Bill > A4863

Introduced Session

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.

AI Summary

Committee Categories

Lou Greenwald (D)*,  Alexander Schnall (D)*,  Shanique Speight (D)*,  Carol Murphy (D),  Chris Tully (D), 

Reported and Referred to Assembly Appropriations Committee (on 12/16/2024)

Official Document