Title 30, Title 30: INSTITUTIONS AND AGENCIES

30:4D-7uu Findings, declarations. 1. The Legislature finds and declares that: a. To address the increasingly high cost of prescription drug utilization and to address patient safety, health insurance carriers and other plan sponsors use step therapy protocols that require patient…

30:4D-7v Imposition of fee. 5. a. The fee imposed pursuant to subsection c. of section 3 of this act shall be imposed in relation to health care items or services provided only during the effective period of this act, and shall not be collected until the commissioner notifies the…

30:4D-7vv Definitions. 2. As used in sections 2 through 6 of this act: "Division" means the Division of Medical Assistance and Health Services in the Department of Human Services. "Health care provider" means an individual or entity which, acting within the scope of its licensure…

30:4D-7w Application by commissioner, approval prior to collection of fee. 6. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this act and to secure federal financial participation for Sta…

30:4D-7ww Clinical review criteria, guidelines, step therapy protocol, Medicaid. 3. a. The division or a managed care organization shall require that clinical review criteria used to establish a step therapy protocol under Medicaid are based on clinical practice guidelines develo…

30:4D-7x Rules, regulations. 7. The commissioner shall promulgate, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary for the implementation of this act which shall include appropriate methodologies for the county…

30:4D-7xx Prescription drug coverage restriction, step therapy protocol, exception process, managed care organization. 4. Notwithstanding the provisions of any law, rule, or regulation to the contrary: a. When coverage of a prescription drug for the treatment of any medical condi…

30:4D-7y Perinatal Risk Assessment form for certain pregnant women. 1. An obstetrical provider, nurse midwife, or other licensed health care professional, approved as a provider under the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), shall complete…

30:4D-7yy Statistics made available, step therapy exception request approvals, denials, managed care organization. 5. A managed care organization shall make statistics available regarding step therapy exception request approvals and denials on its Internet website in a readily ac…

30:4D-7z Submission of form to division. 2. The division shall require providers to submit each Perinatal Risk Assessment form completed pursuant to section 1 of this act to the division, or to a nonprofit entity contracted by the division to process, distribute to appropriate Me…

30:4D-7zz State plan amendments, waivers, apply as necessary for implementation, step therapy. 6. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this act and secure federal financial part…

30:4D-8 Claim payment method. 8. The determination of the method of providing payment of claims under this act shall be made by the State Medicaid Commission on recommendation of the commissioner which method may be: a. (1) By contract, except as prohibited by paragraph (2) of th…

30:4D-8.1 Findings, declarations relative to a Medicaid Accountable Care Organization Demonstration Project. 1. The Legislature finds and declares that: a. The current health care delivery and payment system often fails to provide high quality, cost-effective health care to the m…

30:4D-8.10 Application for State plan amendments, waivers. 10. a. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this act and to secure federal financial participation for State Medicaid …

30:4D-8.11 Construction of act. 11. Nothing in this act shall be construed to limit the choice of a Medicaid recipient to access care for family planning services or any other type of health care services from a qualified health care provider who is not participating in the demon…

30:4D-8.12 Continuation of payments for certain services. 12. a. Under the demonstration project, payment shall continue to be made to providers of services and suppliers participating in the Medicaid ACO for services provided to managed care recipients or individuals who receive…

30:4D-8.13 Certain licensure requirements waived. 13. Notwithstanding the requirements of P.L.1999, c.409 (C.17:48H-1 et seq.), a Medicaid ACO certified pursuant to this act shall not be required to obtain licensure or certification from the Department of Banking and Insurance as…

30:4D-8.14 Report to Governor, Legislature. 14. Upon completion of the demonstration project, the Commissioners of Human Services and Health shall report to the Governor, and to the Legislature pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), on the demonstration project,…

30:4D-8.15 Rules, regulations. 15. The Commissioner of Human Services, in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and with input from the Commissioner of Health, shall, within 180 days of the effective date of this act, adopt rules…

30:4D-8.16 Findings, declarations relative to the establishment of a Regional Health Hub Program. 1. The Legislature finds and declares that: a. Significant State resources are invested in both the health and social service sectors in New Jersey, and the development of improvemen…

30:4D-8.17 Definitions relative to Regional Health Hubs. 2. As used in this act: "Commissioner" means the Commissioner of Human Services. "Core region" means the geographic area of responsibility for a Regional Health Hub. "Data catchment area" means the zip codes in New Jersey f…

30:4D-8.18 Regional Health Hub Program. 3. a. The Department of Human Services shall establish a Regional Health Hub Program, and shall designate Regional Health Hubs in appropriate areas of the State, as provided by this act. The Regional Health Hub Program shall replace the Med…

30:4D-8.19 Designation, delineation of boundaries. 4. a. The commissioner, in consultation with the Commissioner of Health, shall designate and delineate the boundaries of regions of the State that are in need of new Regional Health Hubs within six months of the effective date of…

30:4D-8.2 Definitions relative to a Medicaid ACO. 2. As used in this act: "ACO" means an accountable care organization. "Behavioral health care provider" means a provider licensed or approved by the Department of Human Services to render services to New Jersey residents. "Departm…

30:4D-8.20 Revocation of status. 5. a. The commissioner may revoke an organization's status as a Regional Health Hub if the organization fails to perform the mandatory activities of a Regional Health Hub, as described in subsection a. of section 6 of this act. b. Before revoking …

30:4D-8.21 Mandatory activities. 6. a. Each designated Regional Health Hub shall engage in the following mandatory activities: (1) establish, operate, and maintain a health information platform that allows for population-level views and analytics, and patient-level health interve…

30:4D-8.22 Submission of annual proposal. 7. a. Each Regional Health Hub shall annually submit a proposal to the department, describing the Regional Health Hub's annual goals, and the elective activities that the Regional Health Hub will undertake during the upcoming fiscal year.…

30:4D-8.23 Funding for Regional Health Hub. 8. a. A Regional Health Hub may be funded in part by the department, in accordance with the provisions of the annual appropriations act. As described in paragraph (4) of subsection e. of section 7 of this act, a portion of such funding …

30:4D-8.24 Health information platform. 9. a. A health information platform operated pursuant to paragraph (1) of subsection a. of section 6 of this act shall contain detailed health data from the Regional Health Hub's core region, including macro-level analytics of broad populat…

30:4D-8.25 Consultations relative to pilot program. 10. Any State department that implements a pilot program related to health care delivery shall be encouraged to consult with the Regional Health Hubs operating in the regions of the State that will be affected by the pilot progr…

30:4D-8.26 Application for amendments, waivers. 11. In addition to utilizing any State-appropriated funding that supports Regional Health Hubs, the Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions…

30:4D-8.27 Rules, regulations. 12. 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.), as may be necessary to implement the provisions of this act. L.2019, c.517, s.12.

30:4D-8.3 Establishment of three-year Medicaid ACO Demonstration Project. 3. a. The Department of Human Services shall establish a three-year Medicaid ACO Demonstration Project in which nonprofit corporations organized with the voluntary support and participation of local general…

30:4D-8.4 Applications for certification as a Medicaid ACO. 4. a. The department shall accept applications for certification from demonstration project applicants beginning 60 days following the effective date of this act, and shall certify an applicant as a Medicaid ACO for part…

30:4D-8.5 Eligibility to receive, distribute gainsharing payments. 5. a. A certified Medicaid ACO shall be eligible to receive and distribute gainsharing payments only after having received approval from the department of its gainsharing plan, which approval may be requested by t…

30:4D-8.6 Remission of payment to ACO. 6. The department shall remit payment of cost savings to a participating Medicaid ACO following approval by the department, in consultation with the Department of Health and Senior Services, of the ACO's gainsharing plan and identification o…

30:4D-8.7 Voluntary participation in demonstration project. 7. a. A managed care organization that has contracted with the department may voluntarily seek participation in the demonstration project by notifying the Medicaid ACO of its desire to participate. The ACO shall submit a…

30:4D-8.8 Duties of the department; authorization to seek grants. 8. a. The department, in consultation with the Department of Health, shall: (1) design and implement the application process for approval of participating ACOs in the demonstration project; (2) collect data from pa…

30:4D-8.9 Annual evaluation. 9. The department, in consultation with the Department of Health, shall evaluate the demonstration project annually to assess whether: cost savings, including, but not limited to, savings in administrative costs and savings due to improved health outc…

30:4D-9. Required contents of solicited bids and contracts Any bid solicited and any contract awarded by the commissioner in accordance with 8a, above shall contain: (1) The method of payment subject to an audit of cash needs as determined by the underwriter with approval of the …

30:4D-9.1 Medicaid contract providers to provide coverage regardless of gender identity, expression. 12. a. Notwithstanding the provisions of any other law or regulation to the contrary, any contract between a carrier and the Division of Medical Assistance and Health Services in …

30:4D-9.2 Medicaid to not provide coverage for certain early elective deliveries. 3. a. Notwithstanding the provisions of any other law or regulation to the contrary, any contract between a carrier and the Division of Medical Assistance and Health Services in the Department of Hu…

30:4E-1. Legislative findings and declaration The Legislature hereby finds and declares that the effective and appropriate provision of home health care and homemaker services to persons in their homes can be an important step toward eliminating not only the nursing home bed shor…

30:4E-10. Income eligibility Any person who is a resident of this State, with resources within limits set by the commissioner, and is 65 years of age or older and is eligible for Medicare benefits or has other medical insurance which includes physician coverage and hospitalizatio…

30:4E-11. Criteria for determining eligibility a. The commissioner shall establish criteria for determining medical and financial eligibility, including provisions for submission of proof of income, resources and health insurance, and a system of providing services to eligible pe…

30:4E-12. Medicaid recipients Notwithstanding any provisions of this act to the contrary, a person eligible for comparable home care services assistance available under Title XIX (Medicaid) of the federal Social Security Act (42 U.S.C. s. 1396 et seq.), but who does not receive t…