Bill > S4013

Introduced Session

This bill establishes the "Clinical Laboratory Services Reimbursement and Vulnerable Patient Discount Act," which permits clinical laboratories to provide certain patients with discounts without affecting NJ FamilyCare reimbursement rates or violating NJ FamilyCare rebate prohibitions. N.J.A.C.10:61-1.7 provides that under no circumstances is a clinical laboratory allowed to charge the NJ Family program an amount that exceeds the provider's charge for identical services to other groups or individuals. Moreover, a clinical laboratory in violation of this current NJ FamilyCare reimbursement policy would additionally be non-compliant with the existing anti-rebate regulation as, pursuant to N.J.A.C.10:61-2.4, a discount to a patient is considered a rebate. It is the sponsor's belief that these regulations, in combination, have the effect of impeding access to care for uninsured, underinsured, or underserved individuals by forcing clinical laboratories to stop offering discounted charges to these vulnerable patients. The provisions of this bill are designed to reverse these consequences. Under the bill, notwithstanding the provisions of N.J.A.C.10:61-1.7 to the contrary, reimbursement for items or services provided by a clinical laboratory under NJ FamilyCare are required to be in an amount equal to the lesser of: the amount specified in the maximum fee schedule set forth in existing regulation or future policy; or the clinical laboratory's usual charge for the identical item or service when provided to the general public. Any discount offered by a clinical laboratory is to be deemed permissible as long as it is consistent with federal law and regulation. Moreover, a clinical laboratory may charge or accept a lesser amount than the amount charged to NJ FamilyCare for an item or service, based on the financial hardship of an individual: (1) without affecting the reimbursement amount under NJ FamilyCare for the same or substantially similar item or service; or (2) without constituting a violation of N.J.A.C.10:61-2.4. Additionally, upon the effective date of the bill, all pending or existing actions initiated by the Division of Medical Assistance and Health Services in the Department of Human Services under NJ FamilyCare regarding conduct by a clinical laboratory considered in violation of the provisions of N.J.A.C.10:61-1.7 or N.J.A.C.10:61-2.4, either alone or in combination with each other, which actions are subsequently permissible under the bill, are to be dismissed or vacated. Finally, the bill provides that any discount offered, or amount charged or accepted, by a clinical laboratory in compliance with the bill's provision are not to be subject to penalties under section 17 of P.L.1968, c.413 (C.30:4D-17). This State law, among other things, establishes that it is a crime of the third degree when a Medicaid provider willfully receives medical assistance payments in a greater amount than that to which a provider is entitled.

AI Summary

Committee Categories

Joe Lagana (D)*,  Patrick Diegnan (D), 

Introduced in the Senate, Referred to Senate Health, Human Services and Senior Citizens Committee (on 01/14/2025)

Official Document