Requires Medicaid and NJ FamilyCare managed care organizations to offer patient-centered medical home model or other alternative payment model to primary care providers.

A2150

ASSEMBLY, No. 2150

STATE OF NEW JERSEY

222nd LEGISLATURE

�

PRE-FILED FOR INTRODUCTION IN THE 2026 SESSION

Sponsored by:

Assemblywoman ELIANA PINTOR MARIN

District 29 (Essex and Hudson)

Assemblywoman VERLINA REYNOLDS-JACKSON

District 15 (Hunterdon and Mercer)

SYNOPSIS

���� Requires Medicaid and NJ FamilyCare managed care
organizations to offer patient-centered medical home model or other alternative
payment model to primary care providers.

CURRENT VERSION OF TEXT

���� Introduced Pending Technical Review by Legislative
Counsel.

��

An Act
concerning patient-centered medical homes and
supplementing Title 30 of the Revised Statutes.

����
Be It
Enacted
by the Senate and General Assembly of
the State of New Jersey:

���� 1.��� As used in this act:

���� �Alternative payment model�
means a payment approach that gives providers financial incentives to deliver
high-quality and cost-efficient care and may apply to a specific clinical
condition, care episode, or population.

���� "Department" means
the Department of Human Services.

���� �Division� means the Division
of Medical Assistance and Health Services in the Department of Human Services.

���� "Managed care
organization" means a Medicaid managed care organization, as that term is
defined pursuant to 42 U.S.C. s.1396b(m)(1)(A).

���� "Patient-centered medical
home model" means a type of alternative payment model that supports a
clinical model of team-based health care, led by a health care provider,� to
provide comprehensive, person-centered, and continuous medical care to patients
in order to achieve maximal health outcomes.

���� �Primary care provider� means a
licensed medical doctor, doctor of osteopathy, or a licensed medical
practitioner who, within the scope of practice and in accordance with State
certification or licensure requirements, standards, and practices, is
responsible for maintaining continuity of patient care and providing all
required primary care services to enrollees, including periodic examinations,
preventive health care and counseling, immunizations, diagnosis, and treatment
of illness or injury, coordination of overall medical care, record maintenance,
and initiation of referrals to specialty providers. A primary care provider
shall include general or family practitioners, pediatricians, internists, and
shall include specialist physicians, physician assistants, certified nurse
midwives, certified nurse practitioners, or clinical nurse specialists,
provided that the practitioner carries out all primary care provider
responsibilities in accordance with licensure requirements.

���� 2.���
A
managed care organization that provides benefits to persons who are eligible
for Medicaid under P.L.1968, c.413 (C.30:4D-1 et seq.) or NJ FamilyCare under P.L.2005,
c.156 (C.30:4J-8 et al.) shall offer a patient-centered medical home model to
primary care providers in the managed care organization�s network
.� The
division, in its sole discretion, may waive the requirements of this section if
a managed care organization can demonstrate that the managed care organization
offers an alternative payment model to primary care providers that is not a
patient-centered medical home model but that similarly incentivizes high
quality, efficient, and holistic care.

���� 3.��� a.� A managed care
organization shall submit annually to the division a description of the managed
care organization�s patient-centered medical home model or, if waived by the
division to offer a patient-centered medical home model, the other alternative
payment model offered to primary care providers, which description shall
include, but not be limited to:

���� (1)� the basic financial
structure of the� model, which shall include incentive or population management
payments which may be available to providers participating in the �model;

���� (2)� whether participating
providers are required to obtain any certifications to participate in the�
model;

���� (3)� quality or other
performance metrics which affect provider payment under the alternative payment
model;

���� (4)� the requirements for a
provider to be eligible to participate in the� model, including but not limited
to the number of unique patients seen by a provider or past quality
performance;

���� (5)� whether the �model
qualifies as an �Other Payer Advanced APM� as defined in 42 CFR 414.1305;

���� (6)� a list of all providers
participating in the� model; and

���� (7)� the number of enrollees
provided services by� providers participating in the model, listed by county.

���� b.��� The managed care
organization shall make the description required pursuant to subsection a. of
this section available to the public on the managed care organization�s
Internet website, after division approval. The division may also post such
descriptions on its Internet website.

���� c.��� The division may, in its
discretion, establish a standardized format for managed care organizations to
use in providing the description required pursuant to subsection a. of this
section.

���� d.��� The division may, in its
discretion, extend the requirements of subsection a. of this section to any
other alternative payment models, which are targeted toward non-primary care
provider categories, offered by a managed care organization that contracts to
provide benefits to persons eligible for Medicaid or NJ FamilyCare.

���� 4.��� a.�
Notwithstanding the provisions of the "Administrative Procedure Act,"
P.L.1968, c.410 (C.52:14B-1 et seq.) or any other law to the contrary, the
division
shall establish standardized quality metrics for patient-centered
medical home models and other alternative payment models offered to primary
care providers in accordance with this section.

���� b.� The division shall
develop, through a public stakeholder process, standardized quality metrics for
patient-centered medical home models and other alternative payment models
offered to primary care providers and request public comment on such�
standardized quality metrics.

���� c���� Following the public
comment period, and periodically thereafter, the division shall identify a list
of standardized quality metrics and shall mandate that managed care
organizations utilize only those standardized quality metrics when determining
or calculating payments to providers under the managed care organization�s
patient-centered medical home model or other alternative payment offered to
primary care providers. �To the extent practicable, the standardized quality
metrics shall promote alignment with other non-Medicaid payers.

���� d.��� Nothing in this act
shall be construed as precluding the division from imposing additional
requirements on managed care organizations that relate to patient-center
medical home models or other alternative payment models offered to primary care
providers.

���� 5.��� The division shall
specify a format and methodology through which managed care organizations shall
submit patient-level data and provider-level data on participation and
performance in a patient-centered medical home model or other alternative
payment model in order to facilitate the division�s evaluation of the
performance of such patient-centered medical home models and alternative
payment models offered to primary care providers.

���� 6.��� The Commissioner of
Human Services and the Commissioner of Banking and Insurance may jointly waive
any provision of P.L.1999, c.409 (C.17:48H-1 et seq.) to the extent necessary
to support provider participation in Medicaid patient-care medical home models
or any other Medicaid alternative payment models.� Such waivers shall be
granted, in writing, by both commissioners and shall only be issued if the
Commissioner of Human Services and the Commissioner of Banking and Insurance
jointly determine, in their sole discretion, that any risk of adverse
consequences to the public are minimal.

���� 7.��� The Commissioner of
Human Services shall apply for such waivers, federal approvals, or state plan
amendments 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.

���� 8.��� This act shall take
effect one year following the date of enactment provided that approval of any
waivers, federal approvals, or state plan amendments has been received prior to
that date, otherwise the effective date of this act is delayed until such
approvals are received. The Commissioner of Human Services may take such
anticipatory administrative action in advance thereof as shall be necessary for
the implementation of this act.

STATEMENT

���� This bill requires Medicaid
and NJ FamilyCare beneficiaries managed care organizations to offer
patient-centered medical home models or other alternative payment models to
primary care providers.� As defined under the bill, a �patient-centered medical
home model� means a type of alternative payment model that supports a clinical
model of team-based health care, led by a health care provider, to provide
comprehensive, person-centered, and continuous medical care to patients in
order to achieve maximal health outcomes.� An �alternative payment model� means
a payment approach that gives providers financial incentives to deliver
high-quality and cost-efficient care and may apply to a specific clinical
condition, care episode, or population.

���� Under the bill, a managed care
organization that provides benefits to persons who are eligible for Medicaid
under P.L.1968, c.413 (C.30:4D-1 et seq.) or NJ FamilyCare under P.L.2005,
c.156 (C.30:4J-8 et al.) is to offer a patient-centered medical home model to
primary care providers in the managed care organization�s network.� The
Division of Medical Assistance and Health Services in the Department of Human
Services (division), in its sole discretion, may waive this requirement if a
managed care organization can demonstrate that the managed care organization
offers an alternative payment model to primary care providers that is not a
patient-centered medical home model but that similarly incentivizes high
quality, efficient, and holistic care.

���� The bill provides that a managed
care organization is to submit annually to the division a description of the
managed care organization�s patient-centered medical home model or, if waived
by the division to offer a patient-centered medical home model, the �other
alternative payment model offered to primary care providers, which description
is to include, but not be limited to: 1) the basic financial structure of the�
model, which is to include incentive or population management payments which
may be available to providers participating in the �model; 2) whether
participating providers are required to obtain any certifications to
participate in the� model; 3) quality or other performance metrics which affect
provider payment under the� model; 4) the requirements for a provider to be
eligible to participate in the� model, including but not limited to the number
of unique patients seen by a provider or past quality performance; 5) whether
the �model qualifies as an �Other Payer Advanced APM� as defined in 42 CFR
414.1305; 6) a list of all providers participating in the� model; and 7) the
number of enrollees provided services by� providers participating in the model,
listed by county.

���� Under the bill, the division
is to establish standardized quality metrics for patient-centered medical home
models and other alternative payment models offered to primary care providers.�
The division is to develop, through a public stakeholder process, standardized
quality metrics for patient-centered medical home models and other alternative
payment models offered to primary care providers and request public comment on
such standardized quality metrics.� Following the public comment period, and
periodically thereafter, the division is to identify a list of standardized
quality metrics and is to mandate that managed care organizations utilize only
those standardized quality metrics when determining or calculating payments to
providers under the managed care organization�s patient-centered medical home
model or other alternative payment offered to primary care providers. �To the
extent practicable, the standardized quality metrics are to promote alignment
with other non-Medicaid payers.

���� The bill provides that the
division is to specify a format and methodology through which managed care
organizations are to submit patient-level and provider-level data on
participation and performance in a patient-centered medical home model or other
alternative payment model in order to facilitate the division�s evaluation of
the performance of such patient-centered medical home models and alternative
payment models offered to primary care providers.