Bill > A4080

Introduced Session

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.

AI Summary

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Annette Quijano (D)*, 

Introduced, Referred to Assembly Aging and Human Services Committee (on 02/19/2026)

Official Document