Sponsored by:
Assemblyman LOUIS D. GREENWALD
District 6 (Burlington and Camden)
Assemblyman ALEXANDER "AVI" SCHNALL
District 30 (Monmouth and Ocean)
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 enrollees 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 Childrens 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 enrollees 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 enrollees medical record.