LEGISLATIVE FISCAL ESTIMATE
[Second Reprint]
ASSEMBLY, No. 3585
STATE OF NEW JERSEY
220th LEGISLATURE
DATED: MARCH 31, 2023
SUMMARY
Synopsis: Establishes program for certain individuals to become certified as
homemaker-home health aides and provide services to certain
Medicaid enrollees.
Type of Impact: Annual State cost and revenue impacts.
Agencies Affected: Department of Human Services; Department of Law and Public
Safety.
Office of Legislative Services Estimate
Fiscal Impact Annual
State Cost Impact Indeterminate
State Revenue Impact Indeterminate
 The Office of Legislative Services (OLS) concludes that the certified homemaker-home health
aide (CHHA) program established under the bill would have an indeterminate impact on annual
State expenditures from the General Fund and on State revenues. The fiscal impact will be
determined, in part, by the participation in the program by eligible NJ FamilyCare beneficiaries
and their families.
 If CHHA hours provided by a family member replace existing private duty nursing hours
provided by either a registered nurse (RN) or a licensed practical nurse (LPN), the State will
see a cost savings. Conversely, if CHHA hours provided by a family member supplement
existing private duty nursing hours, the State would incur higher expenditures, depending on
the number of additional hours reimbursed by each party. The net impact of these possible
outcomes on annual State expenditures and revenues cannot be determined.
 To the extent that additional eligible State Medicaid expenditures are matched by federal
Medicaid funds, any additional costs incurred by the State pursuant to the bill would
correspond to an increase in State revenues. Lower overall eligible Medicaid-reimbursable
costs will result in lower State matching revenues from federal reimbursements.
Office of Legislative Services Legislative Budget and Finance Office
State House Annex Phone (609) 847-3105
P.O. Box 068 Fax (609) 777-2442
Trenton, New Jersey 08625 www.njleg.state.nj.us
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BILL DESCRIPTION
This bill requires the Department of Human Services to establish a program under which a
family member of a Medicaid or NJ FamilyCare enrollee, who is under the age of 21, may seek
certification as a homemaker-home health aide and, once certified, provide related services to the
beneficiary through a home care services agency under the direction of a registered nurse. The
bill defines the term “family member” broadly to include individuals with a close association that
is equivalent to a family relationship. The bill also specifies that the department may not establish
the CHHA program prior to receiving federal approval of the State’s Medicaid waiver application
for this initiative. The department, moreover, will be required to develop an assessment tool that
will allow for the identification of NJ FamilyCare beneficiaries who meet the eligibility criteria
for this program. Additionally, the department will be required, within three years of the start of
the CHHA program, to submit a report assessing the viability of the program and the department’s
recommendations concerning this initiative, to the Governor and the Legislature.
The home care services agency employing the individual will be required to pay all costs for
the individual to become certified as a CHHA.
FISCAL ANALYSIS
EXECUTIVE BRANCH
None received.
OFFICE OF LEGISLATIVE SERVICES
The OLS concludes that this bill will have an indeterminate impact on State expenditures due
to unknown variables regarding: 1) the interaction of private duty nursing hours and CHHA hours;
and 2) the participation of eligible individuals in the CHHA program established under the bill.
To the extent that State Medicaid expenditures are matched by federal Medicaid funds, any
additional eligible costs incurred by the State under the bill would correspond to an increase in
State revenues from federal reimbursements. On the other hand, there is the potential for lower
overall eligible State Medicaid-reimbursable costs, which will result in lower State matching
revenues.
During FY 2023, the Medicaid program reimburses home care services agencies $61 per hour
for private duty nursing services provided by a RN and $49 an hour for private duty nursing
services provided by a licensed practical nurse LPN. The Governor’s proposed FY 2024 Budget
recommends increasing these reimbursement rates to $62 per hour for private duty nursing services
rendered by an RN and $50 per hour for such services when provided by an LPN. By comparison,
the Statewide average Medicaid reimbursement rate for services provided by a CHHA is $11.96
per hour in 2023. To the extent that family CHHA hours replace any existing private nursing duty
hours, the State will see a cost savings of between 75.6 percent to 80.4 percent per hour in FY
2023, depending on the credentials of the provider of the existing services.
In order for CHHA hours to replace private duty nursing hours, however, the Department of
Human Services’ assessment of a beneficiary’s needs would need to determine a level of care that
could be fulfilled by a CHHA’s scope of practice, as they cannot perform the same care duties as
an LPN or RN. For example, CHHAs, LPNs, and RNs can all support the daily care needs of
patients, such as bathing, dressing, feeding, taking temperatures, and bed-making. CHHAs,
additionally, may be authorized to assist a beneficiary with select household duties, such as
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shopping or meal planning and preparation, when furnished in combination with personal care and
other health services, as specified in the beneficiary’s plan of care. LPNs and RNs, however, can
provide a higher level of care than a CHHA, which may involve taking and reporting a patient's
vital signs, giving injections, administering medications, and monitoring catheters. Both CHHAs
and LPNs work under the supervision of an RN.
Furthermore, according to State regulation, the department is required to take into account the
ability of a beneficiary’s primary caretaker to provide care when determining the total number of
private duty nursing hours approved for the beneficiary. As such, it is possible the department
may approve fewer private duty nursing hours for those beneficiaries who have family members
that are credentialed and available to provide CHHA hours at the appropriate level of care, which
would effectively decrease certain State expenditures, as less costly CHHA hours could replace
more expensive private duty nursing hours.
Conversely, to the extent that family CHHA hours supplement existing private duty nursing
hours, the State would incur higher Medicaid expenditures, depending on the number of additional
hours reimbursed under the bill.
Currently, there is no minimum number of private duty nursing hours that the department can
approve for beneficiaries under the age of 21. Further, this bill does not establish a cap on the
number of CHHA hours that a family member may provide a beneficiary, leaving open ended the
potential number of maximum supplemental CHHA hours that can be provided.
The OLS notes that a similar Medicaid waiver program implemented in Colorado is designed
to supplement a Medicaid beneficiary’s private duty nursing care with certified nursing assistant
services provided by a family member or other family approved individual. Essentially, the
Colorado program aims to provide income to family caregivers who would be providing support
absent the program.
In addition to variables regarding private duty nursing and CHHA hours, the fiscal impact of
this bill cannot be determined because the OLS cannot predict the rate of participation in this
program among eligible beneficiaries. For context, there were 1,806 recipients of private duty
nursing services under the age of 21 in the managed care system in FY 2018. Comparable data
for the fee-for-service delivery system are unavailable; however, considering that approximately
97 percent of all NJ FamilyCare beneficiaries receive care through the managed care system, the
fee for service population would be considerably smaller. The OLS estimates that the affected fee
for service population under this bill, based on FY2018 data, is less than 100 beneficiaries.
It is possible that the certification requirement established under the bill may pose a barrier for
some families engaging in the program. Furthermore, current regulations authorize family
members of beneficiaries who receive private services, and who are licensed as an RN or an LPN,
to provide reimbursable private duty services to a beneficiary for as many as eight hours per day,
with a limit of 40 hours of care per week. It is possible that such families would not pursue CHHA
certification.
The Department also would incur marginal additional costs to assess and report to the
Governor and the Legislature concerning the CHHA program’s viability and to issue
recommendations concerning the program. Finally, the New Jersey Board of Nursing within the
Division of Consumer Affairs in the Department of Law and Public Safety would incur higher
costs in order to certify family members who apply for CHHA credentials under the bill.
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Section: Human Services
Analyst: Anne Cappabianca
Senior Fiscal Analyst
Approved: Thomas Koenig
Legislative Budget and Finance Officer
This legislative fiscal estimate has been produced by the Office of Legislative Services due to the
failure of the Executive Branch to respond to our request for a fiscal note.
This fiscal estimate has been prepared pursuant to P.L.1980, c.67 (C.52:13B-6 et seq.).