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Now Law: Benson, Verrelli & Vainieri Huttle Bill Establishing Network Adequacy Standards for Pediatric Care in Medicaid

To ensure more New Jersey children covered under Medicaid have access to the medical care they need, the Governor recently signed a bill sponsored by Assembly Democrats Daniel Benson, Anthony Verrelli and Valerie Vainieri Huttle into law that will establish and codify certain network adequacy standards for pediatric care.

Previously, Medicaid managed care organization (MCO) networks were required to ensure that 90 percent of their enrollees were within 60 minutes or 45 miles of each type of medical specialist. Under the new law (formerly bill A-4688/S-3000), those requirements will be changed for pediatric primary care and specialty care in order to improve accessibility for children covered under New Jersey’s Medicaid program.

Going forward, 90 percent of pediatric Medicaid enrollees in urban counties must have access to at least two eligible primary care providers (PCPs) within five miles or 10 minutes driving/public transit time while 90 percent of those in non-urban counties must be able to access two PCPs within 10 miles or 15 minutes. All pediatric enrollees must live no more than 30 minutes from at least one eligible PCP.

“Access to adequate medical care is absolutely crucial for the health and well-being of the children in our state,” said Assemblyman Benson (D-Mercer, Middlesex). “More than 550,000 children enrolled in our Medicaid program – including many with special needs – are counting on New Jersey for sufficient healthcare coverage. Raising the standards for pediatric network adequacy will help give our children the care they deserve and set them up for better, healthier futures.”

Contracts with Medicaid MCOs must also be revised going forward to ensure networks include a sufficient number of pediatric medical specialists within 15 miles or 30 minutes of 90 percent of enrollees in urban counties, and within 40 miles or 60 minutes of those in non-urban counties. Medical specialties represented within the network must include allergy/immunology, cardiology, radiology, ophthalmology, gastroenterology, dermatology, neurology, orthopedics, and more.

The law also mandates a sufficient number of pediatric oncologists, psychiatrists, and developmental/behavioral pediatricians within 10 miles or 20 minutes of enrollees in urban counties and 30 miles or 45 minutes of enrollees in non-urban counties.

“Many working-class families simply do not have the ability to travel long distances for their medical care,” said Assemblyman Verrelli (D-Hunterdon, Mercer). “No parent should have to worry whether they will be able to find a nearby provider to care for their child during an acute or ongoing medical crisis. Improving access to necessary health care providers for children enrolled in our Medicaid program will help improve health parity throughout our state.”

MCOs that cannot meet certain network requirements may request a waiver for those provision(s), but must demonstrate an active, good-faith effort to meet all necessary requirements in that region. In the event a patient needs services that are not yet available in their network and the MCO was unable to obtain a waiver, the MCO must initiate negotiations with non-participating providers and cannot balance-bill or impose any cost-sharing that exceeds the legal limit of the program.

MCOs must also establish a process by which patients or providers can submit a grievance regarding adequacy of their network.

“Our children’s welfare must always be one of New Jersey’s most important priorities,” said Assemblywoman Vainieri Huttle (D-Bergen). “An adequate network of providers can make all the difference in a child’s life, especially if they struggle with complex medical needs. This law will facilitate better access to local providers of all different specialties so that those needs can be adequately addressed.”

The Division of Medical Assistance and Health Services (DMAHS) within the Department of Human Services will be responsible for amending the Medicaid MCO contracts, processing waiver requests, assessing the adequacy of MCO networks, and enforcing appropriate sanctions for non-compliance.

The law will take effect three months from now.