NJ A4080

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 will automatically retain their existing weekly private duty nursing hours, overriding the current MLTSS 16-hour weekly cap.

Beneficiaries may carry forward unused private duty nursing hours from week to week, and managed care organizations can only reduce hours based on documented changes in medical necessity after consultation with the beneficiary's 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 the new provisions.

Appeals of adverse benefit determinations regarding private duty nursing services must be filed within 30 calendar days (expanded from the current 10 days), with automatic continuation of benefits during the appeals process.

Benefits must continue for 30 days after either the beneficiary withdraws the appeal or receives an adverse decision, extending protections beyond the current immediate termination upon appeal resolution.