N.J.S.A. 30:4D-7

Duties of commissioner.

30:4D-7 Duties of commissioner. 7. Duties of commissioner. The commissioner is authorized and empowered to issue, or to cause to be issued through the Division of Medical Assistance and Health Services, all necessary rules and regulations and administrative orders, and to do or cause to be done all other acts and things necessary to secure for the State of New Jersey the maximum federal participation that is available with respect to a program of medical assistance, consistent with fiscal responsibility and within the limits of funds available for any fiscal year, and to the extent authorized by the medical assistance program plan; to adopt fee schedules with regard to medical assistance benefits and otherwise to accomplish the purposes of this act, including specifically the following: a. Subject to the limits imposed by this act, to submit a plan for medical assistance, as required by Title XIX of the federal Social Security Act, to the federal Department of Health and Human Services for approval pursuant to the provisions of such law; to act for the State in making negotiations relative to the submission and approval of such plan, to make such arrangements, not inconsistent with the law, as may be required by or pursuant to federal law to obtain and retain such approval and to secure for the State the benefits of the provisions of such law; b. Subject to the limits imposed by this act, to determine the amount and scope of services to be covered, that the amounts to be paid are reasonable, and the duration of medical assistance to be furnished; provided, however, that the department shall provide medical assistance on behalf of all recipients of categorical assistance and such other related groups as are mandatory under federal laws and rules and regulations, as they now are or as they may be hereafter amended, in order to obtain federal matching funds for such purposes and, in addition, provide medical assistance for the resource family children specified in subsection i.(7) of section 3 of P.L.1968, c.413 (C.30:4D-3). The medical assistance provided for these groups shall not be less in scope, duration, or amount than is currently furnished these groups, and in addition, shall include at least the minimum services required under federal laws and rules and regulations to obtain federal matching funds for such purposes. The commissioner is authorized and empowered, at such times as he may determine feasible, within the limits of appropriated funds for any fiscal year, to extend the scope, duration, and amount of medical assistance on behalf of these groups of categorical assistance recipients, related groups as are mandatory, and resource family children authorized pursuant to section 3i. (7) of this act, so as to include, in whole or in part, the optional medical services authorized under federal laws and rules and regulations, and the commissioner shall have the authority to establish and maintain the priorities given such optional medical services; provided, however, that medical assistance shall be provided to at least such groups and in such scope, duration, and amount as are required to obtain federal matching funds. The commissioner is further authorized and empowered, at such times as he may determine feasible, within the limits of appropriated funds for any fiscal year, to issue, or cause to be issued through the Division of Medical Assistance and Health Services, all necessary rules, regulations and administrative orders, and to do or cause to be done all other acts and things necessary to implement and administer demonstration projects pursuant to Title XI, section 1115 of the federal Social Security Act, including, but not limited to waiving compliance with specific provisions of this act, to the extent and for the period of time the commissioner deems necessary, as well as contracting with any legal entity, including but not limited to corporations organized pursuant to Title 14A, New Jersey Statutes (N.J.S.14A:1-1 et seq.), Title 15, Revised Statutes (R.S.15:1-1 et seq.), and Title 15A, New Jersey Statutes (N.J.S.15A:1-1 et seq.) as well as boards, groups, agencies, persons, and other public or private entities; c. To administer the provisions of this act; d. To make reports to the federal Department of Health and Human Services as from time to time may be required by such federal department and to the New Jersey Legislature as hereinafter provided; e. To assure that any applicant, qualified applicant or recipient shall be afforded the opportunity for a hearing should the person's claim for medical assistance be denied, reduced, terminated, or not acted upon within a reasonable time; f. To assure that providers shall be afforded the opportunity for an administrative hearing within a reasonable time on any valid complaint arising out of the claim payment process; g. To provide safeguards to restrict the use or disclosure of information concerning applicants and recipients to purposes directly connected with administration of this act; h. To take all necessary action to recover any and all payments incorrectly made to or illegally received by a provider from such provider or his estate or from any other person, firm, corporation, partnership, or entity responsible for or receiving the benefit or possession of the incorrect or illegal payments or their estates, successors or assigns, and to assess and collect such penalties as are provided for herein; i. To take all necessary action to recover the cost of benefits incorrectly provided to or illegally obtained by a recipient, including those made after a voluntary divestiture of real or personal property or any interest or estate in property for less than adequate consideration made for the purpose of qualifying for assistance. The division shall take action to recover the cost of benefits from a recipient, legally responsible relative, representative payee, or any other party or parties whose action or inaction resulted in the incorrect or illegal payments or who received the benefit of the divestiture, or from their respective estates, as the case may be and to assess and collect the penalties as are provided for herein, except that no lien shall be imposed against property of the recipient prior to his death except in accordance with section 17 of P.L.1968, c.413 (C.30:4D-17). No recovery action shall be initiated more than five years after an incorrect payment has been made to a recipient when the incorrect payment was due solely to an error on the part of the State or any agency, agent, or subdivision thereof; j. To take all necessary action to recover the cost of benefits correctly provided to a recipient from the estate of said recipient in accordance with sections 6 through 12 of this amendatory and supplementary act; k. To take all reasonable measures to ascertain the legal or equitable liability of third parties to pay for care and services (available under the plan) arising out of injury, disease, or disability; where it is known that a third party has a liability, to treat such liability as a resource of the individual on whose behalf the care and services are made available for purposes of determining eligibility; and in any case where such a liability is found to exist after medical assistance has been made available on behalf of the individual, to seek reimbursement for such assistance to the extent of such liability; l. To compromise, waive, or settle and execute a release of any claim arising under this act including interest or other penalties, or designate another to compromise, waive, or settle and execute a release of any claim arising under this act. The commissioner or the commissioner's designee whose title shall be specified by regulation may compromise, settle or waive any such claim in whole or in part, either in the interest of the Medicaid program or for any other reason which the commissioner by regulation shall establish; m. To pay or credit to a provider any net amount found by final audit as defined by regulation to be owing to the provider. Such payment, if it is not made within 45 days of the final audit, shall include interest on the amount due at the maximum legal rate in effect on the date the payment became due, except that such interest shall not be paid on any obligation for the period preceding September 15, 1976. This subsection shall not apply until federal financial participation is available for such interest payments; n. To issue, or designate another to issue, subpoenas to compel the attendance of witnesses and the production of books, records, accounts, papers, and documents of any party, whether or not that party is a provider, which directly or indirectly relate to goods or services provided under this act, for the purpose of assisting in any investigation, examination, or inspection, or in any suspension, debarment, disqualification, recovery, or other proceeding arising under this act; o. To solicit, receive, and review bids pursuant to the provisions of P.L.1954, c.48 (C.52:34-6 et seq.) and all amendments and supplements thereto, by any corporation doing business in the State of New Jersey, including nonprofit hospital service corporations, medical service corporations, health service corporations, or dental service corporations incorporated in New Jersey and authorized to do business pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), P.L.1940, c.74 (C.17:48A-1 et seq.), P.L.1985, c.236 (C.17:48E-1 et seq.), or P.L.1968, c.305 (C.17:48C-1 et seq.), and to make recommendations in connection therewith to the State Medicaid Commission; p. To contract, or otherwise provide as in this act provided, for the payment of claims in the manner approved by the State Medicaid Commission; q. Where necessary, to advance funds to the underwriter or fiscal agent to enable such underwriter or fiscal agent, in accordance with terms of its contract, to make payments to providers; r. To enter into contracts with federal, State, or local governmental agencies, or other appropriate parties, when necessary to carry out the provisions of this act; s. To assure that the nature and quality of the medical assistance provided for under this act shall be uniform and equitable to all recipients; t. To provide for the reimbursement of State and county-administered skilled nursing and intermediate care facilities through the use of a governmental peer grouping system, subject to federal approval and the availability of federal reimbursement. (1) In establishing a governmental peer grouping system, the State's financial participation is limited to an amount equal to the nonfederal share of the reimbursement which would be due each facility if the governmental peer grouping system was not established, and each county's financial participation in this reimbursement system is equal to the nonfederal share of the increase in reimbursement for its facility or facilities which results from the establishment of the governmental peer grouping system. (2) On or before December 1 of each year, the commissioner shall estimate and certify to the Director of the Division of Local Government Services in the Department of Community Affairs the amount of increased federal reimbursement a county may receive under the governmental peer grouping system. On or before December 15 of each year, the Director of the Division of Local Government Services shall certify the increased federal reimbursement to the chief financial officer of each county. If the amount of increased federal reimbursement to a county exceeds or is less than the amount certified, the certification for the next year shall account for the actual amount of federal reimbursement that the county received during the prior calendar year. (3) The governing body of each county entitled to receive increased federal reimbursement under the provisions of this amendatory act shall, by March 31 of each year, submit a report to the commissioner on the intended use of the savings in county expenditures which result from the increased federal reimbursement. The governing body of each county, with the advice of agencies providing social and health related services, shall use not less than 10% and no more than 50% of the savings in county expenditures which result from the increased federal reimbursement for community-based social and health related programs for elderly and disabled persons who may otherwise require nursing home care. This percentage shall be negotiated annually between the governing body and the commissioner and shall take into account a county's social, demographic, and fiscal conditions, a county's social and health related expenditures and needs, and estimates of federal revenues to support county operations in the upcoming year, particularly in the areas of social and health related services. (4) The commissioner, subject to approval by law, may terminate the governmental peer grouping system if federal reimbursement is significantly reduced or if the Medicaid program is significantly altered or changed by the federal government subsequent to the enactment of this amendatory act. The commissioner, prior to terminating the governmental peer grouping system, shall submit to the Legislature and to the governing body of each county a report as to the reasons for terminating the governmental peer grouping system; u. The commissioner, in consultation with the Commissioner of Health, shall: (1) Develop criteria and standards for comprehensive maternity or pediatric care providers and determine whether a provider who requests to become a comprehensive maternity or pediatric care provider meets the department's criteria and standards; (2) Develop a program of comprehensive maternity care services which defines the type of services to be provided, the level of services to be provided, and the frequency with which qualified applicants are to receive services pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.); (3) Develop a program of comprehensive pediatric care services which defines the type of services to be provided, the level of services to be provided, and the frequency with which qualified applicants are to receive services pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.); (4) Develop and implement a system for monitoring the quality and delivery of comprehensive maternity and pediatric care services and a system for evaluating the effectiveness of the services programs in meeting their objectives; (5) Establish provider reimbursement rates for the comprehensive maternity and pediatric care services; v. The commissioner, jointly with the Commissioner of Health, shall report to the Governor and the Legislature no later than two years following the date of enactment of P.L.1987, c.115 (C.30:4D-2.1 et al.) and annually thereafter on the status of the comprehensive maternity and pediatric care services and their effectiveness in meeting the objectives set forth in section 1 of P.L.1987, c.115 (C.30:4D-2.1) accompanying the report with any recommendations for changes in the law governing the services that the commissioners deem necessary. L.1968, c.413, s.7; amended 1974, c.140; 1976, c.89, s.1; 1979, c.365, s.5; 1985, c.303, s.5; 1985, c.371, ss.3,5; 1985, c.474, s.2; (1985, c.371, s.5 amended 1985, c.510); 1987, c.115, s.4; 1988, c.6, s.1; 2004, c.130, s.94; 2012, c.17, s.361. 30:4D-7a. County welfare agency to provide adequate employees to determine Medicaid eligibility The Commissioner of Human Services shall require that a county welfare agency provide adequate employees to determine Medicaid eligibility to any hospital in the county that has been designated by the Commissioner of Health pursuant to section 9 of P.L.1991, c.187 (C.26:2H-18.32). The Commissioner of Human Services shall bill the designated hospital quarterly for the nonfederal share of costs associated with a county welfare agency employee stationed at the hospital, and reimburse the county welfare agency upon receipt of payment from the hospital. L.1991,c.187,s.10. 30:4D-7b. Preparation of five-year plan for developing Statewide network of managed care providers The Commissioner of Human Services shall prepare a five-year plan to develop a Statewide network of managed care providers for Medicaid recipients pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). A managed care plan may include, but is not limited to, the Garden State Health Plan, or its successor, any other State approved or federally qualified health maintenance organization, or any other cost effective health plan, prepaid or otherwise, that is under contract with the Division of Medical Assistance and Health Services in the Department of Human Services to provide managed care services to Medicaid recipients. The commissioner shall prepare the plan within one year of the effective date of P.L.1991, c.187 (C.26:2H-18.24 et al.) and submit the plan to the Governor and the Chairmen of the Senate Institutions, Health and Welfare and General Assembly Health and Human Services Committees. L.1991,c.187,s.42. 30:4D-7c. Submission of plan to enroll Medicaid recipients by health maintenance organizations Within one year of the effective date of P.L.1991, c.187 (C.26:2H-18.24 et al.), every State approved or federally qualified health maintenance organization in the State shall submit a plan to the Commissioner of Human Services to enroll Medicaid recipients pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). The plan shall include the terms and conditions for enrolling Medicaid recipients, including the number of recipients that can reasonably be enrolled, the health care services that will be offered, and an estimate of the per capita cost for enrollment of these persons. The commissioner shall provide a health maintenance organization, upon written request, with any nonidentifying information about Medicaid recipients that is necessary to assist the health maintenance organization in preparing its plan. L.1991,c.187,s.43. 30:4D-7d. Report by commissioner Within six months of the effective date of P.L.1991, c.187 (C.26:2H-18.24 et al.), the Commissioner of Human Services shall report to the Governor and the Chairmen of the Senate Institutions, Health and Welfare and General Assembly Health and Human Services Committees on ways: to increase the number of providers in the Medicaid program pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.); to improve Medicaid provider relations with the Medicaid program; to reduce administrative burdens encountered by Medicaid providers; and to streamline Statewide administration of the Medicaid program. L.1991,c.187,s.44. 30:4D-7e. Rules, regulations 38. The Commissioner of Human Services shall, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) adopt rules and regulations necessary to implement the provisions of sections 9, 11 and 12 of this act as they relate to payments from the Health Care Subsidy Fund to disproportionate share hospitals. L.1992,c.160,s.38. 30:4D-7f. Access fees charged by fiscal agent; establishment; use 1. Notwithstanding the provisions of the "New Jersey Medical Assistance and Health Services Act," P.L.1968, c.413 (C.30:4D-1 et seq.) or any other law to the contrary, an intermediary vendor under contract with the Division of Medical Assistance and Health Services' fiscal agent, which vendor has direct access to the Medical Assistance Eligibility System, shall be charged an access fee by the fiscal agent. The Commissioner of Human Services shall, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) adopt regulations establishing the access fee. Receipts from access fees in excess of development and operational costs incurred by the division's fiscal agent shall be appropriated annually to the division. L.1994,c.60,s.1. 30:4D-7g. Findings, declarations relative to pediatric rehabilitation hospitals. 1. The Legislature finds and declares that: a. Currently, there are two pediatric rehabilitation hospitals in the State that provide pediatric inpatient and ambulatory rehabilitation and pediatric long-term care services to children throughout the State. These hospitals offer a variety of medical, developmental and educational services to children with severe disabilities and chronic illnesses; and b. There is a tremendous need in the State for the unique services provided by these facilities, and few providers within the health care community have the capability and expertise to properly treat the special needs of these children. L.2001,c.393,s.1. 30:4D-7h Reimbursement by State Medicaid program, rates; other costs. 2. a. A pediatric rehabilitation hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) with 30 or fewer beds shall be reimbursed 100% of its Medicaid allowable reimbursable costs as defined by Medicare Principles of Reimbursement, subject to the "Tax Equity and Fiscal Responsibility Act of 1982" (TEFRA), Pub.L.97-248 as amended, and adjusted for occupancy, if applicable. Any 2001, 2002 or 2003 Medicare cost reports that are not settled for Medicaid reimbursement on or before July 1, 2004 shall be prospectively settled, based on Medicaid allowable reimbursable costs as defined by Medicare Principles of Reimbursement, subject to TEFRA, and adjusted for occupancy, if applicable. b. A pediatric rehabilitation hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) with more than 30 beds shall be reimbursed a prospective per diem rate by the State Medicaid program for Medicaid fee-for-service recipients. The initial prospective per diem rate shall be based on the total allowable cost for Medicaid patients divided by the total Medicaid days from the calendar year 1999 Medicare/Medicaid cost report, and shall be considered the base year rate. If the hospital has been in operation less than two full years prior to fiscal year 1999, the prospective per diem rate will be set using its first finalized audited fiscal year 2000 Medicaid/Medicare cost report. The base year rate shall be updated each year by the economic factor specified in N.J.A.C.10:52-5.13. The Commissioner of Human Services shall adopt regulations to permit a pediatric rehabilitation hospital to seek rate relief or to seek a new base year rate in the event the hospital has experienced an increase in its operating costs which would impact the existing per diem rate, net of capital costs, greater than 5%. The hospital shall furnish evidence of that increase in costs to the Division of Medical Assistance and Health Services in the Department of Human Services and request an adjustment to its prospective inpatient reimbursement rate. c. A pediatric rehabilitation hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall be: (1) reimbursed its outpatient costs based on applicable cost-based Medicare Principles of Reimbursement through the Medicare/Medicaid cost report, and shall not receive final reimbursement based on an outpatient prospective reimbursement methodology. If necessary, the Department of Human Services shall adopt regulations to specify an interim claims processing and payment methodology; (2) entitled to a per diem adjustment to account for increases in its capital expenditures. Adjusted per diem payments shall begin upon project completion and facility operation. The adjustment shall be calculated based on the Medicaid share of the inpatient costs for any capital expenditures made on or after December 31, 2003. Utilizing data from the Medicare/Medicaid Cost Report, the Medicaid share shall be determined by dividing the combined total of Medicaid fee-for-service days and Medicaid managed care days by the total number of inpatient days; and the inpatient costs for capital expenditures shall be determined by dividing the hospital's inpatient costs by its total costs and multiplying that number by its total additional capital costs; and (3) entitled to receive a per diem adjustment for its graduate medical education program, with the adjustment to be based on the Medicaid share of the costs incurred by the graduate medical education program. The Medicaid share shall be determined by dividing the Medicaid inpatient days by the total number of inpatient days and multiplying that number by the total amount of graduate medical education costs as reported on the Medicare/Medicaid cost report. L.2001, c.393, s.2; amended 2003, c.223; 2004, c.76. 30:4D-7i Exemption from close proximity requirements, notification as to off-site location. 3. A pediatric rehabilitation hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall not be subject to the close proximity requirements established pursuant to N.J.A.C.10:52-1.3(b)(1) for the purposes of receiving Medicaid fee-for-service reimbursement for outpatient hospital services. A pediatric rehabilitation hospital which establishes an off-site location to provide outpatient services shall notify the Division of Medical Assistance and Health Services in the Department of Human Services in accordance with the requirements of N.J.A.C.10:52-1.3. L.2001,c.393,s.3. 30:4D-7j Annual cost report to receive reimbursement from Medicaid for personal care assistant services. 1. As a condition of receiving reimbursement from the State Medicaid program, pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), for personal care assistant services, as described in N.J.A.C.10:60-3.3, which are provided to Medicaid recipients, a health care service firm, as defined in N.J.A.C.13:45B-13.2, shall file an annual cost report with the Division of Disability Services in the Department of Human Services. The Division of Disability Services shall develop the form of the annual cost report, which shall include information on costs and revenues. The cost report shall be filed on an annual basis, beginning January 1, 2010, in a form and manner specified by the division. L.2009, c.181, s.1. 30:4D-7k Definitions relative to reimbursement for family planning services. 1. a. The reimbursement rate for an office visit for family planning services billed by a health care facility, which is licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) and receives funding under Title X of the Public Health Service Act (42 U.S.C. s.300 et seq.), to the State Medicaid program shall be an amount that equals at least 90% of the amount of the actual cost of services provided during an office visit, as such rate is in effect on the date of enactment of this act. b. As used in this section: "Family planning services" means comprehensive reproductive health care services, including: contraception; pregnancy detection; options counseling; diagnosis or treatment, or both, of sexually transmitted diseases; routine gynecological and cancer screening services; health promotion activities; and Level I infertility services such as an interview, education, physical examination, laboratory testing, counseling, and appropriate referral. The term does not include termination of pregnancy. Family planning services may also include: prenatal and postpartum care; other gynecological services, including colposcopy and cryotherapy; menopausal services; Level II infertility services, which include semen analysis, assessment of ovulatory function, and post coital testing; and Level III infertility services, which include more sophisticated and complex infertility testing and procedures than Levels I and II. "Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "Office visit" means a procedure billed under a common procedure terminology code that includes a family planning modifier in the description of the code. L.2009, c.268, s.1. 30:4D-7l Department to facilitate implementation of C.30:4D-7k. 2. The Department of Health shall adjust the Family Planning Services Grant-in-Aid appropriation and transfer the appropriate amount of State funds to the Division of Medical Assistance and Health Services in the Department of Human Services to facilitate the implementation of section 1 of this act. The Department of Health shall notify the Legislative Budget and Finance Officer as to the amount that is transferred. L.2009, c.268, s.2; amended 2012, c.17, s.362. 30:4D-7m Certain HMOs, changes in certain reimbursement rates; procedure. 1. Notwithstanding any law, rule, or regulation to the contrary, a health maintenance organization that contracts with the Division of Medical Assistance and Health Services in the Department of Human Services to provide benefits under a managed care plan to persons who are eligible for Medicaid shall not reduce reimbursement rates for personal care assistant services or home based supportive care services, as those services are defined by regulation or in the contract with the division, under the health maintenance organization's Medicaid managed care plan, unless the health maintenance organization notifies the division, in writing, at least 90 days before the effective date of such changes. Such notice shall be accompanied by written assurance that the reduction will not reduce sufficient provider access or quality of service as required by the contract with the division. L.2015, c.234, s.1. 30:4D-7n Hourly reimbursement rate for Medicaid personal care services. 1. The hourly reimbursement rate for personal care services within the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), whether the services are provided in the Medicaid fee-for-service delivery system or through a managed care delivery system, shall be no less than the established State Medicaid fee-for-service rate. On July 1, 2019, the reimbursement rate shall be $18 per hour. L.2017, c.239, s.1; amended 2019, c.275, s.2. 30:4D-7o Report. 2. Every provider that receives reimbursement for personal care services pursuant to a Medicaid managed care contract shall annually provide a report to the Division of Medical Assistance and Health Services in the Department of Human Services regarding the use of funds received as reimbursement for personal care services, including detailed data on any salary increases resulting from section 1 of P.L.2017, c.239 (C.30:4D-7n); including the prior salary, current salary, and other changes to the salary of the workers who directly provide personal care services. L.2017, c.239, s.2; amended 2019, c.275, s.3. 30:4D-7p Medicaid reimbursement for certain emergency services. 1. a. A hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) providing emergency services to patients enrolled in the State Medicaid fee-for-service program shall accept as final payment an emergency room triage reimbursement fee of $140.00 when the emergency services provided are for low acuity emergency room encounters. The Commissioner of Human Services shall publish a list of diagnostic codes that would be considered low acuity emergency room encounters for the purpose of applying this fee. b. As used in this section: "Acuity" means the measurement of the intensity of nursing care required by a patient. "Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). L.2018, c.51, s.1. 30:4D-7q 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. L.2018, c.51, s.3. 30:4D-7r Short title. 1. This act shall be known and may be cited as "The County Option Hospital Fee Program Act." L.2018, c.136, s.1; amended 2022, c.61, s.1. 30:4D-7s Definitions relative to "The County Option Hospital Fee Pilot Program Act." 2. As used in this act: "Commissioner" means the Commissioner of Human Services. "Department" means the Department of Human Services. "Fee" means the local healthcare-related fee authorized pursuant to this act. "Hospital" means a hospital that is licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) and is located within the borders of a participating county. "Medicaid program" means the "New Jersey Medical Assistance and Health Services Program" established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "Participating county" means, notwithstanding the provisions of any other law or regulation to the contrary, a county that chooses to participate in the program, has a population greater than 250,000, according to the federal decennial census immediately preceding the effective date of P.L.2018, c.136 (C.30:4D-7r et seq.), and contains a municipality which: (1) is classified, pursuant to N.J.S.40A:6-4, as a First or Second Class municipality, or a Fourth Class municipality whose population exceeds 20,000, and (2) has a Municipal Revitalization Index Distress score, as last calculated by the New Jersey Department of Community Affairs prior to the effective date of P.L.2018, c.136 (C.30:4D-7r et seq.), that exceeds 55; or, based on the 2019 ACS 5 Year Survey Data, a county that chooses to participate in the program and contains a municipality with a population greater than 30,000 whose 2020 Municipal Revitalization Index Distress score is greater than or equal to 33 (1) excluding counties with a municipality with a population greater than 125,000, (2) excluding counties with a population less than 150,000, and (3) excluding counties with a median household income greater than $110,000. "Program" means "The County Option Hospital Fee Program" established pursuant to this act. "Proposed fee and expenditure report" means a written report by a participating county that describes how the fee will be imposed in the participating county; how the funds collected from the fee will be used by the participating county, including the amount and services the participating county plans to provide with the funds; and how the plan satisfies paragraph (1) of subsection b. of section 3 of this act. L.2018, c.136, s.2; amended 2022, c.61, s.2; 2023, c.337; 2024, c.47, s.1. 30:4D-7t "County Option Hospital Fee Program." 3. a. There is established "The County Option Hospital Fee Program" in the Department of Human Services. b. The purpose of the program is: (1) to increase financial resources through the Medicaid program to support local hospitals and to ensure that they continue to provide necessary services to low-income citizens; and (2) to provide participating counties with new fiscal resources. c. Each participating county shall be authorized by the commissioner to impose a local healthcare-related fee on hospitals within its borders. d. A participating county shall submit a proposed fee and expenditure report to the commissioner to ensure that the proposed fee and expenditure plan satisfies paragraph (1) of subsection b. of this section and subsection e. of this section, and does not create a direct or indirect guarantee to hold harmless, as those terms are used in 42 C.F.R. s.433.68(f). The commissioner shall further review the proposed fee and expenditure report to determine whether it complies with relevant rules and regulations. Each participating county shall consult with affected hospitals within its jurisdiction to prepare the proposed fee and expenditure report before the report is submitted to the commissioner. The commissioner shall make the proposed fee and expenditure report available to the affected hospitals for review and the hospitals shall be permitted to provide comments to the commissioner regarding the report for a period of 21 calendar days from the date the proposed report is made available for review. If a participating county submits a proposed fee and expenditure report that includes plans to increase Medicaid or NJ FamilyCare payments for any hospital within its jurisdiction that exceeds the calculated value of its hospital-specific disproportionate share limit, as outlined in 42 U.S.C. s.1396r-4 and calculated by the State, the proposed fee and expenditure report shall include an attestation from the chief executive officer of any such hospital confirming that the hospital is subject to a reduction in disproportionate share hospital payments, including Charity Care payments, at the commissioner's discretion and upon notice to the hospital and to the extent necessary to comply with payment limits outlined in section 1923(g) of the federal Social Security Act. The Department of Human Services shall take all appropriate action to comply with section 1923(g) of the federal Social Security Act. e. The board of County commissioners of a participating county, following the approval of the participating county's proposed fee and expenditure plan by the commissioner, may adopt an ordinance providing for the imposition of a fee on hospitals located within its borders and for appropriate administrative provisions, including, but not limited to, provisions for the collection of interest, the collection of penalties, and the application of liens. The fee shall be implemented in accordance with the provisions of 42 U.S.C. s.1396b(w)(3)(A), and shall be subject to the maximum aggregate amount that may be assessed pursuant to 42 C.F.R. s.433.68(f)(3), or any subsequent maximum amount as may be established by federal law, and shall be subject to review and approval by the commissioner. The fee shall not exceed the aggregate amount specified in 42 C.F.R. s.433.68(f)(3) minus one percent of total net patient revenues. The participating county may exempt a hospital within its jurisdiction from the fee, provided that the exemption complies with the requirements of 42 C.F.R. s.433.68. The fee authorized pursuant to this act may be collected only to the extent that the commissioner determines that the revenues generated qualify as the State share of Medicaid program expenditures eligible for federal financial participation pursuant to 42 C.F.R. s.433.68. f. Any subsequent alterations to the fee are subject to the approval of the commissioner prior to implementation. Upon approval, the commissioner shall apply for such State plan amendments or waivers as may be necessary to implement the changes and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program. g. (1) Neither the State nor a participating county shall be liable for any amount of a local healthcare-related fee imposed on a hospital pursuant to this act that the hospital fails to pay or does not pay in a timely manner to the assessing county. (2) With the exception of the period of time during which a participating county or Medicaid Managed Care Organization is in possession of payments prior to disbursement, neither a participating county nor Medicaid Managed Care Organization shall be liable for any amount related to an approved expenditure plan determined to be impermissible by a federal agency. The Department of Human Services shall amend related managed care contracts to include this provision. h. Any hospital that exceeds its hospital-specific disproportionate share limit pursuant to 42 U.S.C. s.1396r-4 as a result of payments received pursuant to the County Option Hospital Fee Program or pursuant to other State or federal funding mechanisms or pools shall be liable to the State for any funds the State may be required to reimburse the federal government for any such excess disproportionate share hospital funds attributable to the hospital. L.2018, c.136, s.3; amended 2021, c.41; 2022, c.61, s.3; 2024, c.47, s.2. 30:4D-7u Transfer of funds to commissioner, uses; fee. 4. a. A participating county may transfer funds collected from the fee imposed pursuant to subsection c. of section 3 of this act to the commissioner. The commissioner shall use funds transferred from a participating county, and any matching amount of federal Medicaid funds or other federal funds generated therefrom, for the following purposes: to increase Medicaid payments to hospitals in the jurisdiction from which the funds are received; for payments to managed care organizations that have contracted with Medicaid serving the jurisdiction from which the funds are received for increased hospital or hospital-related payments; and for direct costs related to administrative purposes to implement the program. The commissioner shall seek to minimize the length of time between the collection of the fee by the participating county and the distribution of payments pursuant to this subsection. Notwithstanding any other law to the contrary, the commissioner and a participating county are authorized to enter into an intergovernmental transfer agreement as may be necessary to transfer funds under this subsection or to otherwise satisfy the requirements of this act. b. A participating county may retain the funds collected from the imposition of the fee, in which case the participating county shall generate the same level of funding, in addition to the funds collected from the imposition of the fee, that would be generated by the department through any matching amount of federal Medicaid funds or other federal funds, and use the total funding amount to satisfy paragraph (1) of subsection b. of section 3 of this act. c. At least 90 percent of the funds collected from imposition of the fee shall be used by a participating county or the department for the benefit of local hospitals within the participating county's borders to ensure that the hospitals continue to provide necessary services to low-income citizens. The participating counties shall transfer at least one percent of funds collected from the imposition of the fee to the department for administration of the program. L.2018, c.136, s.4; amended 2022, c.61, s.4. 30:4D-7v Imposition of fee. 5. a. The fee imposed pursuant to subsection c. of section 3 of this act shall be imposed in relation to health care items or services provided only during the effective period of this act, and shall not be collected until the commissioner notifies the appropriate governmental entities that any State plan amendment or waivers submitted pursuant to section 6 of this act have been approved. b. No hospital subject to the fee shall pass on the cost of the fee to any patient, insurer, self-insured employer program, or other responsible party, nor list it separately on any invoice or statement sent to a patient, insurer, self-insured employer program, or other responsible party. c. Unless otherwise prohibited by the federal government, no managed care organization operating in the State that has contracted with Medicaid shall retain any funds generated by the fee, other than to offset any increased administrative costs incurred as a result of the program. d. Funds generated by the fee shall not supplant or offset any current or future State funds allocated to a county participating in the program. e. Payments distributed to hospitals pursuant to this act shall not supplant or offset any current or future funds paid to hospitals through other State or federal funding mechanisms or pools. L.2018, c.136, s.5; amended 2022, c.61, s.5. 30:4D-7w Application by commissioner, approval prior to collection of fee. 6. 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, and shall receive approval for such State plan amendments or waivers prior to collection of a fee authorized pursuant to subsection c. of section 3 of this act. L.2018, c.136, s.6. 30:4D-7x Rules, regulations. 7. The commissioner shall promulgate, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary for the implementation of this act which shall include appropriate methodologies for the county proposed fee and expenditure report. Participating counties shall not submit the proposed fee and expenditure plan to the department prior to the adoption of rules and regulations. L.2018, c.136, s.7. 30:4D-7y Perinatal Risk Assessment form for certain pregnant women. 1. An obstetrical provider, nurse midwife, or other licensed health care professional, approved as a provider under the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), shall complete the Perinatal Risk Assessment form, as used by the Division of Medical Assistance and Health Services in the Department of Human Services, for each pregnant Medicaid recipient and for each individual eligible for Emergency Medical Services for Non-Qualified Aliens who receives prenatal care from the provider. The Perinatal Risk Assessment form shall be the uniform document used by all providers and Medicaid managed care plans. The form shall be completed by the provider during the first prenatal visit with the pregnant Medicaid recipient or other eligible individual and updated by the provider in the third trimester of the recipient or other eligible individual. L.2019, c.88, s.1. 30:4D-7z Submission of form to division. 2. The division shall require providers to submit each Perinatal Risk Assessment form completed pursuant to section 1 of this act to the division, or to a nonprofit entity contracted by the division to process, distribute to appropriate Medicaid managed care plans, and maintain the Perinatal Risk Assessment data. A provider shall not receive authorization for reimbursement for prenatal services provided to a pregnant Medicaid recipient until a Perinatal Risk Assessment form is submitted for that recipient. L.2019, c.88, s.2. 30:4D-7aa Analysis of data. 3. The division, in collaboration with the Department of Health, Medicaid managed care organizations, and any nonprofit entity contracted by the division to process, distribute, and maintain the Perinatal Risk Assessment data, shall analyze the Perinatal Risk Assessment data in order to identify trends in the risk factors associated with Medicaid recipients and individuals eligible for Emergency Medical Services for Non-Qualified Aliens during pregnancy. Commencing no later than 18 months after the effective date of this act, and annually thereafter, the division shall submit a written report to the Governor, and to the Legislature pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), providing a summary of its findings and any proposals for legislative action needed to improve the maternal outcomes of Medicaid recipients and individuals eligible for Emergency Medical Services for Non-Qualified Aliens. L.2019, c.88, s.3. 30:4D-7bb Rules, regulations. 4. The Commissioners of Health and 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.88, s.4. 30:4D-7cc Legislative approval of reimbursement rate increases. 3. a. The Commissioner of Human Services shall submit recommendations to the Legislature, pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), for legislative approval of any reimbursement rate increases as may be needed to comply with minimum wage requirements for long-term care facility direct care staff as provided in subsection i. of section 5 of P.L.1966, c.113 (C.34:11-56a4). The commissioner may recommend that increases for nursing homes be tied to improvements in specific quality and safety metrics. b. No later than 90 days after the effective date of this act, the Commissioner of Human Services shall conduct a review of the Department of Human Services' Medicaid value-based payment strategy, including the Quality Incentive Payment Program, to ensure incentives provided under the strategy focus on priority metrics for quality improvement, and shall review and determine whether incentives are an effective means of driving improvements in quality of care and resident and staff safety in nursing homes. c. (1) The Commissioner of Human Services shall establish a direct care ratio reporting and rebate requirement, which shall take effect no later than July 1, 2021, pursuant to which nursing homes shall be required to report total revenues collected, along with the portion of revenues that are expended on direct care staff wages, other staff wages, taxes, administrative costs, investments in improvements to the facility's equipment and physical plant, profits, and any other factors as the commissioner shall require. (2) The direct care ratio shall require 90 percent, or such higher percentage as the commissioner may establish by regulation, of a facility's aggregate revenue in a fiscal year to be expended on the direct care of residents. The commissioner shall determine which components of the reporting requirements shall be attributed to direct patient care, administrative costs, and profits. The commissioner may adjust the components of the ratio as appropriate based on current financial information reported by nursing homes and overall performance by the nursing home related to patient safety and quality of care. (3) The commissioner or an entity designated by the commissioner may conduct an audit of the financial information reported by nursing homes pursuant to this section to ensure the accuracy of the information reported and compliance with the requirements of this section, as well as to identify and recover any payments that exceed the allowed cost ratio for administrative costs and profits. (4) In each case where the direct care loss ratio fails to substantially comply with the ratio requirement established pursuant to this subsection, the nursing home shall issue a pro rata dividend or credit to the State and to all individuals and entities making payments to the nursing home for resident services in an amount sufficient to assure that the aggregate amount paid for direct care staff wages, other staff wages, taxes, administrative costs, investments in improvements to the nursing home's equipment and physical plant, profits, and other factors, plus the amount of the dividends and credits, equals the mandatory ratio for the previous calendar year. The pro rata dividend or credit shall be equal to the percentage of payments made by the payor to the nursing home in the previous calendar year out of all payments made to the nursing home for services provided in the previous calendar year from all payment sources. All dividends and credits shall be distributed by June 30 of the year following the calendar year in which the ratio requirements were not satisfied. L.2020, c.89, s.3. 30:4D-7dd Risk reduction model to prescription drug services, third party contract. 1. The Division of Medical Assistance and Health Services in the Department of Human Services shall contract with a third party entity to apply a risk reduction model to prescription drug services provided under the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), for the purpose of identifying and reducing simultaneous, multi-drug medication-related risk and adverse drug events, enhancing compliance and quality of care, and improving health-related outcomes while reducing total cost of care in a measurable and reportable manner. In carrying out this purpose, the model, at a minimum, shall leverage Medicaid prescription drug claims data, pharmacokinetic and pharmacodynamic sciences, appropriate technologies, clinical call centers located in New Jersey and staffed by board-certified pharmacists licensed pursuant to P.L.2003, c.280 (C.45:14-40 et seq.), and include coordination of services with a network of local community pharmacies located throughout the State. For the duration of the contract, the division shall share the medical and pharmacy claims data for all Medicaid beneficiaries with the third party administering the model for the purposes of effectuating the model, which claims data shall include historical data. L.2021, c.151. 30:4D-7ee Pharmacy benefits management services, information disclosure 1. a. Any contract or other arrangement entered into by a managed care organization, or by the Division of Medical Assistance and Health Services in the Department of Human Services, for the provision of pharmacy benefits management services under the Medicaid program shall require the pharmacy benefits manager to disclose to the department: (1) all sources and amounts of income, payments, and financial benefits received by the pharmacy benefits manager in relation to the provision and administration of pharmacy benefits management services on behalf of the managed care organization, including, but not limited to, any pricing discounts, rebates of any kind, inflationary payments, credits, clawbacks, fees, grants, chargebacks, reimbursements, or other benefits; (2) all ingredient costs and dispensing fees or similar payments made by the pharmacy benefits manager to any pharmacy in connection with the contract or other arrangement; and (3) the pharmacy benefits manager's payment model for administrative fees. b. Information disclosed by a pharmacy benefits manager to the division pursuant to subsection a. of this section shall be confidential and not be subject to public disclosure under P.L.1963, c.73 (C.47:1A-1 et seq.), or P.L.2001, c.404 (C.47:1A-5 et al.). In addition to any other penalty provided by law, a person who is authorized to access information submitted by a pharmacy benefits manager to the division who knowingly discloses such information to any person or entity who is not authorized to access the information shall be guilty of a crime of the fourth degree and shall be subject to a civil penalty in an amount not to exceed $10,000. A civil penalty imposed under this subsection shall be collected by the director pursuant to the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.). c. As used in this section: "Pharmacy benefits manager" means a corporation, business, or other entity, or unit within a corporation, business, or other entity, that administers prescription drug benefits on behalf of a managed care organization. "Pharmacy benefits management services" mean the provision of any of the following services on behalf of a managed care organization: the procurement of prescription drugs at a negotiated rate for dispensation within this State; the processing of prescription drug claims; or the administration of payments related to prescription drug claims. L.2021, c.257. 30:4D-7ff Amendment of the Medicaid managed care organization contract provisions. 1. a. At the next regular opportunity, the Division of Medical Assistance and Health Services in the Department of Human Services shall amend the Medicaid managed care organization contract provisions on network adequacy to require: (1) a sufficient number of pediatric primary care physicians (PCPs) to assure that: (a) at least two physicians eligible as PCPs are within five miles or 10 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan's pediatric enrollees who live in urban counties; (b) at least two physicians eligible as PCPs are within 10 miles or 15 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan's pediatric enrollees who live in non-urban counties; and (c) 100 percent of all pediatric enrollees live no more than 30 minutes from at least one physician eligible as a PCP; (2) a sufficient number of pediatric medical specialists to assure: (a) access within 15 miles or 30 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan's pediatric enrollees who live in urban counties; and (b) access within 40 miles or 60 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan's pediatric enrollees who live in non-urban counties; (3) a sufficient number of pediatric oncologists and developmental and behavioral pediatricians and psychiatrists to assure: (a) access within 10 miles or 20 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan's pediatric enrollees who live in urban counties; and (b) access within 30 miles or 45 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan's pediatric enrollees who live in non-urban counties; and (4) the following types of pediatric medical specialties represented within the plan's network: adolescent medicine; allergy and immunology; cardiology; developmental and behavioral pediatrics; psychiatry, emergency medicine; endocrinology and diabetes; gastroenterology and nutrition; general pediatrics; general pediatrics - dermatology; hematology; human genetics and metabolism; infectious disease; neonatology; nephrology; neurology; oncology; ophthalmology; orthopedics; otolaryngology; plastic surgery; pulmonary medicine, including sleep medicine; radiology; rehabilitative medicine; and rheumatology. b. In each reporting period, a managed care organization may seek a waiver of a specific network adequacy provision established in paragraphs (2) through (3) of subsection a. of this section from the Division of Medical Assistance and Health Services. The division shall establish a waiver process where, at a minimum, the managed care organization must demonstrate both an active, good faith effort to meet requirements for applicable specialties in each applicable county, and certify to the division which specialty or specialties, and in which counties, for which insufficient providers exist. c. The Division of Medical Assistance and Health Services shall require each managed care organization to establish a process by which a patient or provider may submit a grievance regarding the adequacy of its provider network. This process shall include response timeframes, but no more than 30 days, and reporting defined in the managed care contract, including documentation of specific provider availability addressing each grievance. d. In order to provide timely services to patients, when a managed care organization is notified that care is needed for a Medicaid beneficiary in a county where a managed care organization was unable to certify that it meets, or received a waiver of, the network adequacy standards as required in subsection a. of this section, the managed care organization shall initiate negotiations with non-participating providers of that service, and shall provide timely authorization to ensure services can be provided to the beneficiary without delay and consistent with timeframes defined in the managed care contract for all routine and urgent services. Balance-billing of Medicaid beneficiaries shall be prohibited. Any copayments or other forms of cost-sharing imposed on services rendered under this paragraph shall be limited to the maximum amount allowed under State law for the Medicaid program. The Commissioner of Human Services may promulgate rules or regulations to resolve in a timely manner contracting disputes that arise under this subsection. e. The Division of Medical Assistance and Health Services shall establish an enhanced system to assess the network adequacy of a managed care organization contracted with the division to provide benefits under Medicaid, including, but not limited to, requiring the managed care organization to certify, at a minimum on an annual basis, that the managed care organization meets the network adequacy requirements contained in their contract. The division shall enforce appropriate sanctions for non-compliance with this section, including, but not limited to, financial penalties that accrue during the period of non-compliance. f. A managed care organization shall annually provide a report of the number of out-of-network contracts and waivers sought and granted by pediatric specialty, as listed in paragraph (4) of subsection a. of this section, and county to the Division of Medical Assistance and Health Services, who shall make that information publicly available by request. g. For the purposes of this section: "Medicaid" means the program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "Network adequacy" means the adequacy of the provider network with respect to the scope and type of health care benefits provided by the managed care plan, the geographic service area covered by the provider network, and access to medical specialists pursuant to the standards in the regulations promulgated pursuant to section 19 of P.L.1997, c.192 (C.26:2S-18) and in the existing contract between a managed care organization and the Division of Medical Assistance and Health Services in the Department of Human Services. "Non-urban county" shall mean: Atlantic, Cape May, Cumberland, Gloucester, Hunterdon, Morris, Salem, Somerset, Sussex, and Warren counties, or as otherwise defined for the purposes of this section by the Commissioner of Human Services. "Urban county" shall mean: Bergen, Burlington, Camden, Essex, Hudson, Mercer, Middlesex, Monmouth, Ocean, Passaic, and Union counties, or as otherwise defined for the purposes of this section by the Commissioner of Human Services. L.2021, c.276, s.1. 30:4D-7gg Rules, regulations. 2. 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. L.2021, c.276, s.2. 30:4D-7hh Per diem reimbursement rate compared to established State Medicaid fee-for-service rate. 1. a. Notwithstanding the provisions of any law or regulation to the contrary, the per diem reimbursement rate for providers of adult medical day care services within the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), whether the services are provided in the Medicaid fee-for-service delivery system or through a managed care delivery system, shall be no less than the established State Medicaid fee-for-service rate. b. As used in this section: "Provider of adult medical day care services" means an adult day health services facility licensed by the Department of Health, which provides preventive, diagnostic, therapeutic, and rehabilitative services under medical and nursing supervision to meet the needs of functionally impaired adult participants for a period of time that does not exceed 12 hours during any calendar day. L.2021, c.452, s.1. 30:4D-7ii Restricting modification, termination of existing provider network contract. 2. A managed care organization contracted with the Division of Medical Assistance and Health Services within the Department of Human Services to provide benefits under the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), shall not terminate or modify an existing provider network contract solely due to a change of provider ownership or ownership structure. L.2021, c.452, s.2. 30:4D-7jj Findings, declarations. 1. The Legislature funds and declares: a. An acquired brain injury is an injury caused by an event, either internal or external to the injured individual, and does not include congenital or degenerative disorders, or those injuries induced by birth trauma. An acquired brain injury can either be categorized as a traumatic brain injury or non-traumatic brain injury. A traumatic brain injury is an alteration in brain function caused by an external force and may be caused by falls, assaults, motor vehicle accidents, or sports injuries. A non-traumatic brain injury is damage to the brain caused by internal factors, such as stroke, aneurysm, tumor, infectious disease, or anoxia. b. A severe acquired brain injury can produce an altered or diminished state of consciousness and result in an impairment of cognitive abilities or physical functioning. It can also effect behavioral or emotional functioning. These impairments may be permanent and cause partial or total functional disability, leading to the injured individual requiring long-term care supports. c. The State's Medicaid program provides brain injury services under the Managed Long-Term Supports and Services program, with the goal of providing community alternatives for individuals with brain injuries residing in nursing facilities or who are in the community and at risk for placement in nursing facilities. d. Unlike other Medicaid community-based services, reimbursement rates for brain injury services have remained static in recent years despite growing costs, which threatens the ability of providers to meet the complex health needs of individuals with brain injuries and provide services within a safe and fulfilling community environment. e. Despite the similar model of care, reimbursement rates for services provided to Medicaid beneficiaries with intellectual and developmental disabilities have not only increased, but have been restructured to account for adequate consideration for acuity, increased minimum wage requirements, and other inflationary trends that assert pressure on providers' cost structures. f. By failing to receive reimbursement rates that adequately support services, brain injury providers are being forced to return this fragile population to more costly institutional care in nursing home facilities. g. It is imperative that the Legislature take action and increase Medicaid rates for these essential services and ensure that individuals with brain injuries can continue to thrive and reach their optimal recoveries in community settings. L.2022, c.78, s.1. 30:4D-7kk Medicaid per diem, encounter reimbursement rates, eligible brain injury services, minimum requirements. 2. a. Notwithstanding the provisions of any law or regulation to the contrary, the Medicaid per diem or encounter reimbursement rates for eligible brain injury services, when such services are provided by an approved brain injury service provider to a Medicaid beneficiary requiring treatment for a brain injury, shall be, at minimum, as follows: (1) The reimbursement rate for Community Residential Services - Low Supervision provided to a Medicaid beneficiary eligible for brain injury services shall be equal to the reimbursement rate for Individuals Supports Services - Tier B provided to a Medicaid beneficiary eligible for services provided by the Division of Developmental Disabilities in the Department of Human Services; (2) The reimbursement rate for Community Residential Services - Moderate Supervision provided to a Medicaid beneficiary eligible for brain injury services shall be equal to the reimbursement rate for Individuals Supports Services - Tier C provided to a Medicaid beneficiary eligible for services provided by the Division of Developmental Disabilities in the Department of Human Services; and (3) The reimbursement rate for Community Residential Services - High Supervision provided to a Medicaid beneficiary eligible for brain injury services shall be equal to the average of the reimbursement rates for Individuals Supports Services - Tiers D and E provided to a Medicaid beneficiary eligible for services provided by the Division of Developmental Disabilities in the Department of Human Services. b. As used in this section: "Brain injury service" means community-based services, residential services, day care services, and home care services provided to a Medicaid beneficiary requiring treatment for traumatic or non-traumatic brain injuries, regardless of whether such services are provided through the Medicaid fee-for-service delivery system or the managed care delivery system. "Brain injury service provider" means a facility licensed by the Division of Disability Services in the Department of Human Services to provide traumatic or non-traumatic brain injury services. "Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "Non-traumatic brain injury" means an injury to the brain caused by internal factors, such as stroke, aneurysm, tumor, infectious disease, or anoxia, where continued impairment can be demonstrated. This term does not include brain dysfunction caused by congenital or degenerative disorders, birth trauma, or injuries caused by other circumstances. "Traumatic brain injury" means an injury to the brain caused by a blow or jolt to the head or a penetrating head injury or neuro-trauma that disrupts the normal brain function, where continued impairment can be demonstrated. This term does not include brain dysfunction caused by congenital or degenerative disorders, birth trauma, or injuries caused by other circumstances. L.2022, c.78, s.2. 30:4D-7ll State plan amendments, waivers, brain injury services, application; implementation of provisions. 3. The Commissioner of Human Services shall apply for such State plan amendments or waivers specific to brain injury services, that currently exist or may arise in the future which affect reimbursement rates, 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.2022, c.78, s.3. 30:4D-7ll.1 Definitions. 1. As used in this act: "Division" mean the Division of Medical Assistance and Health Services in the Department of Human Services. "NJ FamilyCare" means the program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), which includes the State's Medicaid Program and the Children's Health Insurance Program. "Nursing facility" means a long-term care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.), which has been approved by the Department of Human Services to provide care to NJ FamilyCare beneficiaries who require conventional nursing facility services. "Special care nursing facility" means a nursing facility or a separate and distinct unit within a conventional nursing facility, licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.), which has been approved by the Department of Human Services to provide care to NJ FamilyCare beneficiaries who require specialized health care services beyond the scope of conventional nursing facility services. "Traumatic brain injury" means an acquired injury to the brain, but does not include brain dysfunction caused by congenital or degenerative disorders, or birth trauma, but may include brain injuries caused by anoxia due to trauma. "Traumatic brain injury unit" means an inpatient unit in special care nursing facility that provides services to NJ FamilyCare beneficiaries who require treatment for traumatic brain injuries. L.2023, c.181, s.1. 30:4D-7ll.2 Special care nursing facility, reimbursement, traumatic brain injury, NJ FamilyCare beneficiary. 2. The division shall reimburse a special care nursing facility for services provided to a NJ FamilyCare beneficiary residing in a traumatic brain injury unit at a base per diem reimbursement rate that is $400 above the special care nursing facility's FY 2022 base per diem reimbursement rate in order to cover the higher staffing ratios required, and abundance of therapy services provided, in a traumatic brain injury unit. Issuance of the reimbursement rate established in this section shall require the special care nursing facility to be in compliance with all applicable State and federal laws and regulations concerning licensure, patient safety, and quality of care. L.2023, c.181, s.2. 30:4D-7ll.3 Nursing facility, reimbursement, traumatic brain injury, NJ FamilyCare beneficiary, single-occupancy room. 3. a. The division shall reimburse a nursing facility for services provided to a NJ FamilyCare beneficiary residing in a single-occupancy room at an enhanced per diem reimbursement rate equal to 150 percent of the nursing facility's base per diem reimbursement rate, provided that, on any date after the effective date of this act, the nursing facility voluntarily delicensed beds in order to establish the single-occupancy room in which the beneficiary resides. b. Reimbursements received under this section by a nursing facility that are in excess of the facility's base per diem reimbursement rate shall be utilized by the facility for the following purposes: (1) renovation costs to convert multiple-occupancy rooms to single-occupancy rooms; (2) establishment and implementation of infection control policies and infrastructure, particularly for any remaining multiple-occupancy rooms; and (3) compensation for revenue losses due to the facility's decreased census. c. Issuance of the enhanced reimbursement per diem rate established in subsection a. of this section shall be contingent upon the following: (1) The nursing facility submits a proposed plan to, and receives approval from, the Department of Human Services and the Department of Health regarding the voluntary delicensing of beds. The plan shall include a description of the facility's use of reimbursement payments received under this section in excess of the facility's base rate; and (2) The nursing facility is in compliance with all applicable State and federal laws and regulations concerning licensure, patient safety, and quality of care. d. The Commissioners of Human Services and Health shall establish a method and manner for nursing facilities to submit plans, as required under paragraph (1) of subsection c. of this section. The evaluation of a nursing facility's plan shall include metrics for ensuring that the voluntary delicensing of beds at a nursing facility does not negatively affect the ability of the NJ FamilyCare program to provide nursing facility services to enrollees. L.2023, c.181, s.3. 30:4D-7ll.4 State plan amendments, waivers. 5. The Commissioner of Human Services shall apply for such State plan amendments or waivers as shall be necessary to implement the provisions of this act and to ensure federal financial participation for State expenditures under the federal Medicaid program and the Children's Health Insurance Program. L.2023, c.181, s.5. 30:4D-7mm Assisted living residences, comprehensive personal care homes, assisted living programs, reimbursement, Medicaid beneficiaries, minimum per diem rates; definitions. 1. a. Notwithstanding the provisions of any other law or regulation to the contrary, commencing upon the effective date of P.L.2023, c.80 (C.30:4D-7mm et seq.), assisted living residences, comprehensive personal care homes, and assisted living programs shall receive a per diem rate of no less than $89.50, $79.50, and $89.50, respectively, as reimbursement for each Medicaid beneficiary under the care of the residence, home, or program, as applicable. b. In addition to the minimum per diem rates established pursuant to subsection a. of this section, assisted living residences and comprehensive personal care homes shall receive an increased per diem rate based on the percentage of residents who are Medicaid beneficiaries. Rate increases for assisted living residences and comprehensive personal care homes shall be as follows: (1) in the case of an assisted living residence or comprehensive personal care home that is not a Medicaid partner community as described pursuant to subsection d. of this section, the following rate increases shall apply: (a) those assisted living residences and comprehensive personal care homes with a population of Medicaid beneficiaries that is at least 15 percent but less than 30 percent of the total resident population shall receive a per diem rate that is $10 higher than the minimum per diem rate established under subsection a. of this section; (b) those assisted living residences and comprehensive personal care homes with a population of Medicaid beneficiaries that is at least 30 percent but less than 50 percent of the total resident population shall receive a per diem rate that is $15 higher than the minimum per diem rate established under subsection a. of this section; (c) those assisted living residences and comprehensive personal care homes with a population of Medicaid beneficiaries that is at least 50 percent but less than 70 percent of the total resident population shall receive a per diem rate that is $30 higher than the minimum per diem rate established under subsection a. of this section; and (d) those assisted living residences and comprehensive personal care homes with a population of Medicaid beneficiaries that is at least 70 percent shall receive a per diem rate that is $35 higher than the minimum per diem rate established under subsection a. of this section. (2) in the case of an assisted living residence or comprehensive personal care home that is a Medicaid partner community as described pursuant to subsection d. of this section, a per diem rate that is $35 higher than the minimum per diem rate established under subsection a. of this section shall apply. c. For the purposes of subsection b. of this section, the population percentage of Medicaid beneficiaries at an assisted living residence or comprehensive personal care home shall be determined on a yearly basis using the average census of Medicaid beneficiaries at the assisted living residence or comprehensive personal care home during the measurement period, as determined by paid claims, measured against the total number of licensed beds approved for the assisted living residence or comprehensive personal care home by the Department of Health. d. For the purposes of applying the per diem rate established pursuant to paragraph (2) of subsection b. of this section, an assisted living residence or comprehensive personal care home shall be deemed to be a Medicaid partner community if the assisted living residence or comprehensive personal care home: (1) has participated in the NJ FamilyCare program for two or fewer cycles of the yearly rate measurement period described in subsection c. of this section or has submitted its first NJ FamilyCare claim within the preceding 18 months, whichever period is longer; (2) has provided NJ FamilyCare with a valid land use restriction agreement encumbering the applicable facility site, which land use restriction agreement limits the use of the facility to serving low-income residents such that 100 percent of residents are required to have an annual income that is below 80 percent of the area median income; (3) has not met the requirements in paragraphs (1) or (2) solely as the result of a name change or change of ownership; and (4) meets such other requirements as may be required by the Commissioner of Human Services. e. As used in this act: "Area median income" means the median income by household size for an applicable county as determined by the division. "Division" means the Division of Medical Assistance and Health Services in the Department of Human Services. "NJ FamilyCare" means the program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), which includes the State's Medicaid Program and the Children's Health Insurance Program. "Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). L.2023, c.80, s.1. 30:4D-7nn State plan amendments, waivers, provisions, implementation. 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.80, s.2. 30:4D-7oo Per diem reimbursement rate, pediatric medical day care services, on-site. 1. a. Notwithstanding any other provision of law or regulation to the contrary, the per diem reimbursement rate for pediatric medical day care services delivered by a pediatric medical day care provider offering on-site services shall be as follows: Beginning July 1, 2023, and annually adjusted in each subsequent fiscal year, the per diem reimbursement rate shall be equal to 45 percent of the average prevailing Medicaid fee-for-service per diem rate for all pediatric skilled care nursing facilities in the State. b. The provisions of this act shall apply to pediatric medical day care services provided under the Medicaid fee-for-service and managed care delivery systems. c. As used in this section, "Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "Pediatric medical day care services" means a health care service designed to meet the medical, developmental, educational, nutritional and psycho-social needs of medically complex or technology-dependent children whose medical condition requires treatment and services beyond the scope provided to children with special health care needs by day care centers or preschool programs. L.2023, c.85, s.1. 30:4D-7pp State plan amendments, waivers, provisions, implementation. 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.85, s.2. 30:4D-7qq Homemaker-home health aide certification program, family member; definition; report to Governor, Legislature. 1. a. As used in this section, "family member" means a child, parent, parent-in-law, sibling, grandparent, grandchild, spouse, domestic partner, or one partner in a civil union couple, or any other individual related by blood, and any other individual with a close association that is the equivalent of a family relationship. b. No later than nine months after the effective date of this act and receipt of federal approval for the program, the Division of Medical Assistance and Health Services in the Department of Human Services shall establish a program under which a family member of an enrollee in Medicaid or NJ FamilyCare may seek to be certified by the New Jersey Board of Nursing as a homemaker-home health aide and, after receiving that certification, may, under the direction of a registered nurse, provide homemaker-home health aide services to the enrollee through a home care services agency, provided that the enrollee is under 21 years of age and otherwise qualifies to receive those services under Medicaid or NJ FamilyCare. The division shall develop an assessment tool that will allow the division to readily identify enrollees who meet these eligibility criteria. c. The program established pursuant to this section shall require the family member to complete all the training, testing, and other qualification criteria as are required under State and federal law for certification as a homemaker-home health aide. The home care services agency that will employ the family member to provide homemaker-home health aide services to the enrollee shall pay all costs for the family member to become certified as a homemaker-home health aide, and to receive certification as a homemaker-home health aide from the New Jersey Board of Nursing, before providing services under the program established pursuant to this section. In no case shall a family member who becomes a certified homemaker-home health aide under the program established pursuant to this section be required to repay or reimburse the home care services agency for the costs of the family member becoming certified as a homemaker-home health aide under the program. d. The Director of the Division of Medical Assistance and Health Services in the Department of Human Services shall, no later than three years after the date the program is established pursuant to this section, prepare and submit a report to the Governor and, pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), to the Legislature, concerning the viability of the program and the director's recommendations concerning the program. L.2023, c.90, s.1. 30:4D-7rr State plan amendments, waivers, apply, Commissioner, Human Services. 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. L.2023, c.90, s.3. 30:4D-7ss Definitions. 1. a. As used in this section: "Division" means the Division of Medical Assistance and Health Services in the Department of Human Services. "Local education agency" means a public authority legally constituted by the State as an administrative agency to provide control of and direction for kindergarten through grade 12 public educational institutions. "Medicaid" means the program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). b. The division, or a managed care organization contracted with the division to provide benefits to Medicaid beneficiaries, shall reimburse a local education agency for behavioral health services covered under Medicaid, delivered in-person or via telehealth, and provided to a student who is an eligible Medicaid beneficiary. Services provided under this subsection shall be: (1) reimbursable by Medicaid regardless of the following: whether the student participates in an Individualized Education program, 504 Accommodation Plan, Individualized Health Care Plan, or Individualized Family Service Plan; or whether the covered services are provided at no charge to the student; and (2) provided by a licensed medical practitioner approved as a Medicaid provider or a local education agency approved as a Medicaid provider. c. Any local education agency claiming reimbursement under this section shall take all reasonable measures to ascertain and pursue any claims for reimbursement for services under this section against legally liable third parties in accordance with section 1902(a)(25) of the federal Social Security Act (42 U.S.C.s.1396a(a)(25)). If there is no response to a claim submitted by a local educational agency to a legally liable third party within 45 days, the local educational agency may bill Medicaid. The local educational agency shall retain a copy of the claim submitted to the legally liable third party for a period of three years. d. A local education agency shall utilize Medicaid reimbursement payments issued under this section to provide behavioral health services for students and their families. e. The provisions of this section shall not be construed to: (1) prohibit a Medicaid beneficiary from receiving behavioral health services covered under Medicaid from a Medicaid provider who is not a local education agency, provided that the services provided comply with all State and federal laws and regulations; and (2) require Medicaid reimbursement for behavioral health services covered under Medicaid provided to a Medicaid beneficiary by a local education agency in tandem with duplicative behavioral health services provided by another approved Medicaid provider located in the community to the same beneficiary, to the extent that State or federal law or regulation prohibit the provision of such duplicative services. f. The division, in conjunction with the Department of Education and the Department of the Treasury, shall assist a local education agency in implementing a plan to submit Medicaid claims for covered behavioral health services and obtain Medicaid reimbursements under this section. To the extent possible, this system shall overlap with the claims, reimbursement, and administrative procedures associated with the Special Education Medicaid Initiative as a means to streamline all school-based Medicaid claims, which system shall include the requirement for a local education agency to obtain parental or guardian consent prior to billing Medicaid for any service provided under this section. A local education agency may enter into an agreement with one or more other local education agencies in the State for the purposes of contracting with a third-party entity to process and submit Medicaid claims for covered behavioral health services provided under this section. L.2023, c.108, s.1. 30:4D-7tt State plan amendments, waivers, application, implementation, secure 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. L.2023, c.108, s.2. 30:4D-7uu Findings, declarations. 1. The Legislature finds and declares that: a. To address the increasingly high cost of prescription drug utilization and to address patient safety, health insurance carriers and other plan sponsors use step therapy protocols that require patients to try one or more prescription drugs before coverage is provided for a drug selected by the patient's health care provider. b. Step therapy protocols, if based on well-developed scientific standards and administered in a flexible manner that takes into account the individual needs of patients, can play an important role in controlling health care costs. c. Requiring a patient to follow a step therapy protocol may have adverse and even dangerous consequences for the patient, who may either not realize a benefit from taking a prescription drug or may suffer harm from taking an inappropriate drug. d. It is imperative that step therapy protocols in the State preserve the heath care provider's right to make medically necessary treatment decisions in the best interest of the patient. e. The Legislature declares, therefore, that it is a matter of public interest that the State Health Benefits Program, the School Employers Health Benefits Program, and NJ FamilyCare be required to base step therapy protocols on appropriate clinical practice guidelines or published peer-reviewed data developed by independent experts with knowledge of the condition or conditions under consideration; that patients be exempt from step therapy protocols when those protocols are inappropriate or otherwise not in the best interest of the patients; and that patients have access to a fair, transparent, and independent process for requesting an exception to a step therapy protocol when the patient's physician deems appropriate. L.2025, c.50, s.1. 30:4D-7vv Definitions. 2. As used in sections 2 through 6 of this act: "Division" means the Division of Medical Assistance and Health Services in the Department of Human Services. "Health care provider" means an individual or entity which, acting within the scope of its licensure or certification, provides a covered service. Health care provider includes, but is not limited to, a physician and other health care professionals licensed pursuant to Title 45 of the Revised Statutes and a hospital and other health care facilities licensed pursuant to Title 26 of the Revised Statutes. "Managed care organization" means a health maintenance organization contracted with the division to provide benefits to Medicaid beneficiaries. "Medicaid" means the program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "Medical necessity" or "medically necessary" means the same as those terms are defined in section 4 of P.L.2023, c.296 (C.17B:30-55.3). "Step therapy exception" means the overriding of a step therapy protocol in favor of immediate coverage of the health care provider's selected prescription drug. "Step therapy protocol" means a protocol, policy, or program that establishes the specific sequence in which prescription drugs for a specified medical condition, and medically appropriate for a particular patient, are required to be administered in order to be covered by the division or a managed care organization. L.2025, c.50, s.2. 30:4D-7ww Clinical review criteria, guidelines, step therapy protocol, Medicaid. 3. a. The division or a managed care organization shall require that clinical review criteria used to establish a step therapy protocol under Medicaid are based on clinical practice guidelines developed by the division or a managed care organization that: (1) recommend that the prescription drugs be taken in the specific sequence required by the step therapy protocol; (2) are developed and endorsed by a multidisciplinary panel of experts that: (a) relies on objective data; and (b) manages conflicts of interest among the members by requiring members to disclose any potential conflict of interests with entities, including managed care organizations, carriers, and pharmaceutical manufacturers and recuse themselves from voting if they have a conflict of interest; (3) are based on high-quality studies, research, and medical practice; (4) are created by an explicit and transparent process that: (a) minimizes biases and conflicts of interest; (b) explains the relationship between treatment options and outcomes; (c) rates the quality of the evidence supporting recommendations; and (d) considers relevant patient subgroups and preferences; and (5) are reviewed annually or quarterly if there is a new indication or new clinical information available and updated when such review reveals new evidence necessitating modification. b. In the absence of clinical guidelines that meet the requirements in subsection a. of this section, peer-reviewed publications may be substituted. c. When establishing a step therapy protocol, the division or managed care organization shall also consider the needs of atypical patient populations and diagnoses when establishing clinical review criteria. d. A managed care organization shall: (1) upon written request, provide written clinical review criteria relating to a particular condition or disease, including clinical review criteria relating to a step therapy protocol exception determination; and (2) make available the clinical review criteria and other clinical information on its Internet website and to a health care professional on behalf of an insured person upon written request. e. This section shall not be construed to require managed care organizations or the State to establish a new entity to develop clinical review criteria used for step therapy protocols. L.2025, c.50, s.3. 30:4D-7xx Prescription drug coverage restriction, step therapy protocol, exception process, managed care organization. 4. Notwithstanding the provisions of any law, rule, or regulation to the contrary: a. When coverage of a prescription drug for the treatment of any medical condition is restricted for use by a managed care organization pursuant to a step therapy protocol, the managed care organization shall provide the enrollee and prescribing practitioner a clear, readily accessible, and convenient process to request a step therapy exception. A managed care organization may use its existing medical exceptions process to satisfy this requirement. An explanation of the process shall be made available on the managed care organization's website. A managed care organization shall disclose all rules and criteria related to the step therapy protocol upon request to all prescribing practitioners, including the specific information and documentation required to be submitted by a prescribing practitioner or patient for an exception request to be complete. b. A step therapy exception shall be granted if the prescribing health care provider determines that: (1) the required prescription drug is contraindicated or is likely to cause an adverse reaction or physical or mental harm to the patient; (2) the required prescription drug is expected to be ineffective or less effective than an alternative based on the known clinical characteristics of the patient and the known characteristics of the prescription drug regimen; or (3) all formulary drugs used to treat each disease state have been ineffective or less effective than an alternative in the treatment of the enrollee's disease or condition or all such drugs have caused or are reasonably expected to cause adverse or harmful reactions in the enrollee. If requested by a managed care organization, the prescribing health care provider shall provide documentation to support the determinations made by the provider pursuant to paragraphs (1) through (3) of this subsection. c. When a step therapy exception is granted, the managed care organization shall authorize coverage for the prescription drug prescribed by the patient's treating health care provider at least 180 days or the duration of therapy if less than 180 days, provided that the prescription drug is covered under the managed care organization's formulary. d. Any step therapy exception shall be eligible for appeal by an enrollee. The managed care organization shall grant or deny a step therapy exception request or an appeal of a step therapy exception request within a time frame appropriate to the medical exigencies of the case, but no later than 24 hours for urgent requests and 72 hours for non-urgent requests after obtaining all necessary information to make the approval or adverse determination. e. Any step therapy exception pursuant to this section shall be eligible for appeal by an enrollee. f. This section shall not be construed to prevent: (1) a managed care organization from requiring a patient to try an AB-rated generic equivalent, biosimilar, or interchangeable biological product prior to providing coverage for the equivalent branded prescription drug; (2) a managed care organization from requiring a pharmacist to effect substitutions of prescription drugs consistent with the laws of this State; or (3) a health care provider from prescribing a prescription drug that is determined to be medically appropriate. L.2025, c.50, s.4. 30:4D-7yy Statistics made available, step therapy exception request approvals, denials, managed care organization. 5. A managed care organization shall make statistics available regarding step therapy exception request approvals and denials on its Internet website in a readily accessible format, as determined by the Commissioner of Human Services, or the commissioner's designee. The commissioner shall determine by regulation the statistics and format of the statistics that are made available. L.2025, c.50, s.5. 30:4D-7zz State plan amendments, waivers, apply as necessary for implementation, step therapy. 6. 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 secure federal financial participation for State Medicaid expenditures under the federal Medicaid program. Prior to the implementation of this act, the Commissioner of Human Services shall provide a separate rate certification for this program and benefit change within the acute care and managed long-term services and supports programs in compliance with federal standards, including, but not limited to, 42 C.F.R. 438.4. Implementation of this program and benefit change during the course of a state fiscal year shall require a mid-year managed care rate adjustment for the acute care and managed long term services and supports program. L.2025, c.50, s.6. 30:4D-7aaa NJ FamilyCare reimbursement rates for certain special care nursing facilities. 1. a. Beginning January 1, 2024, the division shall reimburse a special care nursing facility, issued a certificate of need by the Department of Health as of July 1, 2023 to operate a neurologically impaired young adult unit, a base NJ FamilyCare per diem reimbursement rate that is, at a minimum, the greater of the special care nursing facility�s FY 2022 base per diem reimbursement rate or $1,100 per diem. The provision of the reimbursement rate established in this section will be contingent upon the special care nursing facility�s compliance with all applicable State and federal laws and regulations concerning licensure, patient safety, and quality of care. b. As used in this section: �Division� means the Division of Medical Assistance and Health Services in the Department of Human Services. �NJ FamilyCare� means the program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), which includes the State�s Medicaid Program and the Children�s Health Insurance Program. �Special care nursing facility� means a nursing facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) that is not a unit attached to, or on the same campus as, a rehabilitation or acute care hospital and is not a distinct unit within a NJ FamilyCare-certified conventional nursing facility, and which has been approved by the Department of Human Services to provide care to NJ FamilyCare recipients who require specialized nursing facility services beyond the scope of a conventional nursing facility. L.2025, c.206, s.1. 30:4D-7bbb Application for State plan amendments, waivers as necessary. 3. The Commissioner of Human Services shall apply for such State plan amendments or waivers as shall be necessary to implement the provisions of this act and to ensure federal financial participation for State expenditures under the federal Medicaid program and the Children�s Health Insurance Program. L.2025, c.206, s.3.

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This is the verbatim text of N.J.S.A. 30:4D-7, 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.