Requires NJ FamilyCare payment for multiple medical encounters per day for enrollee at federally qualified health center.

S3769

SENATE, No. 3769

STATE OF NEW JERSEY

222nd LEGISLATURE

�

INTRODUCED MARCH 5, 2026

Sponsored by:

Senator� ANGELA V. MCKNIGHT

District 31 (Hudson)

SYNOPSIS

���� Requires NJ FamilyCare payment for multiple medical
encounters per day for enrollee at federally qualified health center.

CURRENT VERSION OF TEXT

���� As introduced.

��

An Act

concerning federally qualified health centers
and supplementing Title 30 of the Revised Statutes.

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

���� 1.��� a.� To the extent not
otherwise prohibited by federal statute, the NJ FamilyCare program shall
reimburse for multiple medical encounters per day at a federally qualified
health center for an enrollee, provided:

���� (1)�� the referring health
care provider documents, in a manner to be determined by the Commissioner of
Human Services, the medical necessity of each referral to a specialty provider;
and

���� (2)�� each of the enrollee�s
medical encounters in a given day is with a different specialty provider.

���� b.��� Nothing in this act
shall be construed to authorize the Commissioner of Human Services to waive or
limit any provisions of federal statute or any other State reimbursement
methodologies governing NJ FamilyCare reimbursement for services provided by
federally qualified health centers.

���� c.���� As used in this
section:

���� �Federally qualified health
center� means a community-based health care provider that delivers integrated
primary care services in medically underserved areas and meets the criteria
established under section 1905(l)(2)(B) of the Social Security Act (42 U.S.C.
s.1396(d)).�

���� �NJ FamilyCare� means the
program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), which
includes the Medicaid program and the Children�s Health Insurance Program.

���� �Specialty provider� means a
licensed physician who:

���� (1)�� is a diplomate of a
specialty board approved by the American Board of Medical Specialties or the Bureau
of Osteopathic Specialists of the American Osteopathic Association;

���� (2)�� is a fellow of the
appropriate American specialty college or a member of an osteopathic specialty
college;

���� (3)�� is currently admissible
to take the examination administered by a specialty board approved by the
American Board of Medical Specialties or the Bureau of Osteopathic Specialists of
the American Osteopathic Association, or has evidence of completion of an
appropriate qualifying residency approved by the American Medical Association
or American Osteopathic Association;

���� (4)�� holds an active staff
appointment with specialty privileges in a hospital which is licensed pursuant
to P.L.1971, c.136 (C.26:2H-1 et seq.) and which is approved for training in
the specialty in which the physician has privileges; or

���� (5)�� is recognized in the
community as a specialist by his or her peers.

���� 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.

���� 3.��� 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.

���� 4. This act shall take effect
on the first day of the fourth month next following the date of enactment.

STATEMENT

���� This bill provides for NJ
FamilyCare reimbursement for multiple medical encounters with federally
qualified health center (FQHC) specialists on a single day for an enrollee,
provided:

���� 1.��� the referring provider
documents the reason for referring the patient to each specialty provider;

���� 2.��� each of the enrollee�s
medical encounters is with different specialty provider; and

���� 3.��� NJ FamilyCare reimbursement
for multiple medical encounters per day at a FQHC does not violate federal
statute.

���� The bill defines a �federally
qualified health center� as a community-based health care provider that
delivers integrated primary care services in medically underserved areas, and
meets the criteria established under section 1905(l)(2)(B) of the Social
Security Act (42 U.S.C. s.1396(d)).�

���� The bill defines a �specialty
provider� as a licensed physician who:

���� (1)�� is a diplomate of a
specialty board approved by the American Board of Medical Specialties or the
Bureau of Osteopathic Specialists of the American Osteopathic Association (AOA);

���� (2)�� is a fellow of the
appropriate American specialty college or a member of an osteopathic specialty
college;

���� (3)�� is currently admissible
to take the examination administered by a specialty board approved by the
American Board of Medical Specialties or the Bureau of Osteopathic Specialists
of the AOA, or has evidence of completion of an appropriate qualifying
residency approved by the American Medical Association or the AOA;

���� (4)�� holds an active staff
appointment with specialty privileges in a hospital which is licensed pursuant
to P.L.1971, c.136 (C.26:2H-1 et seq.) and which is approved for training in
the specialty in which the physician has privileges; or

���� (5)�� is recognized in the
community as a specialist by his or her peers.

���� Nothing in this bill should be
construed to authorize the Commissioner of Human Services to waive or limit any
provisions of federal statute or any other State reimbursement methodologies
governing NJ FamilyCare reimbursement to federally qualified health centers.

���� State regulations, found at
N.J.A.C.10:66-4.1, generally limit NJ FamilyCare coverage for medical
encounters at a FQHC to one encounter per NJ FamilyCare beneficiary per day.�
Additional encounters in a given day are covered if:

���� 1.��� the NJ FamilyCare
enrollee is seen by more than one provider for the prevention, diagnosis, or
treatment of different illnesses or injuries; or

���� 2.��� the enrollee leaves the
FQHC following an encounter with one practitioner, and subsequently returns to
the FQHC and is seen by another practitioner on the same day.

���� Under N.J.A.C.10:66-4.1, if an
NJ FamilyCare enrollee has more than two medical encounters at a FQHC in a
given week, the FQHC must document the medical necessity of the encounters in
the enrollee�s medical record.