Requires Medicaid reimbursement of mental health rehabilitation services provided via clubhouse program.

A2266

ASSEMBLY, No. 2266

STATE OF NEW JERSEY

222nd LEGISLATURE

�

PRE-FILED FOR INTRODUCTION IN THE 2026 SESSION

Sponsored by:

Assemblywoman MARGIE DONLON, M.D.

District 11 (Monmouth)

Assemblywoman LUANNE M. PETERPAUL

District 11 (Monmouth)

SYNOPSIS

���� Requires Medicaid reimbursement of mental health
rehabilitation services provided via clubhouse program.

CURRENT VERSION OF TEXT

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

��

An Act
concerning Medicaid reimbursement for clubhouse mental
health rehabilitation services and amending
P.L.1968, c.413.

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

���� 1.� Section 6 of P.L.1968,
c.413 (c.30:4D-6) is amended to read as follows:

�����
6.� a.� Subject to the
requirements of Title XIX of the federal Social Security Act, the limitations
imposed by this act and by the rules and regulations promulgated pursuant
thereto, the department shall provide medical assistance to qualified applicants,
including authorized services within each of the following classifications:

���� (1)� Inpatient hospital
services

���� (2)� Outpatient hospital
services;

���� (3)� Other laboratory and
X-ray services;

���� (4)� (a)� Skilled nursing or
intermediate care facility services;

���� (b)� Early and periodic
screening and diagnosis of individuals who are eligible under the program and
are under age 21, to ascertain their physical or mental health status and the
health care, treatment, and other measures to correct or ameliorate defects and
chronic conditions discovered thereby, as may be provided in regulation of the
Secretary of the federal Department of Health and Human Services and approved
by the commissioner;

���� (5)� Physician's services
furnished in the office, the patient's home, a hospital, a skilled nursing, or
intermediate care facility or elsewhere.

���� As used in this subsection,
"laboratory and X-ray services" includes HIV drug resistance testing,
including, but not limited to, genotype assays that have been cleared or
approved by the federal Food and Drug Administration, laboratory developed
genotype assays, phenotype assays, and other assays using phenotype prediction
with genotype comparison, for persons diagnosed with HIV infection or AIDS.

���� b.� Subject to the limitations
imposed by federal law, by this act, and by the rules and regulations
promulgated pursuant thereto, the medical assistance program may be expanded to
include authorized services within each of the following classifications:

���� (1)� Medical care not included
in subsection a.(5) above, or any other type of remedial care recognized under
State law, furnished by licensed practitioners within the scope of their
practice, as defined by State law;

���� (2)� Home health care
services;

���� (3)� Clinic services;

���� (4)� Dental services;

���� (5)� Physical therapy and
related services;

���� (6)� Prescribed drugs,
dentures, and prosthetic devices; and eyeglasses prescribed by a physician
skilled in diseases of the eye or by an optometrist, whichever the individual
may select;

���� (7)� Optometric services;

���� (8)� Podiatric services;

���� (9)� Chiropractic services;

���� (10)� Psychological services;

���� (11)� Inpatient psychiatric
hospital services for individuals under 21 years of age, or under age 22 if
they are receiving such services immediately before attaining age 21;

���� (12)� Other diagnostic,
screening, preventative, and rehabilitative services, and other remedial care;

���� (13)� Inpatient hospital
services, nursing facility services, and immediate care facility services for
individuals 65 years of age or over in an institution for mental diseases;

���� (14)� Intermediate care
facility services;

���� (15)� Transportation services;

���� (16)� Services in connection
with the inpatient or outpatient treatment or care of substance use disorder,
when the treatment is prescribed by a physician and provided in a licensed
hospital or in a narcotic and substance use disorder treatment center approved
by the Department of Health pursuant to P.L.1970, c.334 (C.26:2G-21 et. seq.)
and whose staff includes a medical director, and limited those services
eligible for federal financial participation under Title XIX of the federal
Social Security Act;

���� (17)� Any other medical care
and any other type of remedial care recognized under State law, specified by
the Secretary of the federal Department of Health and Human Services, and
approved by the commissioner;

���� (18)� Comprehensive maternity
care, which may include: the basic number of prenatal and postpartum visits
recommended by the American College of Obstetrics and Gynecology; additional
prenatal and postpartum visits that are medically necessary; necessary laboratory,
nutritional assessment and counseling, health education, personal counseling,
managed care, outreach, and follow-up services; treatment of conditions which
may complicate pregnancy doula care; and physician or certified nurse midwife
delivery services.� For the purposes of this paragraph, "doula" means
a trained professional who provides continuous physical, emotional, and
informational support to a mother before, during, and shortly after childbirth,
to help her to achieve the healthiest, most satisfying experience possible;

���� (19)� Comprehensive pediatric
care, which may include: ambulatory, preventive, and primary care health
services.� The preventive services shall include, at a minimum, the basic
number of preventive visits recommended by the American Academy of Pediatrics;

���� (20)� Services provided by a
hospice which is participating in the Medicare program established pursuant to
Title XVIII of the Social Security Act, Pub.L.89-97 (42 U.S.C. s.1395 et
seq.).� Hospice services shall be provided subject to approval of the Secretary
of the federal Department of Health and Human Services for federal
reimbursement;

���� (21)� Mammograms, subject to
approval of the Secretary of the federal Department of Health and Human
Services for federal reimbursement, including one baseline mammogram for women
who are at least 35 but less than 40 years of age; one mammogram examination
every two years or more frequently, if recommended by a physician, for women
who are at least 40 but less than 50 years of age; and one mammogram
examination every year for women age 50 and over;

���� (22)� Upon referral by a
physician, advanced practice nurse, or physician assistant of a person who has
been diagnosed with diabetes, gestational diabetes, or pre-diabetes, in
accordance with standards adopted by the American Diabetes Association:

���� (a)� Expenses for diabetes
self-management education or training to ensure that a person with diabetes,
gestational diabetes, or pre-diabetes can optimize metabolic control, prevent
and manage complications, and maximize quality of life.� Diabetes self-management
education shall be provided by an in-State provider who is:

���� (i)� a licensed, registered,
or certified health care professional who is certified by the National
Certification Board of Diabetes Educators as a Certified Diabetes Educator, or
certified by the American Association of Diabetes Educators with a Board Certified-Advanced
Diabetes Management credential, including, but not limited to: a physician, an
advanced practice or registered nurse, a physician assistant, a pharmacist, a
chiropractor, a dietitian registered by a nationally recognized professional
association of dietitians, or a nutritionist holding a certified nutritionist
specialist (CNS) credential from the Board for Certification of Nutrition
Specialists; or

���� (ii)� an entity meeting the
National Standards for Diabetes Self-Management Education and Support, as
evidenced by a recognition by the American Diabetes Association or
accreditation by the American Association of Diabetes Educators;

���� (b)� Expenses for medical
nutrition therapy as an effective component of the person's overall treatment
plan upon a: diagnosis of diabetes, gestational diabetes, or pre-diabetes;
change in the beneficiary's medical condition, treatment, or diagnosis; or determination
of a physician, advanced practice nurse, or physician assistant that
reeducation or refresher education is necessary.� Medical nutrition therapy
shall be provided by an in-State provider who is a dietitian registered by a
nationally-recognized professional association of dietitians, or a nutritionist
holding a certified nutritionist specialist (CNS) credential from the Board for
Certification of Nutrition Specialists, who is familiar with the components of
diabetes medical nutrition therapy;

���� (c)� For a person diagnosed
with pre-diabetes, items and services furnished under an in-State diabetes
prevention program that meets the standards of the National Diabetes Prevention
Program, as established by the federal Centers for Disease Control and Prevention;
and

���� (d)� Expenses for any
medically appropriate and necessary supplies and equipment recommended or
prescribed by a physician, advanced practice nurse, or physician assistant for
the management and treatment of diabetes, gestational diabetes, or pre-diabetes,
including, but not limited to: equipment and supplies for self-management of
blood glucose; insulin pens; insulin pumps and related supplies; and other
insulin delivery devices;

���� (23)� Expenses incurred for
the provision of group prenatal services to a pregnant woman, provided that:

���� (a)� the provider of such
services, which shall include, but not be limited to, a federally qualified
health center or a community health center operating in the State:

���� (i) is a site accredited by
the Centering Healthcare Institute, or is a site engaged in an active
implementation contract with the Centering Healthcare institute, that utilizes
the Centering Pregnancy model; and

���� (ii)� incorporates the
applicable information outlined in any best practices manual for prenatal and
postpartum maternal care developed by the Department of Health into the
curriculum for each group prenatal visit;

���� (b)� each group prenatal care
visit is at least 1.5 hours in duration, with a. minimum of two women and a
maximum of 20 women in participation; and

���� (c)� no more than 10 group
prenatal care visits occur per pregnancy.� As used in this paragraph,
"group prenatal care services" means a series of prenatal care visits
provided in a group setting which are based upon the Centering Pregnancy model
developed by the Centering Healthcare Institute and which include health
assessments, social and clinical support, and educational activities;

���� (24)� Expenses incurred for
the provision of pasteurized donated human breast milk, which shall include
human milk fortifiers if indicated in a medical order provided by a licensed
medical practitioner, to an infant under the age of six months; provided that
the milk is obtained from a human milk bank that meets quality guidelines
established by the Department of Health and a licensed medical practitioner has
issued a medical order for the infant under at least one of the following
circumstances:

���� (a)� the infant is medically
or physically unable to receive maternal breast milk or participate in breast
feeding, or the infant's mother is medically or physically unable to produce
maternal breast milk in sufficient quantities or participate in breast feeding
despite optimal lactation support; or

���� (b)� the infant meets any of
the following conditions:

���� (i)� a body weight below
healthy levels, as determined by the licensed medical practitioner issuing the
medical order for the infant;

���� (ii)� the infant has a
congenital or acquired condition that places the infant at a high risk for
development of necrotizing enterocolitis; or

���� (iii)� the infant has a
congenital or acquired condition that may benefit from the use of donor breast
milk and human milk fortifiers, as determined by the Department of Health;

���� (25)� Comprehensive tobacco
cessation benefits to an individual who is 18 years of age or older, or who is
pregnant.� Coverage shall include: brief and high intensity individual
counseling, brief and high intensity group counseling, and telemedicine as defined
by section 1 of P.L.2017, c.117 (C.45:1-61); all medications approved for
tobacco cessation by the U.S. Food and Drug Administration; and other tobacco
cessation counseling recommended by the Treating Tobacco Use and Dependence
Clinical Practice Guideline issued by the U.S. Public Health Service.�
Notwithstanding the provisions of any other law, rule, or regulation to the
contrary, and except as otherwise provided in this section:

���� (a)� Information regarding the
availability of the tobacco cessation services described in this paragraph
shall be provided to all individuals authorized to receive the tobacco
cessation services pursuant to this paragraph at the following times: no later
than 90 days after the effective date of P.L.2019, c.473: upon the
establishment of an individual's eligibility for medical assistance; and upon
the redetermination of an individual's eligibility for medical assistance;

���� (b) The following conditions
shall not be imposed on any tobacco cessation services provided pursuant to
this paragraph: copayments or any other forms of cost-sharing, including
deductibles; counseling requirements for medication; stepped care therapy or
similar restrictions requiring the use of one service prior to another; limits
on the duration of services; or annual or lifetime limits on the amount,
frequency, or cost of services, including, but not limited to, annual or
lifetime limits on the number of covered attempts to quit; and

���� (c)� Prior authorization
requirements shall not be imposed on any tobacco cessation services provided
pursuant to this paragraph except in the following circumstances where prior
authorization may be required: for a treatment that exceeds the duration recommended
by the most recently published United States Public Health Service clinical
practice guidelines on treating tobacco use and dependence; or for services
associated with more than two attempts to quit within a 12-month period;

���� (26)� Provided that there is
federal financial participation available, benefits for expenses incurred in
conducting a colorectal cancer screening in accordance with United States
Preventive Services Task Force recommendations.� The method and frequency of
screening to be utilized shall be in accordance with the most recent published
recommendations of the United States Preventive Services Task Force and as
determined medically necessary by the covered person's physician, in
consultation with the covered person.

���� No deductible, coinsurance,
copayment, or any other cost-sharing requirement shall be imposed for a
colonoscopy performed following a positive result on a non-colonoscopy,
colorectal cancer screening test recommended by the United States Preventive
Services Task Force;
[
and
]

���� (27) (a)� Within 24 months of
the effective date of P.L.2023, c.187 (C.30:4D-6u et al.), and conditional on
the receipt of all necessary federal approvals and the securing of federal
financial participation pursuant to section 2 of P.L.2023, c.187 (C.30:4D-6u),
community-based palliative care benefits which shall include, but not be
limited to, all of the following:

���� (i)� specialized medical care
and emotional and spiritual support for beneficiaries with serious advanced
illnesses;

���� (ii)� relief of symptoms,
pain, and stress of serious illness;

���� (iii)� improvement of quality
of life for both the beneficiary and the beneficiary's family; and

���� (iv)� appropriate care for any
age and for any stage of serious illness, along with curative treatment.

���� (b)� Benefits provided under
this paragraph shall include, but shall not be limited to, services provided by
a hospice pursuant to paragraph (20) of subsection b. of this section, provided
that:

���� (i)� hospice services may be
provided at the same time that curative treatment is available, to the extent
that services are not duplicative;

���� (ii)� hospice services may be
provided to beneficiaries whose conditions may result in death, regardless of
the estimated length of the beneficiary's remaining period of life; and

���� (iii)� the Division of Medical
Assistance and Health Services in the Department of Human Services may include
any other service deemed appropriate under the benefits provided under this
paragraph.

���� (c)� Providers authorized to
deliver benefits provided under this paragraph shall include Medicaid-approved
licensed hospice agencies, Medicaid-approved home health agencies licensed to
provide hospice care, and other Medicaid-approved licensed health care
providers.

���� (d)� Nothing in this paragraph
shall be construed to result in the elimination or reduction of covered
benefits or services under the Medicaid program.

���� (e)� This paragraph shall not
affect a beneficiary's eligibility to receive, concurrently with services
provided for in this paragraph, any services, including home health services,
for which the beneficiary would have been eligible in the absence of this
paragraph, to the extent that services are not duplicative
; and

����
(28) Mental health
rehabilitation services provided via a clubhouse program.� Coverage of mental
health rehabilitation services provided via a clubhouse program shall not
preclude the coverage of mental health services prescribed in conjunction with
participation in a clubhouse program.� As used in this paragraph, �clubhouse
program� means a non-residential, community-based psychosocial rehabilitation
program accredited by Clubhouse International that is membership based and is designed
to alleviate a member's emotional or behavior problems with the goal of
transitioning the member to a less restrictive level of care, reintegrating the
member into the community, and increasing social connectedness beyond a
clinical or employment setting.� Members of the program, with staff assistance,
engage in operating all aspects of the program, including food service,
clerical, reception, janitorial and other member services such as employment
training, housing assistance and educational support
.

���� c.� Payments for the foregoing
services, goods and supplies furnished pursuant to this act shall be made to
the extent authorized by this act, the rules and regulations promulgated
pursuant thereto and, where applicable, subject to the agreement of insurance
provided for under this act.� The payments shall constitute payment in full to
the provider on behalf of the recipient.� Every provider making a claim for
payment pursuant to this act shall certify in writing on the claim submitted
that no additional amount will be charged to the recipient, the recipient's
family, the recipient's representative or others on the recipient's behalf for
the services, goods, and supplies furnished pursuant to this act.

���� No provider whose claim for
payment pursuant to this act has been denied because the services, goods, or
supplies were determined to be medically unnecessary shall seek reimbursement
form the recipient, his family, his representative or others on his behalf for
such services, goods, and supplies provided pursuant to this act; provided,
however, a provided may seek reimbursement from a recipient for services,
goods, or supplies not authorized by this act, if the recipient elected to
receive the services, goods or supplies with the knowledge that they were not
authorized.

���� d.� Any individual eligible
for medical assistance (including drugs) may obtain such assistance from any
person qualified to 33 perform the service or services required (including an
organization which provides such services, or arranges for their availability
on a prepayment basis), who undertakes to provide the individual such services.

���� No copayment or other form of
cost-sharing shall be imposed on any individual eligible for medical
assistance, except as mandated by federal law as a condition of federal
financial participation.

���� e.� Anything in this act to
the contrary notwithstanding, no payments for medical assistance shall be made
under this act with respect to care or services for any individual who:

���� (1)� Is an inmate of a public
institution (except as a patient in a medical institution); provided, however,
that an individual who is otherwise eligible may continue to receive services
for the month in which he becomes an inmate, should the commissioner determine
to expand the scope of Medicaid eligibility to include such an individual,
subject to the limitations imposed by federal law and regulations, or

���� (2)� Has not attained 65 years
of age and who is a patient in an institution for mental diseases, or

���� (3)� Is over 21 years of age
and who is receiving inpatient psychiatric hospital services in a psychiatric
facility; provided, however, that an individual who was receiving such services
immediately prior to attaining age 21 may continue to receive such services
until the individual reaches age 22.� Nothing in this subsection shall prohibit
the commissioner from extending medical assistance to all eligible persons
receiving inpatient psychiatric services; provided that there is federal
financial participation available.

���� f.� (1)� A third party as
defined in section 3 of P.L.1968, c.413 (C.30:4D-3) shall not consider a
person's eligibility for Medicaid in this or another state when determining the
person's eligibility for enrollment or the provision of benefits by that third
party.

���� (2)� In addition, any
provision in a contract of insurance, health benefits plan, or other health
care coverage document, will, trust, agreement, court order, or other
instrument which reduces or excludes coverage or payment for health
care-related goods and services to or for an individual because of that
individual's actual or potential eligibility for or receipt of Medicaid
benefits shall be null and void, and no payments shall be made under this act
as a result of any such provision.

���� (3)� Notwithstanding any
provision of law to the contrary, the provisions of paragraph (2) of this
subsection shall not apply to a trust agreement that is established pursuant to
42 U.S.C. s.1396p(d)(4)(A) or (C) to supplement and augment assistance provided
by government entities to a person who is disabled as defined in section
1614(a)(3) of the federal Social Security Act (42 31 U.S.C. s.1382c (a)(3)).

���� g.� The following services
shall be provided to eligible medically needy individuals as follows:

���� (1)� Pregnant women shall be
provided prenatal care and delivery services and postpartum care, including the
services cited in subsections a.(1), (3), and (5) of this section and
subsections b.(1)-(10), (12), (15), and (17) of this section, and nursing facility
services cited in subsection b.(13) of this section.

���� (2)� Dependent children shall
be provided with services cited in subsections a.(3) and (5) of this section
and subsections b.(1), (2), (3), (4), (5), (6), (7), (10), (12), (15), and (17)
of this section, and nursing facility services cited in subsection b.(13) of
this section.

���� (3) Individuals who are 65
years of age or older shall be provided with services cited in subsections
a.(3) and (5) of this section and subsections b.(1)-(5), (6) excluding
prescribed drugs, (7), (8), (10), (12), (15), and (17) of this section, and
nursing facility services cited in subsection b.(13) of this section.

���� (4)� Individuals who are blind
or disabled shall be provided with services cited in subsections a.(3) and (5)
of this section and subsections b.(1)-(5), (6) excluding prescribed drugs, (7),
(8), (10), 3 (12), (15), and (17) of this section, and nursing facility
services cited in subsection b.(13) of this section.

���� (5)� (a)� Inpatient hospital
services, subsection a.(1) of this section, shall only be provided to eligible
medically needy individuals, other than pregnant women, if the federal
Department of Health and Human Services discontinues the State's waiver to establish
inpatient hospital reimbursement rates for the Medicare and Medicaid programs
under the authority of section 601(c)(3) of the Social Security Act Amendments
of 1983, Pub.L.98-21 (42 U.S.C. s.1395ww(c)(5)).� Inpatient hospital services
may be extended to other eligible medically needy individuals if the federal
Department of Health and Human Services directs that these services be
included.

���� (b)� Outpatient hospital
services, subsection a.(2) of this section, shall only be provided to eligible
medically needy individuals if the federal Department of Health and Human
Services discontinues the State's waiver to establish outpatient hospital reimbursement
rates for the Medicare and Medicaid programs under the authority of section
601(c)(3) of the Social Security Amendments of 1983, Pub.L.98-21 (42 U.S.C.
s.1395ww(c)(5)).� Outpatient hospital services may be extended to all or to
certain medically needy individuals if the federal Department of Health and
Human Services directs that these services be included.� However, the use of
outpatient hospital services shall be limited to clinic services and to
emergency room services for injuries and significant acute medical conditions.

���� (c)� The division shall
monitor the use of inpatient and outpatient hospital services by medically
needy persons.

���� h.� In the case of a qualified
disabled and working individual pursuant to section h6408 of Pub.L.101-239 (42
U.S.C. s.1396d), the only medical assistance provided under this act shall be
the payment of premiums for Medicare part A under 42 U.S.C. ss.1395i-2 and
1395r.

���� i.� In the case of a specified
low-income Medicare beneficiary pursuant to 42 U.S.C. s.1396a(a)10(E)iii, the
only medical assistance provided under this act shall be the payment of
premiums for Medicare part B under 42 U.S.C. s.1395r as provided for in 42
U.S.C. s.1396d(p)(3)(A)(ii).

���� j.� In the case of a qualified
individual pursuant to 42 U.S.C. s.1396a(aa), the only medical assistance
provided under this act shall be payment for authorized services provided
during the period in which the individual requires treatment for breast or cervical
cancer, in accordance with criteria established by the commissioner.

���� k.� In the case of a qualified
individual pursuant to 42 U.S.C. s.1396a(ii), the only medical assistance
provided under this act shall be payment for family planning services and
supplies as described at 42 U.S.C. s.1396d(a)(4)(C), including medical diagnosis
and treatment services that are provided pursuant to a family planning service
in a family planning setting.

(cf: P.L.2023, c.187, s.1)

���� 2.��� (New section)� 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.

���� 3.��� This act shall take
effect immediately.

STATEMENT

����� This bill requires Medicaid reimbursement of mental
health rehabilitation services provided via a clubhouse program.� Coverage of
mental health rehabilitation services provided via a clubhouse program will not
preclude the coverage of mental health services prescribed in conjunction with
participation in a clubhouse program.�

����� Under the bill, �clubhouse program� is defined as a
non-residential, community-based psychosocial rehabilitation program accredited
by Clubhouse International that is membership based and is designed to
alleviate a member's emotional or behavior problems with the goal of
transitioning the member to a less restrictive level of care, reintegrating the
member into the community, and increasing social connectedness beyond a
clinical or employment setting.� Members of the program, with staff assistance,
engage in operating all aspects of the program, including food service,
clerical, reception, janitorial and other member services such as employment
training, housing assistance and educational support.