Sponsored by:
Senator LORETTA WEINBERG
District 37 (Bergen)
SYNOPSIS
Codifies and establishes certain network adequacy standards for pediatric primary and specialty care in Medicaid program.
CURRENT VERSION OF TEXT
As reported by the Senate Health, Human Services and Senior Citizens Committee on January 14, 2021, with amendments.
An Act concerning network adequacy of pediatric providers in the Medicaid program and supplementing P.L.1997, c.192 (C.26:2S-1 et al.).
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. Pursuant to section 19 of P.L.1997, c.192 (C.26:2S-18), the commissioner shall only approve the network adequacy of a managed care plan provided by a managed care organization contracted with the Division of Medical Assistance and Health Services in the Department of Human Services to provide benefits under Medicaid if the plan has:
(1) a sufficient number of pediatric primary care physicians (PCPs) to assure that:
(a) at least two physicians eligible as PCPs are within five miles or 10 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan’s pediatric enrollees who live in urban counties;
(b) at least two physicians eligible as PCPs are within 10 miles or 15 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan’s pediatric enrollees who live in non-urban counties; and
(c) 100 percent of all pediatric enrollees live no more than 30 minutes from at least one physician eligible as a PCP;
(2) a sufficient number of pediatric medical specialists to assure:
(a) access within 15 miles or 30 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan’s pediatric enrollees who live in urban counties; and
(b) access within 40 miles or 60 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan’s pediatric enrollees who live in non-urban counties;
(3) a sufficient number of pediatric oncologists and developmental and behavioral pediatricians to assure:
(a) access within 10 miles or 20 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan’s pediatric enrollees who live in urban counties; and
(b) access within 30 miles or 45 minutes driving time or public transit time, whichever is less, of 90 percent of the managed care plan’s pediatric enrollees who live in non-urban counties; and
(4) the following types of pediatric medical specialties represented within the plan’s network: adolescent medicine; allergy and immunology; cardiology; developmental and behavioral pediatrics; emergency medicine; endocrinology and diabetes; gastroenterology and nutrition; general pediatrics; general pediatrics dermatology; hematology; human genetics and metabolism; infectious disease; neonatology; nephrology; neurology; oncology; ophthalmology; 1[orthopaedics] orthopedics1; otolaryngology; plastic surgery; pulmonary medicine, including sleep medicine; radiology; rehabilitative medicine; and rheumatology.
b. A managed care organization that violates any provision of this act shall be liable for penalties described under section 16 of 1[P.L.2018, c. 32] P.L.1997, c.1921 (C.26:2S-16).
c. For the purposes of this section:
"Medicaid" means the program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.).
"Network adequacy" means the adequacy 1of1 the provider network with respect to the scope and type of health care benefits provided by the managed care plan, the geographic service area covered by the provider network, and access to medical specialists pursuant to the standards in the regulations promulgated pursuant to section 19 of P.L.1997, c.192 (C.26:2S-18) and in the existing contract between a managed care organization and the Division of Medical Assistance and Health Services in the Department of Human Services.
“Non-urban county” shall mean: 1[Hunterdon, Morris, Somerset, Sussex, Warren,]1 Atlantic, Cape May, Cumberland, Gloucester, 1[and] Hunterdon, Morris,1 Salem 1, Somerset, Sussex, and Warren1 counties.
“Urban county” shall mean: Bergen, 1[Hudson, and Passaic, Essex, Union, Middlesex, Mercer,]1 Burlington, Camden, 1[Monmouth and Ocean] Essex, Hudson, Mercer, Middlesex, Monmouth, Ocean, Passaic, and Union1 counties.
2. The Commissioner of Banking and Insurance, in conjunction with the Commissioner of Human Services, shall adopt rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) 1,1 to effectuate the purposes of this act.
3. This act shall take effect on the first day of the third month following enactment, except that the Commissioner of Banking and Insurance, in conjunction with the Commissioner of Human Services, may take such anticipatory administrative action in advance thereof as shall be necessary for the implementation of this act.