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A4080
ASSEMBLY, No. 4080
STATE OF NEW JERSEY
222nd LEGISLATURE
�
INTRODUCED FEBRUARY 19, 2026
Sponsored by:
Assemblywoman� ANNETTE QUIJANO
District 20 (Union)
SYNOPSIS
���� Provides for certain pediatric NJ FamilyCare
beneficiaries to maintain private duty nursing hours when transitioning to
Managed Long Term Services and Supports; codifies and expands appeals
provisions for private duty nursing services.
CURRENT VERSION OF TEXT
���� As introduced.
��
An Act
concerning private duty nursing services covered under
NJ FamilyCare and supplementing P.L.1968, c.413 (C.30:4D-1 et seq.).
����
Be It
Enacted
by the Senate and General Assembly of
the State of New Jersey:
���� 1.��� a. Notwithstanding the
provisions of N.J.A.C.10:60-5.1 et seq. or any law or regulation to the
contrary, a NJ FamilyCare beneficiary transitioning from the Early and Periodic
Screening, Diagnosis, and Treatment program to the
Managed Long Term
Services
and Supports program
shall:
���� (1)�� automatically receive
coverage under the
Managed Long Term
Services
and Supports program
for no less than the number of weekly private duty nursing service hours the
beneficiary was eligible to receive pursuant to the most recent nursing
assessment completed under the Early and Periodic Screening, Diagnosis, and
Treatment program
; and
���� (2)�� be allowed to carry forward unused private duty
nursing service hours from week to week.
���� b.��� The managed care organization responsible for a
beneficiary�s NJ FamilyCare benefits under the Managed Long Term
Services
and Supports program shall be
authorized to
decrease the number of covered private duty nursing
service hours authorized for a beneficiary under paragraph (1) of subsection a.
of this section, if the managed care organization
, upon consultation
with the beneficiary�s primary
care physician and other relevant members of the beneficiary�s medical team,
can demonstrate that the beneficiary�s medical need for private duty nursing
services has changed since the beneficiary�s most recent nursing assessment
under the Early and Periodic Screening, Diagnosis, and Treatment program.�
Under no circumstances shall a managed care organization be authorized to
justify a decrease in the number
of
a beneficiary�s covered
private duty nursing service hours, as
authorized in paragraph (1) of subsection a. of this section, based on anything
other than a change in medical necessity.� A beneficiary shall have the right
to a continuation of benefits, as outlined in section 2 of
this act,
during an appeal of any decrease in the
number
of the beneficiary�s covered
private
duty nursing service hours determined by a managed care organization pursuant
to this section
.
���� c.���� Upon the effective date
of this act, the Department of Human Services shall review the records of all
beneficiaries who have transitioned from the Early and Periodic Screening,
Diagnosis, and Treatment program to the
Managed Long Term
Services
and Supports program
in the preceding five years to determine if any
beneficiaries may be eligible for coverage of an increased number of private
duty nursing services hours pursuant to the provisions of this section.� Upon
identifying a beneficiary eligible for coverage of an increased number of
private duty nursing service hours pursuant to this section, the department
shall notify the beneficiary and the beneficiary�s managed care organization,
and direct the managed care organization to implement the coverage change,
provided that the beneficiary consents.�
���� 2.��� Notwithstanding the
provisions of any law or regulation to the contrary, a managed care
organization
contracted with the Division of Medical
Assistance and Health Services in the Department of Human Services shall:
���� a.����
automatically
continue a beneficiary�s private duty nursing services benefits during an
appeal of an adverse benefit determination, provided that:
���� (1)�� the appeal involves the
termination, suspension, or reduction of previously authorized private duty
nursing services;
���� (2)�� the private duty nursing
services were ordered by an authorized provider; and
���� (3)�� the appeal request is
made by the beneficiary, provider, or the beneficiary�s authorized
representative within 30 calendar days of the date of the notification of
adverse benefit determination; and
���� b.��� continue the
beneficiary�s private duty nursing services benefits while an appeal of an
adverse benefit determination is pending until 30 calendar days after one of
the following occurs:
���� (1)�� the beneficiary
withdraws the appeal; or
���� (2)�� the appeal results in a
decision adverse to the beneficiary.
���� 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.
���� 4.��� 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.
���� 5.��� This act shall take
effect immediately.
STATEMENT
���� This bill provides that a NJ
FamilyCare beneficiary transitioning from the Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT) program for children under age 21 to the
Managed Long Term
Services
and Supports (MLTSS) program for
people of all ages with long-term care needs
will automatically receive
coverage under the
MLTSS program
for no less than the number of weekly private duty nursing service hours that
the beneficiary was eligible to receive pursuant to the most recent nursing
assessment completed under the EPSDT program
.�� Moreover, the bill requires that such beneficiaries will
be allowed to carry forward unused private duty nursing service hours from week
to week.
�
A managed care organization may decrease
the number of covered
private duty nursing service hours for such a
beneficiary only based on a change in medical necessity, as determined by an
authorized provider.
The
MLTSS program currently limits the number of weekly private duty nursing hours
to 16.� By contrast, there is no cap on such services under the EPSDT program.�
���� Furthermore, the bill directs
the Department of Human Services to review the records of all beneficiaries who
have transitioned from the EPSDT program to the
MLTSS program
in the five years preceding the bill�s
enactment to determine if any beneficiaries may be eligible for coverage of an
increased number of private duty nursing services hours pursuant to the
provisions of the bill.�
���� The bill also codifies and
expands certain provisions in the contract between the Medicaid managed care
organizations and the State for all private duty nursing services appeals.�
Under the bill, a managed care organization
is
required to
automatically continue a beneficiary�s provider-authorized
private duty nursing services benefits during an appeal of a change of
previously authorized private duty nursing services, provided that the appeal
request is made by an eligible entity within 30 calendar days of the date of
notification of the adverse benefit determination.� These provisions reflect
existing contract elements, except that currently an appeal request must be
made within 10 calendar days, rather than 30.
���� The bill also requires managed
care organizations to continue the beneficiary�s private duty nursing services
benefits while an appeal is pending until 30 days after either the beneficiary
withdraws the appeal or the appeal results in a decision adverse to the
beneficiary.� Currently, the managed care organizations can discontinue
benefits upon the date of either of these two events.