ASSEMBLY HEALTH COMMITTEE

STATEMENT TO

ASSEMBLY, No. 4863

STATE OF NEW JERSEY

DATED:  DECEMBER 16, 2024

      The Assembly Health Committee reports favorably Assembly Bill No. 4863.

      This bill requires NJ FamilyCare to reimburse for multiple medical encounters with federally qualified health center (FQHC) specialists per day for an enrollee, provided:

      1.   the referring provider documents the reason for each specialist referral;

      2.   each encounter is with different specialist; and

      3.   NJ FamilyCare reimbursement for multiple 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 in medically underserved areas and meets certain federal statutory criteria.

      The bill defines a “specialty provider” as a licensed physician who:

      (1)  is board certified by a medical specialty board approved by the American Board of Medical Specialties or the American Osteopathic Association’s (AOA) Bureau of Osteopathic Specialists;

      (2)  is a fellow of the appropriate American specialty college or an osteopathic specialty college;

      (3)  is admissible for the exam given by certain medical specialty boards or can document completion of a qualifying residency;

      (4)  holds a staff appointment with specialty privileges in a licensed hospital approved for training in the physician’s specialty; or

      (5)  is recognized as a specialist by his or her peers.

      Nothing in this bill authorizes 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 FQHCs.

      State regulations limit NJ FamilyCare coverage for medical encounters at an FQHC to one encounter per enrollee per day.  Additional encounters in a day are covered if:

      1.   the enrollee is seen by more than one provider for different illnesses or injuries; or

      2.   the enrollee leaves the FQHC after an encounter with one practitioner, and returns to the FQHC and is seen by another practitioner on the same day.