This bill aims to enhance the coverage and appeal process for pediatric NJ FamilyCare beneficiaries transitioning from the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to the Managed Long Term Services and Supports (MLTSS) program. It mandates that these beneficiaries automatically receive coverage for at least the same number of weekly private duty nursing service hours they were eligible for under the EPSDT program, and allows them to carry forward any unused hours. A managed care organization can only reduce these hours based on a demonstrated change in medical necessity, as determined by an authorized provider. Additionally, the Department of Human Services is tasked with reviewing records of beneficiaries who transitioned in the past five years to identify those eligible for increased nursing service hours.

The bill also codifies and expands the appeals process for private duty nursing services. It requires managed care organizations to automatically continue a beneficiary's nursing services during an appeal of an adverse benefit determination, provided the appeal is filed within 30 calendar days of notification. This extends the current timeframe from 10 to 30 days. Furthermore, benefits must continue while the appeal is pending until either the beneficiary withdraws the appeal or the appeal results in an adverse decision, which contrasts with the current practice where benefits can be discontinued immediately upon these events.