NJ S2435

Pediatric NJ FamilyCare beneficiaries transitioning from the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to Managed Long Term Services and Supports (MLTSS) would automatically retain their existing weekly private duty nursing hours, rather than being subject to the current MLTSS cap of 16 hours per week.

Beneficiaries would be permitted to carry forward unused private duty nursing hours from week to week under the MLTSS program.

Managed care organizations could only reduce a transitioning beneficiary's nursing hours based on a documented change in medical necessity, determined in consultation with the beneficiary's primary care physician and medical team.

The Department of Human Services must review records of all beneficiaries who transitioned from EPSDT to MLTSS in the preceding five years to identify those eligible for increased nursing hours under these new provisions.

Appeals of adverse benefit determinations for private duty nursing services must include automatic continuation of benefits when filed within 30 calendar days (expanded from the current 10 days), with benefits continuing until 30 days after appeal withdrawal or an adverse decision.