: a physician, an advanced practice or registered nurse, a physician assistant, a pharmacist, a chiropractor, a dietitian registered by a nationally recognized professional association of dietitians, or a nutritionist holding a certified nutritionist specialist (CNS) credential from the Board for Certification of Nutrition Specialists; or (ii) an entity meeting the National Standards for Diabetes Self-Management Education and Support, as evidenced by a recognition by the American Diabetes Association or accreditation by the American Association of Diabetes Educators; (b) Expenses for medical nutrition therapy as an effective component of the person's overall treatment plan upon a: diagnosis of diabetes, gestational diabetes, or pre-diabetes; change in the beneficiary's medical condition, treatment, or diagnosis; or determination of a physician, advanced practice nurse, or physician assistant that reeducation or refresher education is necessary. Medical nutrition therapy shall be provided by an in-State provider who is a dietitian registered by a nationally recognized professional association of dietitians, or a nutritionist holding a certified nutritionist specialist (CNS) credential from the Board for Certification of Nutrition Specialists, who is familiar with the components of diabetes medical nutrition therapy; (c) For a person diagnosed with pre-diabetes, items and services furnished under an in-State diabetes prevention program that meets the standards of the National Diabetes Prevention Program, as established by the federal Centers for Disease Control and Prevention; and (d) Expenses for any medically appropriate and necessary supplies and equipment recommended or prescribed by a physician, advanced practice nurse, or physician assistant for the management and treatment of diabetes, gestational diabetes, or pre-diabetes, including, but not limited to: equipment and supplies for self-management of blood glucose; insulin pens; insulin pumps and related supplies; and other insulin delivery devices; (23) Expenses incurred for the provision of group prenatal services to a pregnant woman, provided that: (a) the provider of such services, which shall include, but not be limited to, a federally qualified health center or a community health center operating in the State: (i) is a site accredited by the Centering Healthcare Institute, or is a site engaged in an active implementation contract with the Centering Healthcare Institute, that utilizes the Centering Pregnancy model; and (ii) incorporates the applicable information outlined in any best practices manual for prenatal and postpartum maternal care developed by the Department of Health into the curriculum for each group prenatal visit; (b) each group prenatal care visit is at least 1.5 hours in duration, with a. minimum of two women and a maximum of 20 women in participation; and (c) no more than 10 group prenatal care visits occur per pregnancy. As used in this paragraph, "group prenatal care services" means a series of prenatal care visits provided in a group setting which are based upon the Centering Pregnancy model developed by the Centering Healthcare Institute and which include health assessments, social and clinical support, and educational activities; (24) Expenses incurred for the provision of pasteurized donated human breast milk, which shall include human milk fortifiers if indicated in a medical order provided by a licensed medical practitioner, to an infant under the age of six months; provided that the milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health and a licensed medical practitioner has issued a medical order for the infant under at least one of the following circumstances: (a) the infant is medically or physically unable to receive maternal breast milk or participate in breast feeding, or the infant's mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or (b) the infant meets any of the following conditions: (i) a body weight below healthy levels, as determined by the licensed medical practitioner issuing the medical order for the infant; (ii) the infant has a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis; or (iii) the infant has a congenital or acquired condition that may benefit from the use of donor breast milk and human milk fortifiers, as determined by the Department of Health; (25) Comprehensive tobacco cessation benefits to an individual who is 18 years of age or older, or who is pregnant. Coverage shall include: brief and high-intensity individual counseling, brief and high-intensity group counseling, and telemedicine as defined by section 1 of P.L.2017, c.117 (C.45:1-61); all medications approved for tobacco cessation by the U.S. Food and Drug Administration; and other tobacco cessation counseling recommended by the Treating Tobacco Use and Dependence Clinical Practice Guideline issued by the U.S. Public Health Service. Notwithstanding the provisions of any other law, rule, or regulation to the contrary, and except as otherwise provided in this section: (a) Information regarding the availability of the tobacco cessation services described in this paragraph shall be provided to all individuals authorized to receive the tobacco cessation services pursuant to this paragraph at the following times: no later than 90 days after the effective date of P.L.2019, c.473: upon the establishment of an individual's eligibility for medical assistance; and upon the redetermination of an individual's eligibility for medical assistance; (b) The following conditions shall not be imposed on any tobacco cessation services provided pursuant to this paragraph: copayments or any other forms of cost-sharing, including deductibles; counseling requirements for medication; stepped care therapy or similar restrictions requiring the use of one service prior to another; limits on the duration of services; or annual or lifetime limits on the amount, frequency, or cost of services, including, but not limited to, annual or lifetime limits on the number of covered attempts to quit; and (c) Prior authorization requirements shall not be imposed on any tobacco cessation services provided pursuant to this paragraph except in the following circumstances where prior authorization may be required: for a treatment that exceeds the duration recommended by the most recently published United States Public Health Service clinical practice guidelines on treating tobacco use and dependence; or for services associated with more than two attempts to quit within a 12-month period; (26) Provided that there is federal financial participation available, benefits for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recent published recommendations of the United States Preventive Services Task Force and as determined medically necessary by the covered person's physician, in consultation with the covered person. No deductible, coinsurance, copayment, or any other cost-sharing requirement shall be imposed for a colonoscopy performed following a positive result on a non-colonoscopy, colorectal cancer screening test recommended by the United States Preventive Services Task Force; (27) (a) Within 24 months of the effective date of P.L.2023, c.187 (C.30:4D-6u et al.), and conditional on the receipt of all necessary federal approvals and the securing of federal financial participation pursuant to section 2 of P.L.2023, c.187 (C.30:4D-6u), community-based palliative care benefits which shall include, but not be limited to, all of the following: (i) specialized medical care and emotional and spiritual support for beneficiaries with serious advanced illnesses; (ii) relief of symptoms, pain, and stress of serious illness; (iii) improvement of quality of life for both the beneficiary and the beneficiary's family; and (iv) appropriate care for any age and for any stage of serious illness, along with curative treatment. (b) Benefits provided under this paragraph shall include, but shall not be limited to, services provided by a hospice pursuant to paragraph (20) of subsection b. of this section, provided that: (i) hospice services may be provided at the same time that curative treatment is available, to the extent that services are not duplicative; (ii) hospice services may be provided to beneficiaries whose conditions may result in death, regardless of the estimated length of the beneficiary's remaining period of life; and (iii) the Division of Medical Assistance and Health Services in the Department of Human Services may include any other service deemed appropriate under the benefits provided under this paragraph. (c) Providers authorized to deliver benefits provided under this paragraph shall include Medicaid-approved licensed hospice agencies, Medicaid-approved home health agencies licensed to provide hospice care, and other Medicaid-approved licensed health care providers. (d) Nothing in this paragraph shall be construed to result in the elimination or reduction of covered benefits or services under the Medicaid program. (e) This paragraph shall not affect a beneficiary's eligibility to receive, concurrently with services provided for in this paragraph, any services, including home health services, for which the beneficiary would have been eligible in the absence of this paragraph, to the extent that services are not duplicative; and (28) (a) medically necessary treatment for women with a diagnosis of perimenopause, menopause, and symptoms associated with perimenopause and menopause, including, but not limited to: (i) hormonal therapies such as hormone replacement therapy and bioidentical hormone treatments; (ii) non-hormonal treatments, including medications to manage menopausal symptoms; (iii) behavioral health care services; (iv) pelvic floor physical therapy; (v) bone health treatments, including screenings and medications due to hormonal changes related to perimenopause and menopause; (vi) preventative services that have a rating of �A� or �B� in the current recommendations of the United States Preventive Services Task Force for early detection and treatment of health conditions related to perimenopause and menopause such as osteoporosis and cancer; and (vii) counseling and education regarding menopause management. (b) Individuals receiving medical assistance shall be provided with clear and accessible information regarding covered perimenopause and menopause related treatments. (c) As used in this paragraph: �Menopause� means the permanent end of a female�s menstrual cycle, diagnosed by a licensed medical provider after 12 consecutive months without a menstrual period. �Perimenopause� means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in menstrual cycles. c. Payments for the foregoing services, goods, and supplies furnished pursuant to this act shall be made to the extent authorized by this act, the rules and regulations promulgated pursuant thereto and, where applicable, subject to the agreement of insurance provided for under this act. The payments shall constitute payment in full to the provider on behalf of the recipient. Every provider making a claim for payment pursuant to this act shall certify in writing on the claim submitted that no additional amount will be charged to the recipient, the recipient's family, the recipient's representative, or others on the recipient's behalf for the services, goods, and supplies furnished pursuant to this act. No provider whose claim for payment pursuant to this act has been denied because the services, goods, or supplies were determined to be medically unnecessary shall seek reimbursement from the recipient, his family, his representative, or others on his behalf for such services, goods, and supplies provided pursuant to this act; provided, however, a provider may seek reimbursement from a recipient for services, goods, or supplies not authorized by this act, if the recipient elected to receive the services, goods, or supplies with the knowledge that they were not authorized. d. Any individual eligible for medical assistance (including drugs) may obtain such assistance from any person qualified to perform the service or services required (including an organization which provides such services or arranges for their availability on a prepayment basis), who undertakes to provide the individual such services. No copayment or other form of cost-sharing shall be imposed on any individual eligible for medical assistance, except as mandated by federal law as a condition of federal financial participation. e. Anything in this act to the contrary notwithstanding, no payments for medical assistance shall be made under this act with respect to care or services for any individual who: (1) Is an inmate of a public institution (except as a patient in a medical institution); provided, however, that an individual who is otherwise eligible may continue to receive services for the month in which he becomes an inmate, should the commissioner determine to expand the scope of Medicaid eligibility to include such an individual, subject to the limitations imposed by federal law and regulations, or (2) Has not attained 65 years of age and who is a patient in an institution for mental diseases, or (3) Is over 21 years of age and who is receiving inpatient psychiatric hospital services in a psychiatric facility; provided, however, that an individual who was receiving such services immediately prior to attaining age 21 may continue to receive such services until the individual reaches age 22. Nothing in this subsection shall prohibit the commissioner from extending medical assistance to all eligible persons receiving inpatient psychiatric services; provided that there is federal financial participation available. f. (1) A third party as defined in section 3 of P.L.1968, c.413 (C.30:4D-3) shall not consider a person's eligibility for Medicaid in this or another state when determining the person's eligibility for enrollment or the provision of benefits by that third party. (2) In addition, any provision in a contract of insurance, health benefits plan, or other health care coverage document, will, trust, agreement, court order, or other instrument which reduces or excludes coverage or payment for health care-related goods and services to or for an individual because of that individual's actual or potential eligibility for or receipt of Medicaid benefits shall be null and void, and no payments shall be made under this act as a result of any such provision. (3) Notwithstanding any provision of law to the contrary, the provisions of paragraph (2) of this subsection shall not apply to a trust agreement that is established pursuant to 42 U.S.C. s.1396p(d)(4)(A) or (C) to supplement and augment assistance provided by government entities to a person who is disabled as defined in section 1614(a)(3) of the federal Social Security Act (42 31 U.S.C. s.1382c (a)(3)). g. The following services shall be provided to eligible medically needy individuals as follows: (1) Pregnant women shall be provided prenatal care and delivery services and postpartum care, including the services cited in subsections a.(1), (3), and (5) of this section and subsections b.(1)-(10), (12), (15), and (17) of this section, and nursing facility services cited in subsection b.(13) of this section. (2) Dependent children shall be provided with services cited in subsections a.(3) and (5) of this section and subsections b.(1), (2), (3), (4), (5), (6), (7), (10), (12), (15), and (17) of this section, and nursing facility services cited in subsection b.(13) of this section. (3) Individuals who are 65 years of age or older shall be provided with services cited in subsections a.(3) and (5) of this section and subsections b.(1)-(5), (6) excluding prescribed drugs, (7), (8), (10), (12), (15), and (17) of this section, and nursing facility services cited in subsection b.(13) of this section. (4) Individuals who are blind or disabled shall be provided with services cited in subsections a.(3) and (5) of this section and subsections b.(1)-(5), (6) excluding prescribed drugs, (7), (8), (10), 3 (12), (15), and (17) of this section, and nursing facility services cited in subsection b.(13) of this section. (5) (a) Inpatient hospital services, subsection a.(1) of this section, shall only be provided to eligible medically needy individuals, other than pregnant women, if the federal Department of Health and Human Services discontinues the State's waiver to establish inpatient hospital reimbursement rates for the Medicare and Medicaid programs under the authority of section 601(c)(3) of the Social Security Act Amendments of 1983, Pub.L.98-21 (42 U.S.C. s.1395ww(c)(5)). Inpatient hospital services may be extended to other eligible medically needy individuals if the federal Department of Health and Human Services directs that these services be included. (b) Outpatient hospital services, subsection a.(2) of this section, shall only be provided to eligible medically needy individuals if the federal Department of Health and Human Services discontinues the State's waiver to establish outpatient hospital reimbursement rates for the Medicare and Medicaid programs under the authority of section 601(c)(3) of the Social Security Amendments of 1983, Pub.L.98-21 (42 U.S.C. s.1395ww(c)(5)). Outpatient hospital services may be extended to all or to certain medically needy individuals if the federal Department of Health and Human Services directs that these services be included. However, the use of outpatient hospital services shall be limited to clinic services and to emergency room services for injuries and significant acute medical conditions. (c) The division shall monitor the use of inpatient and outpatient hospital services by medically needy persons. h. In the case of a qualified disabled and working individual pursuant to section h6408 of Pub.L.101-239 (42 U.S.C. s.1396d), the only medical assistance provided under this act shall be the payment of premiums for Medicare part A under 42 U.S.C. ss.1395i-2 and 1395r. i. In the case of a specified low-income Medicare beneficiary pursuant to 42 U.S.C. s.1396a(a)10(E)iii, the only medical assistance provided under this act shall be the payment of premiums for Medicare part B under 42 U.S.C. s.1395r as provided for in 42 U.S.C. s.1396d(p)(3)(A)(ii). j. In the case of a qualified individual pursuant to 42 U.S.C. s.1396a(aa), the only medical assistance provided under this act shall be payment for authorized services provided during the period in which the individual requires treatment for breast or cervical cancer, in accordance with criteria established by the commissioner. k. In the case of a qualified individual pursuant to 42 U.S.C. s.1396a(ii), the only medical assistance provided under this act shall be payment for family planning services and supplies as described at 42 U.S.C. s.1396d(a)(4)(C), including medical diagnosis and treatment services that are provided pursuant to a family planning service in a family planning setting. L.1968, c.413, s.6; amended 1977, c.63, s.13; 1979, c.365, s.4; 1984, c.56; 1984, c.86; 1985, c.371, ss.2,5; (1985, c.371, s.5 amended 1985, c.510); 1987, c.115, s.3; 1989, c.251, s.1; 1991, c.20, ss.2,3; 1991, c.371; 1992, c.208, s.2; 1995, c.153, s.2; 1995, c.292, s.2; 2000, c.96, s.2; 2001, c.186, s.2; 2003, c.294; 2012, c.17, s.359; 2017, c.131, s.117; 2017, c.161, s.1; 2018, c.1, s.2; 2019, c.85; 2019, c.317, s.1; 2019, c.473; 2023, c.8, s.11; 2023, c.187, s.1; 2025, c.200, s.11. 30:4D-6a. $35 monthly personal needs allowance Any person who is eligible for medical assistance and health services under P.L. 1968, c. 413 (C. 30:4D-1 et seq.) and who receives medical assistance under subparagraph (4)(a) of subsection a. or under paragraph (11), (13) or (14) of subsection b. of section 6 of P.L. 1968, c. 413 (C. 30:4D-6), who is not eligible for Supplemental Security Income benefits pursuant to 42 U.S.C. s. 1382(e)(1)(B), is entitled to a $35.00 monthly personal needs allowance. L. 1985, c. 286, s. 1, eff. Nov. 1, 1985. 30:4D-6c. Continued Medicaid eligibility 2. A dependent child or the parent or caretaker relative of a dependent child who would lose eligibility for the aid to families with dependent children program under the State Plan for Title IV-A of the federal Social Security Act in effect as of July 16, 1996 due to earnings from, or increased hours of, employment, or receipt of benefits under the "unemployment compensation law," R.S.43:21-1 et seq. or the "Temporary Disability Benefits Law," P.L.1948, c.110 (C.43:21-25 et seq.), is eligible to continue receiving Medicaid benefits pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) for a period of 24 consecutive months, commencing with the month in which eligibility under provisions of the State Plan for Title IV-A of the federal Social Security Act in effect as of July 16, 1996 is no longer met, if the person: a. (Deleted by amendment, P.L.1997, c.13). b. would be eligible in accordance with the State Plan for Title IV-A of the federal Social Security Act in effect as of July 16, 1996, except for the person's income, resources or hours of employment. L.1987,c.283,s.2; amended 1991, c.523, s.17; 1997, c.13, s.11. 30:4D-6d. Third party, certain; primary payer 3. If a person who is eligible for continued Medicaid benefits pursuant to section 2 of this act obtains employment which provides health insurance coverage through a third party as defined in section 3 of P.L.1968, c.413 (C.30:4D-3), the third party shall be the primary payer and the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) shall be the secondary payer. L.1987,c.283,s.3; amended 1995,c.292,s.3. 30:4D-6e. Uninsured, ineligible persons may purchase health care coverage a. Any person who is not eligible for medical assistance pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) who is employed full-time or part-time and does not have health insurance coverage provided by his employer or by his spouse's employer, if any, or who cannot afford to purchase health insurance coverage that may be offered by his employer or his spouse's employer, if any, shall be eligible to purchase health care coverage through the Garden State Health Plan operated by the Division of Medical Assistance and Health Services in the Department of Human Services. b. A small employer, as defined by the Commissioner of Human Services, who has not provided or offered to provide health insurance coverage anytime during the 12-month period immediately preceding the effective date of coverage pursuant to this section, shall be eligible to purchase health care coverage for its employees through the Garden State Health Plan operated by the Division of Medical Assistance and Health Services in the Department of Human Services. c. The Commissioner of Human Services shall design one or more plans of benefits for employees and small employers who wish to purchase health care coverage through the Garden State Health Plan. The commissioner shall establish a schedule of premiums for enrollment in the plan, which shall ensure that the premiums charged are adequate to fund the costs of the benefits provided by the plan to persons not otherwise eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.). d. The commissioner shall make the purchase of health care coverage through the Garden State Health Plan available to employees and small employers within one year of the effective date of P.L.1991, c.187 (C.26:2H-18.24 et al.). e. Nothing in this section shall be construed to include the Garden State Health Plan as a health maintenance organization in any other provision of law regarding the offering or availability of coverage by a health maintenance organization. L.1991,c.187,s.45. 30:4D-6f Eligibility of aliens for medical assistance. 2. An eligible alien as defined in section 3 of P.L.1968, c.413 (C.30:4D-1 et seq.) who otherwise meets all eligibility criteria therefor is entitled to medical assistance provided pursuant to section 6 of P.L.1968, c.413 (C.30:4D-6). An alien who does not qualify as an eligible alien but who is a resident of New Jersey and would otherwise be eligible for medical assistance provided pursuant to section 6 of P.L.1968, c.413 is entitled only to care and services necessary for the treatment of an emergency medical condition as defined in section 1903(v)(3) of the federal Social Security Act (42 U.S.C. s.1396b(v)(3)). L.1997,c.352,s.2. 30:4D-6g Findings, declarations relative to emergency care. 1. The Legislature finds and declares that: a. In accordance with the "Health Care Reform Act," P.L.1992, c.160 (C.26:2H-18.51 et al.), it has been and continues to be of paramount public interest for the State to take all necessary and appropriate actions to ensure access to, and the provision of, cost-effective and high-quality hospital care to its citizens. Consistent with these goals, it is and has been the policy of this State that reimbursement for emergency services and related screening and hospitalization be reasonable, in order to promote access to such care without overburdening the health care payment system. These imperative public policies continue to apply equally to both public and private payers of health care services; b. In light of the provisions of section 14 of the "Health Care Reform Act," P.L.1992, c.160 (C.26:2H-18.64), which prohibits hospitals from denying admission or appropriate services to a patient on the basis of that patient's ability to pay or source of payment, questions have arisen as to the rates at which emergency services should be reimbursed when they are provided to enrollees in Medicaid and NJ FamilyCare managed care plans by non-participating hospitals. In order to ensure that the goal of cost-efficient access to emergency services is furthered, it is necessary to clarify the rates that have been and continue to be deemed reasonable reimbursement; and c. It is necessary that the reimbursement clarification be understood as reaffirming the paramount public health and welfare purpose of promoting cost-efficiency in the delivery of emergency services and related screening and hospitalization. L.2004,c.103,s.1. 30:4D-6h Definitions relative to emergency care. 2. As used in this act: "Contractor" means a health maintenance organization authorized to operate in this State which contracts with the Department of Human Services for the provision of health care services to recipients of Medicaid and enrollees of NJ FamilyCare. "Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "NJ FamilyCare" means the Children's Health Care Coverage Program established pursuant to P.L.1997, c.272 (C.30:4I-1 et seq.) and the FamilyCare Health Coverage Program established pursuant to P.L.2000, c.71 (C.30:4J-1 et seq.). "Non-participating hospital" means a hospital with which the contractor does not have a written provider agreement that complies with applicable State law and regulations, including N.J.A.C.8:38-15.2 and 10:74-2.1. L.2004,c.103,s.2. 30:4D-6i Non-participating hospital, payment for emergency treatment for Medicaid recipient. 3. A non-participating hospital that provides emergency health care services to a Medicaid recipient enrolled in a managed care plan shall accept, as payment in full, the amount that the non-participating hospital would otherwise receive from the Medicaid program for the emergency services and any related hospitalization if the recipient were a participant in fee-for-service Medicaid. L.2004,c.103,s.3. 30:4D-6j Criteria for Medicaid admission to certain long-term care facilities for HIV/AIDS patients. 1. a. Subject to federal financial participation under Title XIX of the federal Social Security Act (42 U.S.C. s.1396 et seq.), the Commissioner of Health shall establish special long-term care facility admission criteria for Medicaid-eligible persons with HIV infection or AIDS, which would apply to facilities that only serve persons with HIV infection or AIDS. b. The criteria shall enable admission of: (1) persons with HIV infection who have medical or psycho-social co-morbidities, including, but not limited to: diabetes, cancer, hypertension, hyperlipidemia, asthma, chronic obstructive pulmonary disease, hepatitis B or C, substance use disorder, mental illness or dementia; and (2) persons with AIDS-defining illness and infection, including those persons newly diagnosed with HIV infection, which illness or infection includes, but is not limited to: pneumocystis carinii pneumonia (PCP), toxoplasmosis, cytomegalovirus (CMV), oral-esophageal candidiasis, wasting, bacterial pneumonia, lymphoma, cryptococcal meningitis, mycobacterium avium complex (MAC) or Kaposi's sarcoma. L.2005, c.111, s.1; amended 2023, c.177, s.100. 30:4D-6k State Medicaid, NJ FamilyCare programs to provide coverage, payment 7. a. The State Medicaid and NJ FamilyCare programs shall provide coverage and payment for health care services delivered to a benefits recipient through telemedicine or telehealth, on the same basis as, and at a provider reimbursement rate that does not exceed the provider reimbursement rate that is applicable, when the services are delivered through in-person contact and consultation in New Jersey, provided the services are otherwise covered when delivered through in-person contact and consultation in New Jersey. Reimbursement payments under this section may be provided either to the individual practitioner who delivered the reimbursable services, or to the agency, facility, or organization that employs the individual practitioner who delivered the reimbursable services, as appropriate. b. The State Medicaid and NJ FamilyCare programs may limit coverage to services that are delivered by participating health care providers, but may not charge any deductible, copayment, or coinsurance for a health care service, delivered through telemedicine or telehealth, in an amount that exceeds the deductible, copayment, or coinsurance amount that is applicable to an in-person consultation. In no case shall the State Medicaid and NJ FamilyCare programs: (1) impose any restrictions on the location or setting of the distant site used by a health care provider to provide services using telemedicine and telehealth or on the location or setting of the originating site where the patient is located when receiving services using telemedicine and telehealth, except to ensure that the services provided using telemedicine and telehealth meet the same standard of care as would be provided if the services were provided in person; (2) restrict the ability of a provider to use any electronic or technological platform to provide services using telemedicine or telehealth, including, but not limited to, interactive, real-time, two-way audio, which may be used in combination with asynchronous store-and-forward technology without video capabilities, including audio-only telephone conversations, to provide services using telemedicine or telehealth, provided that the platform used: (a) allows the provider to meet the same standard of care as would be provided if the services were provided in person; and (b) is compliant with the requirements of the federal health privacy rule set forth at 45 CFR Parts 160 and 164; (3) deny coverage for or refuse to provide reimbursement for routine patient monitoring performed using telemedicine and telehealth, including remote monitoring of a patient's vital signs and routine check-ins with the patient to monitor the patient's status and condition, if coverage and reimbursement would be provided if those services are provided in person, and the provider is able to meet the same standard of care as would be provided if the services were provided in person; or (4) limit coverage only to services delivered by select third-party telemedicine or telehealth organizations. c. Nothing in this section shall be construed to: (1) prohibit the State Medicaid or NJ FamilyCare programs from providing coverage for only those services that are medically necessary, subject to the terms and conditions of the recipient's benefits plan; or (2) allow the State Medicaid or NJ FamilyCare programs to require a benefits recipient to use telemedicine or telehealth in lieu of obtaining an in-person service from a participating health care provider. d. The Commissioner of Human Services, in consultation with the Commissioner of Children and Families, shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this section and to secure federal financial participation for State expenditures under the federal Medicaid program and Children's Health Insurance Program. e. As used in this section: "Asynchronous store-and-forward" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Benefits recipient" or "recipient" means a person who is eligible for, and who is receiving, hospital or medical benefits under the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or under the NJ FamilyCare program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), as appropriate. "Distant site" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Originating site" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Participating health care provider" means a licensed or certified health care provider who is registered to provide health care services to benefits recipients under the State Medicaid or NJ FamilyCare programs, as appropriate. "Telehealth" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Telemedicine" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Telemedicine or telehealth organization" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). L.2017, c.117, s.7; amended 2021, c.310, s.2. 30:4D-6l Enrollment in Medicaid for medical parolee. 3. Any inmate who is an applicant for medical parole pursuant to the provisions of section 1 of P.L.1997, c.214 (C.30:4-123.51c) shall not be denied enrollment into the Medicaid program on the sole basis that the applicant is an inmate in a correctional facility. For an inmate who becomes enrolled in Medicaid while incarcerated in a correctional facility, payments for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.) shall commence upon the inmate's release from the correctional facility. L.2017, c.235, s.3. 30:4D-6m Provision of benefits for certain treatments for substance use disorder. 1. a. Notwithstanding any State law or regulation to the contrary, the Department of Human Services shall ensure that the provision of benefits for methadone, buprenorphine, naltrexone, combination drugs containing buprenorphine and naloxone, and, if authorized by the Commissioner of Human Services, other medications approved by the federal Food and Drug Administration for the treatment of substance use disorders, to eligible persons receiving services funded by the Division of Mental Health and Addiction Services in the Department of Human Services as well as to eligible persons under the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), shall be provided without the imposition of any prior authorization requirements, provided that the treatment is prescribed or administered by a licensed medical practitioner who is authorized to prescribe or administer that treatment pursuant to State and federal law. The Commissioner of Human Services may develop and issue guidelines to ensure the safety and efficacy of benefits provided pursuant to this section. b. As used in this act: "Substance use disorder" is as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and any subsequent editions and shall include substance use withdrawal. L.2019, c.163, s.1. 30:4D-6n Rules, regulations. 3. 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. L.2019, c.163, s.3. 30:4D-6o Provision of breastfeeding support through Medicaid. 11. a. Notwithstanding any State law or regulation to the contrary, the Department of Human Services shall, contingent on maintaining or receiving necessary federal approvals, ensure that benefits for comprehensive lactation support, counseling, and consultation, and the costs for renting or purchasing breastfeeding equipment, in conjunction with each birth, for the duration of breastfeeding shall be provided with no cost-sharing to eligible persons under the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). b. Benefits for breastfeeding equipment shall include: (1) Purchase of a single-user breast pump, subject to the following conditions: (a) Benefits for the purchase of a double electric breast pump. If an individual requests a manual pump in lieu of the double electric breast pump, benefits shall be provided for the purchase of a manual pump. (b) A double electric breast pump provided pursuant to this paragraph shall be of sufficient power and durability to establish and maintain milk supply for the duration of breastfeeding. (c) The department shall not require documentation of medical necessity, prior authorization, or a prescription for a breast pump provided pursuant to this paragraph. (d) Benefits shall be available at any time during pregnancy and the postpartum period, and shall continue for the duration of breastfeeding as defined by the individual. (e) Benefits for breast pumps shall include repair or replacement if necessary. (2) Rental or purchase of a multi-user breast pump, on the recommendation of a licensed health care provider, subject to the following conditions: (a) When recommended by a licensed health care provider, benefits shall be provided for a multi-user breast pump. (b) The department may determine whether a rental or purchase is covered. (c) Benefits for a multi-user breast pump shall be provided without regard to the provision or acquisition of a single-user breast pump. (d) The department may require a letter of medical necessity from a lactation consultant or other health care provider for benefits of a multi-user pump. The letter shall not interfere with the timely acquisition of a multi-user pump. (3) Benefits of breastfeeding equipment pursuant to this section shall include two breast pump kits per birth event, as well as appropriate size breast pump flanges, or other lactation accessories recommended by a health care provider. (4) Breastfeeding equipment specified in paragraphs (1) and (3) of this subsection shall be furnished: within 48 hours of notification of need, if requested after the birth of the child; or by the later of two weeks before the enrollee's expected due date or 72 hours after notification, if requested prior to the birth of the child. If the department cannot ensure an individual shall receive breastfeeding equipment within 48 hours, an individual may purchase the equipment and the department shall reimburse all out-of-pocket expenses incurred by the individual, including any balance billing amounts. (5) Breastfeeding equipment specified in paragraph (2) of this subsection shall be made available within 12 hours of notification of need. If equipment is not available within 12 hours of notification of need, the department shall reimburse all out-of-pocket rental expenses incurred by an individual, including any balance billing amounts, until the individual receives breastfeeding equipment. c. Benefits for comprehensive lactation counseling and lactation consultation shall include: (1) In-person, one-on-one lactation counseling and lactation consultation, subject to the following conditions: (a) Benefits shall include visits that occur inside and outside a hospital or office setting. In-person lactation counseling and lactation consultation shall be covered regardless of location of service provision and shall include home visits. (b) Lactation counseling and lactation consultation shall be made available within 24 hours of notification of need. (2) Telephonic lactation assistance shall be covered in addition to, and not as a substitute for, in-person, one-on-one lactation counseling or lactation consultation, when an individual requests one-on-one, in-person lactation counseling or lactation consultation. The telephonic lactation assistance shall be provided within 12 hours of notification of need. (3) Group lactation counseling shall be covered in addition to, and not as a substitute for, one-on-one, in-person lactation counseling or lactation consultation, if an individual requests one-on-one, in-person lactation counseling or lactation consultation. Group counseling shall include educational classes and support groups. (4) The department shall not require prior authorization, prescription or referral for any lactation counseling or lactation consultation, regardless of provider type or setting. (5) The department shall not impose medical management techniques not described in this section. d. Except as otherwise authorized pursuant to this section, the department shall not impose restrictions on the benefits provided pursuant to this section, including, but not limited to, limitations on reimbursement to allowable amounts or reasonable and customary charges, documentation requests, or delays on the benefits provided. e. As used in this section: "Cost-sharing" means deductible, co-insurance or co-payments, or similar charges. "Breast pump kit" means a collection of tubing, valves, flanges, collection bottles, or other parts required to extract human milk using a breast pump. "Lactation consultant" means an individual who is an International Board Certified Lactation Consultant. "Lactation consultation" means the clinical application by a lactation consultant or other licensed health care provider of scientific principles and a multidisciplinary body of evidence for evaluation, problem identification, treatment, education, and consultation to child-bearing families utilizing lactation care and services. Lactation care and services shall include, but not be limited to: (1) lactation assessment through the systematic collection of subjective and objective data; (2) analysis of data and creation of a plan of care; (3) implementation of a lactation care plan with demonstration and instruction to parents and communication to the primary health care provider; (4) evaluation of outcomes; (5) provision of lactation education to parents and health care providers; and (6) the recommendation and use of assistive devices. "Lactation counseling" means breastfeeding education and support services provided by a lactation counselor, such as: (1) educating women, families, health care professionals, and the community about the impact of breastfeeding and human lactation on health and what to expect in the normal course of breastfeeding; (2) acting as an advocate for breastfeeding as the norm for feeding infants and young children; (3) providing breastfeeding support, encouragement, and care from preconception to weaning in order to help women and their families meet their breastfeeding goals; (4) using principles of adult education when teaching clients, health care providers, and others in the community; and (5) identifying and referring high-risk mothers and babies and those requiring clinical treatment appropriately. "Lactation counselor" means an individual, other than an International Board Certified Lactation Consultant or a licensed health care provider, who is: (1) licensed or certified to practice lactation counseling under any law, or who is an accredited member belonging to another profession or occupation, who provides breastfeeding education and support services for which that person is licensed, regulated, accredited, or certified; or (2) a community-based lactation supporter who has received at least 40 hours of specialty education in breastfeeding and lactation, and who works within a lactation counselor's scope of practice. "Telephonic lactation assistance" means lactation counseling or consultation with a lactation counselor or lactation consultant conducted remotely through live voice communication. f. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this section and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program. L.2019, c.343, s.11. 30:4D-6p Coverage of certain prescription refills by Medicaid, NJ FamilyCare during state of emergency. 1. a. Subject to subsection b. of this section and to the extent consistent with clinical guidelines, the State Medicaid and NJ FamilyCare programs shall provide coverage of prescription drug refills even when the covered person has not yet reached the scheduled refill date, provided that the prescription itself would remain valid beyond the refill date, in a manner calculated to ensure an enrollee's ability to maintain at least a 30-day supply, or a 90-day supply of a maintenance medication supply at home but not to exceed a 120-day supply on-hand at any given time. The coverage shall be provided based on the authorization for the most recently filled prescription and additional authorization for the refill shall not be required. b. The provisions of this section shall be in effect if: (1) a state of emergency or public health emergency is declared by the State or federal government, or an emergency supply of a drug is recommended by the Centers for Disease Control and Prevention; and (2) the Commissioner of Human Services determines that an emergency supply of prescription drugs is necessary. c. The coverage shall be provided on an in-network basis to the same extent as for any other refills of prescription drugs, except that: (1) in the event of a drug shortage or access issue, formulary flexibility shall be provided for a covered alternative; and (2) no fees shall be imposed for home delivery of the drugs. d. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this section and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program. e. The Division of Consumer Affairs, in consultation with the Commissioner of Human Services, may develop restrictions on the filling or refilling of prescriptions by pharmacists to address shortage concerns, provided those restrictions shall exclude restricting use for existing conditions to the maximum extent practicable. L.2020, c.30, s.1. 30:4D-6q Medicaid, NJ FamilyCare, opioid antidote coverage. 2. a. The Division of Medical Assistance and Health Services in the Department of Human Services shall provide coverage for an opioid antidote under the Medicaid program and the NJ FamilyCare program without the imposition of any prior authorization or other utilization management requirements, provided that the drug is: (1) prescribed or administered to an enrollee by a licensed medical practitioner who is authorized to prescribe or administer that treatment pursuant to State and federal law; or (2) dispensed to an enrollee by a licensed pharmacist under a standing order to dispense an opioid antidote pursuant to section 1 of P.L.2017, c.88 (C.45:14-67.2). b. The provisions of this section shall not be construed to limit the coverage of an opioid antidote only when administered by a medical practitioner. c. The division shall require each managed care organization contracted with the division to provide pharmacy benefits to Medicaid and NJ FamilyCare enrollees to comply with the provisions of this section. d. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this section and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program. e. As used in this section: "Medicaid program" means the program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "Opioid antidote" means naloxone hydrochloride, or any other similarly acting drug approved by the United States Food and Drug Administration for self-administration for the treatment of an opioid overdose. "NJ FamilyCare program" means the program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.). L.2021, c.157, s.2. 30:4D-6r Medicaid to cover newborn home nurse visitation. 13. a. Notwithstanding any State law or regulation to the contrary, the Department of Human Services shall, contingent on maintaining or receiving necessary federal approvals, ensure that expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) shall be provided with no cost-sharing to eligible persons under the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). The coverage provided under this section shall: (1) provide coverage for the services provided by the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159); (2) notify a covered person of the services provided by the newborn home nurse visitation program, upon application by the covered person for coverage of a newborn infant; (3) ensure that the plan does not contain any provision that requires a covered person to receive the services provided by the newborn home nurse visitation program as a condition of coverage, or that denies or limits benefits to the covered person if that person declines the services provided under the program; and (4) have the discretion to determine how best to reimburse for the expenses incurred for services provided under the newborn home nurse visitation program, including, but not limited to, utilizing: (a) a value-based payment methodology; (b) an invoice claim process; (c) a capitated payment arrangement; (d) a payment methodology that takes into account the need for an agency or organization providing services under the program to expand its capacity to provide services and address health disparities; or (e) any other payment arrangement agreed to by the carrier and an agency or organization providing services under the program. b. Any copayment, coinsurance, or deductible that may be required pursuant to the contract for services covered pursuant to subsection a. of this section shall be waived. c. The Assistant Commissioner of Human Services shall submit to the Department of Children and Families, in a form and manner prescribed by the department, a report on the claims submitted for services provided under the newborn home nurse visitation program. The information contained in the report shall be used by the department to assess the newborn home nurse visitation program pursuant to subsection a. of section 4 of P.L.2021, c.187 (C.26:2H-161). d. The benefits shall be provided to the same extent as for any other medical condition under the contract. L.2021, c.187, s.13. 30:4D-6s State Medicaid program, coverage for family planning services. 11. Coverage for family planning services under the State Medicaid program shall include prescriptions for dispensing contraceptives for up to a 12-month period at one time. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this section and to secure federal financial participation for State Medicare expenditures under the federal Medicaid program. L.2021, c.376, s.11. 30:4D-6t Remote participation in certain meetings, eligible Medicaid recipients, authorization. 1. The Division of Medical Assistance and Health Services in the Department of Human Services, to the extent permitted under federal law, shall authorize a recipient of Medicaid benefits who is determined eligible to receive a personal care service benefit and who is attending a post-secondary educational institution and residing on that institution's campus to participate remotely by telephone or other means in a meeting of a non-medical nature regarding the recipient's Medicaid benefits. The provisions of this section shall apply to any meeting between the recipient and the division, a managed care organization contracted with the division to provide benefits under the Medicaid program, or any other entity or individual authorized by the division to conduct such meetings. As used in this section, "Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). L.2021, c.443. 30:4D-6u Commissioner of Human Services, waivers, implementation, provisions, secure federal financial participation. 2. 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. Coverage to eligible beneficiaries of the community-based palliative care benefit established by the amendments made by section 1 of P.L.2023, c.187 (C.30:4D-6) to section 6 of P.L.1968, c.413 (C.30:4D-6) shall be contingent on securing federal financial participation pursuant to this section. L.2023, c.187, s.2. 30:4D-6v Rules, regulations. 3. The Commissioner of Human Services shall adopt rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to effectuate the purposes of this act including guidance on the medical conditions and prognoses that render a beneficiary eligible for community-based palliative care services. L.2023, c.187, s.3. 30:4D-6w Division of Medical Assistance and Health Services, managed care organization, NJ FamilyCare beneficiaries, reimbursement, claims, conditions. 1. a. Notwithstanding any law, rule, or regulation to the contrary, the Division of Medical Assistance and Health Services within the Department of Human Services, or a managed care organization that contracts with the division to provide medical services to beneficiaries of the NJ FamilyCare program, shall: (1) accept and reimburse claims for services under the NJ FamilyCare program when submitted by a clinical social worker, a professional counselor, or a marriage and family therapist provided that: (a) the services are rendered to a NJ FamilyCare beneficiary; (b) the services rendered are covered under the NJ FamilyCare program; (c) the provider holds a current, valid license issued pursuant to P.L.1991, c.134 (C.45:15BB-1 et seq.) if a clinical social worker, P.L.1993, c.340 (C.45:8B-34 et seq.) if a professional counselor, and P.L.1968, c.401 (C.45:8B-1 et seq.) if a marriage and family therapist; and (d) the provider is an approved provider of services under the NJ FamilyCare program; and (2) expand eligibility for reimbursable services under the NJ FamilyCare program to include those services provided by a social worker, an associate counselor, or an associate marriage and family therapist provided that: (a) the services are rendered to a NJ FamilyCare beneficiary; (b) the services rendered are covered under the NJ FamilyCare program; (c) the provider holds a current, valid license issued pursuant to P.L.1991, c.134 (C.45:15BB-1 et seq.) if a social worker, P.L.1993, c.340 (C.45:8B-34 et seq.) if an associate counselor, and P.L.1968, c.401 (C.45:8B-1 et seq.) and P.L.2017, c.350 (C.45:8B-18.1 et al.) if an associate marriage and family therapist; (d) the claim is submitted by a licensed clinical social worker, a licensed professional counselor, or a licensed marriage and family therapist who serves as the provider's supervising practitioner, as approved by: (i) the State Board of Social Work Examiners pursuant to subsection d. of section 4 of P.L.1991, c.134 (C.45:15BB-4) in the case of a social worker; (ii) the State Board of Marriage and Family Therapy Examiners pursuant to section 17 of P.L.1993, c.340 (C.45:8B-50) in the case of an associate counselor; or (iii) the State Board of Marriage and Family Therapy Examiners pursuant to section 10 of P.L.2017, c.350 (C.45:8B-18.2) in the case of an associate marriage and family therapist; and (e) the provider's supervising practitioner is an approved provider of services under the NJ FamilyCare program and serves as the rendering practitioner for the purposes of the claim. b. Nothing in this section shall be construed to allow a licensed social worker, licensed associate counselor, or licensed associate marriage and family therapist to practice within the scope of their license without a supervising practitioner or to require NJ FamilyCare to reimburse a claim for covered services submitted by a licensed social worker, licensed associate counselor, or licensed associate marriage and family therapist. c. For the purpose of this section, "NJ FamilyCare" means the program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.). L.2023, c.213, s.1. 30:4D-6x Commissioner of Human Services, State plan amendments, waivers, apply as may be necessary. 2. 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. L.2023, c.213, s.2. 30:4D-6y Biomarker precision medical testing, Medicaid recipients, no cost-sharing. 11. a. Notwithstanding any State law or regulation to the contrary, the Department of Human Services shall ensure that expenses incurred for biomarker precision medical testing shall be provided with no cost-sharing to persons served under the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). b. Biomarker precision medical testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a disease or condition, excluding asymptomatic screening, to guide treatment decisions of an individual when the efficacy and appropriateness of biomarker precision medical testing for the diagnosis, treatment, appropriate management, or guiding treatment decisions for an individual's disease or condition is recognized by: (1) labeled indications for an FDA-approved or -cleared test; (2) indicated tests for an FDA-approved drug; (3) actions to address warnings and precautions on FDA-approved drug labels; (4) Centers for Medicare and Medicaid Services National Coverage Determinations or Medicare Administrative Contractor Local Coverage Determinations; or (5) nationally recognized clinical practice guidelines. c. Coverage, pursuant to subsection b. of this section, shall be provided in a manner that limits disruption, including multiple biopsies or biospecimen samples, in the care of an individual. d. If the Division of Medical Assistance and Health Services in the Department of Human Services contracts with a third-party entity to deliver biomarker precision medical testing services pursuant to this section to beneficiaries under the Medicaid program, the third-party entity shall provide biomarker precision medical testing at the same scope, duration, and frequency as the Medicaid program otherwise provides to individuals. e. (1) If utilization review is required, a decision shall be provided pursuant to the guidelines and timeframes set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.). (2) The individual and the treating health care provider or treating health care entity prescribing biomarker precision medical testing for the individual shall have access to clear, readily accessible, and conspicuous information on the process to submit an appeal to an adverse determination. f. As used in this section: "Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. Biomarkers shall also include, but not be limited to, gene mutations, characteristics of genes, or protein expression. "Biomarker precision medical testing" means the analysis of tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker precision medical testing includes, but is not limited to, single-analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing. L.2025, c.49, s.11. 30:4D-6z Department of Human Services, HIV preexposure prophylaxis, HIV postexposure prophylaxis. 11. a. (1) Notwithstanding any State law or regulation to the contrary, and except as provided in paragraph (2) of this subsection, the Department of Human Services shall ensure that the provision of benefits for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L.2025, c.196 (C.45:14-67.13) to eligible persons under the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), shall be provided without the imposition of any prior authorization or step therapy requirements. (2) If the federal Food and Drug Administration has authorized or approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the department to ensure coverage of all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy. b. Reimbursement issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the Department of Human Services to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria: (1) the service or procedure is within the scope of practice of the treating pharmacist; and (2) the service or procedure would otherwise be covered by the department if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant. c. The Department of Human Services shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the department to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service. d. As used in this section: �HIV preexposure prophylaxis� means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12). �HIV postexposure prophylaxis� means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12). �Step therapy� means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits coverage for the prophylaxis. L.2025, c.196, s.11. 30:4D-6aa State plan amendments, waivers, HIV preexposure prophylaxis, HIV postexposure prophylaxis, benefits. 13. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of section 11 of this act and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program. L.2025, c.196, s.13.

This is the verbatim text of N.J.S.A. 30:4D-6, retrieved from the New Jersey Legislature's public statute corpus. Statutes are amended periodically — for the most current version, check the external source link above. Kyzer is not a law firm and this page is not legal advice.