"Healthy Smiles Act"; increases NJ FamilyCare fee-for-service reimbursement rates for pediatric dental services; requires NJ FamilyCare managed care rates for identical services be no less than fee-for-service rates.

A2229

ASSEMBLY, No. 2229

STATE OF NEW JERSEY

222nd LEGISLATURE

�

PRE-FILED FOR INTRODUCTION IN THE 2026 SESSION

Sponsored by:

Assemblywoman SHANIQUE SPEIGHT

District 29 (Essex and Hudson)

Assemblywoman CARMEN THERESA MORALES

District 34 (Essex)

Assemblywoman SHAMA A. HAIDER

District 37 (Bergen)

Co-Sponsored by:

Assemblywomen Dunn, Reynolds-Jackson and Park

SYNOPSIS

���� "Healthy Smiles Act"; increases NJ
FamilyCare fee-for-service reimbursement rates for pediatric dental services;
requires NJ FamilyCare managed care rates for identical services be no less
than fee-for-service rates.

CURRENT VERSION OF TEXT

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

��

An Act

concerning NJ FamilyCare reimbursement rates for
pediatric dental services and supplies, and supplementing Title 30 of the
Revised Statutes.

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

���� 1.��� This act shall be known
and may be cited as the �Healthy Smiles Act.�

���� 2.��� The Legislature finds
and declares that:

���� a.����
Oral health is a key
indicator of overall health, well-being, and quality of life
, and proper oral hygiene requires regular
visits with a dentist as well as good oral health hygiene at home.

���� b.��� According to the American Academy of Pediatrics,
the American Dental Association, the Centers for Disease Control, and many
other scientific and medical institutions and experts, it is critical to begin
oral health services at the age of one or when the teeth begin to erupt.

���� c.���� Because of the importance of early dental care,
the NJ FamilyCare program includes regular dental care services and requires
managed care organizations to assist in connecting each covered child to a
dental home for a regular source of oral health services by the age of one.

���� d.��� Overall, New Jersey children have poorer dental
health compared to children across the United States.

���� (1) New Jersey children have higher rates of untreated
tooth decay, with 36 percent of third-graders experiencing tooth decay compared
to the national average of 20 percent for the same age group.

���� (2) Low-income children fare even worse, with 24 percent
of New Jersey�s Head Start children experiencing untreated tooth decay,
compared to 12 percent nationwide.

���� (3) Disparities in dental health are also evident across
race, with Black/African-American and Hispanic/Latinx children experiencing a
higher prevalence of untreated tooth decay than their White, non-Hispanic
counterparts.

���� e.���� In
addition to physical health concerns, tooth loss can take a
heavy
psychological
toll o
n individuals, causing them to feel less confident, more
inhibited, and self-conscious about their appearance.

���� f.���� Despite the importance
of oral health, low NJ FamilyCare reimbursement rates to providers of oral
health services and supplies
presents
barriers to dental care for the 20 percent of New Jersey�s population enrolled
in this health insurance program.� Based on a national survey from 2020 by the
American Dental Association, the NJ FamilyCare fee-for-service reimbursement
rates for children are in the bottom 10 percent of the reimbursement rates paid
in the country for dental services.� These fee-for-service rates for children
have not been comprehensively changed since 2007.

����
g.��� Low
NJ FamilyCare reimbursement rates can significantly limit access to dental care
for enrollees by reducing provider participation in the program, causing delays
in securing appointments for recommended check-ups and for emergent concerns,
and diminishing the quality of care delivered by network providers.�

���� h.��� It is fitting and appropriate for the Legislature
to address these long-standing issues before more children suffer from tooth
decay and its serious consequences due to their inability to find dentists
participating in NJ FamilyCare.� Therefore, it is necessary for the Legislature
to increase
NJ FamilyCare reimbursement rates to providers of pediatric oral
health services and supplies in order to ensure that the State�s most
vulnerable residents can obtain the clinical care required to support proper
oral hygiene and health.�

���� 3.��� As used in this act:

���� �Commissioner� means the
Commissioner of Human Services.

���� �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 Children�s Health Insurance Program and the
Medicaid Program
.

���� �Provider� means an individual
or entity who, acting within the scope of its licensure pursuant to Title 45 of
the Revised Statutes, renders oral health services and supplies to persons
covered by NJ FamilyCare.� �Provider� shall include a dentist, physician, or
other health care professional licensed pursuant to Title 45 of the Revised
Statutes acting within the scope of their licensure.� �Provider� shall not
include a dental service corporation, dental provider organization, organized
delivery system, third party administrator, or similar entity.

���� 4.��� a.� Commencing upon July
1, 2025 or 60 days following the enactment of this act, whichever is later, the
NJ FamilyCare fee-for-service reimbursement rates for covered oral health
services and supplies for children under 21 years of age paid to a provider
shall be increased by 20 percent from the NJ FamilyCare fee-for-service reimbursement
rates in use upon the effective date of the this act for identical oral health
services and supplies.

��

���� b.��� Commencing one year
after the effective date of subsection a. of this section, and annually
thereafter, the commissioner shall adjust the existing NJ FamilyCare fee-for-service
reimbursement rates for covered oral health services and supplies for children
under 21 years of age
in direct
proportion to any increase or decrease in the Consumer Price Index for All
Urban Consumers as published by the United States Department of Labor
for the Northeast region of the country in the previous
January over the immediately preceding 12-month period
.

���� 5.��� a.� The commissioner
shall ensure that every contract entered into on and after the effective date
of this act between the division and a managed care organization for the
provision of health care services under NJ FamilyCare, including oral health
services and supplies, provides that the reimbursement rates paid to a provider
shall be equal to or greater than the NJ FamilyCare fee-for-service reimbursement
rates for the identical oral health services and supplies for children under 21
years of age.

���� b.��� A managed care
organization that pays a reimbursement rate to a provider in violation of
subsection a. of this section shall be liable for a civil penalty of not more
than $10,000 for each day that the non-compliant reimbursement rate was
issued.� Any penalties assessed under this section shall be collected by the
commissioner in the name of the State in a summary proceeding in accordance
with the �Penalty Enforcement Law of 1999,� P.L. 1999, c. 274 (C.2A:58-10 et
seq.).� The commissioner�s determination of a violation pursuant to this
section shall be a final agency decision, subject to review by the Appellate
Division of the Superior Court.

����
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 NJ
FamilyCare expenditures under the federal Medicaid Program and Children�s
Health Insurance Program.

����
7.��� The Commissioner of Human Services, pursuant to the
"Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.),
shall adopt rules and regulations necessary to implement the provisions of this
act.

���� 8.��� The act shall take
effect immediately.

STATEMENT

���� This bill makes certain
adjustments to the NJ FamilyCare reimbursement rates for oral health services
and supplies.� The bill requires that, commencing upon July 1, 2025 or 60 days
following the enactment of this bill, whichever is later, the NJ FamilyCare
fee-for-service reimbursement rates for covered pediatric oral health services
and supplies will be increased by 20 percent from the reimbursement rates in
use for identical services at the time of the bill�s adoption.

���� Commencing one year after the
implementation of the increased reimbursement rates, and annually thereafter,
the bill directs the Commissioner of Human Services (commissioner) to adjust
the existing fee-for-service reimbursement rates according to changes in
the Consumer Price Index (CPI) for All
Urban Consumers as published by the United States Department of Labor
for the Northeast region of the country in the previous
January over the immediately preceding 12-month period
.� For reference, in November 2024, the most recent time this data was
assessed over a 12-month period, the CPI increased by 3.5 percent.

���� Finally, the commissioner is
required to ensure that every contract entered into on and after the effective
date of this bill between the State and a managed care organization (MCO) for
the provision of NJ FamilyCare services provides that the reimbursement rates for
pediatric oral health services and supplies are equal to or greater than the NJ
FamilyCare fee-for-service reimbursement rates for the identical services and
supplies.

���� Under the bill, an MCO in
violation of this provision would be liable for a civil penalty of not more
than $10,000 for each day that the non-compliant reimbursement rate was
issued.� Any penalties assessed are to be collected by the commissioner in the
name of the State in a summary proceeding in accordance with State law.� The
commissioner�s determination regarding violations is the final agency decision,
subject to review by the Appellate Division of the Superior Court.