ASSEMBLY APPROPRIATIONS COMMITTEE

STATEMENT TO

ASSEMBLY, No. 5052

STATE OF NEW JERSEY

DATED:  DECEMBER 18, 2025

      The Assembly Appropriations Committee reports favorably Assembly Bill No. 5052.

      As reported, this bill requires health insurers (health, hospital and medical service corporations, commercial individual and group health insurers, health maintenance organizations, health benefits plans issued pursuant to the New Jersey Individual Health Coverage and Small Employer Health Benefits Programs, the State Health Benefits Program, and the School Employees’ Health Benefits Program) and the State Medicaid program to provide benefits to any covered person for medical expenses incurred relating to screening, prevention, and treatment of behavioral health issues in children.  Carriers and the State Medicaid program are required to accept and reimburse claims for screening, prevention, and treatment using an at-risk diagnosis.

      As used in the bill, an “at-risk diagnosis” is a diagnosis made after consideration of factors influencing behavioral health and child development, such as family circumstances or life challenges, that does not lead to a formal mental health diagnosis and instead promotes preventive care.  Allowing providers to bill for an “at-risk diagnosis” authorizes providers to use an alternative code, including a Social Determinants of Health Z-code, to the codes of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders or the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood when billing for services, without a formal mental health diagnosis for children who are 18 years of age or younger.

FISCAL IMPACT:

      The Office of Legislative Services (OLS) estimates that requiring the State Health Benefits Program, the School Employees’ Health Benefits Program, and the NJ FamilyCare program to provide coverage for screening, prevention, and treatment services for children diagnosed as being at risk for behavioral health issues will result in indeterminate annual State and local expenditure increases.

      The OLS finds the expenditure increases under the bill could be millions of dollars annually, but lacks the empirical basis to provide a more precise estimate.

      Any increase in State expenditures under the NJ FamilyCare program will be eligible for additional federal Medicaid reimbursements, thereby increasing State revenues, albeit by an indeterminate amount.