ASSEMBLY OVERSIGHT, REFORM AND FEDERAL RELATIONS COMMITTEE

STATEMENT TO

ASSEMBLY, No. 5209

STATE OF NEW JERSEY

DATED:  SEPTEMBER 10, 2026

      The Assembly Oversight, Reform and Federal Relations Committee reports favorably Assembly Bill No. 5209.

      As reported by the committee, this bill requires health insurers to provide a reason for the denial of coverage for private duty nursing services.

      Specifically, if a payer denies a prior authorization request for private duty nursing services that has been determined to be medically necessary by the covered person’s physician, the bill requires the payer to provide a full description of the reason for the denial.  If the denial is based on a finding that the private duty nursing services are not medically necessary, the payer is required to provide its rationale for that finding, including an explanation of why the determination of the covered person’s physician is invalid.  The payer is also required to provide examples of when prior authorization requests for private duty nursing are approved, including the submitted documentation necessary for those approvals.