New Jersey § 30:4d-6

§ 30:4d-6.

a. Subject to the requirements of Title XIX of the federal Social Security Act, 1 the limitations imposed by this act and by the rules and regulations promulgated

pursuant thereto, the department shall provide medical assistance to qualified applicants,

including authorized services within each of the following classifications: (1) Inpatient hospital services; (2) Outpatient hospital services; (3) Other laboratory and X-ray services; (4) (a). Skilled nursing or intermediate care facility services; (b) Early and periodic screening and diagnosis of individuals who are eligible under

the program and are under age 21, to ascertain their physical or mental health status

and the health care, treatment, and other measures to correct or ameliorate defects

and chronic conditions discovered thereby, as may be provided in regulation of the

Secretary of the federal Department of Health and Human Services and approved by the

commissioner; (5) Physician's services furnished in the office, the patient's home, a hospital,

a skilled nursing, or intermediate care facility or elsewhere. As used in this subsection, “ laboratory and X-ray services ” includes HIV drug resistance testing, including, but not limited to, genotype assays

that have been cleared or approved by the federal Food and Drug Administration, laboratory

developed genotype assays, phenotype assays, and other assays using phenotype prediction

with genotype comparison, for persons diagnosed with HIV infection or AIDS. b. Subject to the limitations imposed by federal law, by this act, and by the rules

and regulations promulgated pursuant thereto, the medical assistance program may be

expanded to include authorized services within each of the following classifications: (1) Medical care not included in subsection a.(5) above, or any other type of remedial care recognized under State law, furnished

by licensed practitioners within the scope of their practice, as defined by State

law; (2) Home health care services; (3) Clinic services; (4) Dental services; (5) Physical therapy and related services; (6) Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed

by a physician skilled in diseases of the eye or by an optometrist, whichever the

individual may select; (7) Optometric services; (8) Podiatric services; (9) Chiropractic services; (10) Psychological services; (11) Inpatient psychiatric hospital services for individuals under 21 years of age,

or under age 22 if they are receiving such services immediately before attaining age

21; (12) Other diagnostic, screening, preventative, and rehabilitative services, and other

remedial care; (13) Inpatient hospital services, nursing facility services, and immediate care facility

services for individuals 65 years of age or over in an institution for mental diseases; (14) Intermediate care facility services; (15) Transportation services; (16) Services in connection with the inpatient or outpatient treatment or care of

substance use disorder, when the treatment is prescribed by a physician and provided

in a licensed hospital or in a narcotic and substance use disorder treatment center

approved by the Department of Health pursuant to P.L.1970, c. 334 ( C.26:2G-21 et. seq. ) and whose staff includes a medical director, and limited those services eligible

for federal financial participation under Title XIX of the federal Social Security

Act; (17) Any other medical care and any other type of remedial care recognized under State

law, specified by the Secretary of the federal Department of Health and Human Services,

and approved by the commissioner; (18) Comprehensive maternity care, which may include: the basic number of prenatal

and postpartum visits recommended by the American College of Obstetrics and Gynecology;

additional prenatal and postpartum visits that are medically necessary; necessary

laboratory, nutritional assessment and counseling, health education, personal counseling,

managed care, outreach, and follow-up services; treatment of conditions which may

complicate pregnancy doula care; and physician or certified nurse midwife delivery

services. For the purposes of this paragraph, “ doula ” means a trained professional who provides continuous physical, emotional, and informational

support to a mother before, during, and shortly after childbirth, to help her to achieve

the healthiest, most satisfying experience possible; (19) Comprehensive pediatric care, which may include: ambulatory, preventive, and

primary care health services. The preventive services shall include, at a minimum, the basic number of preventive

visits recommended by the American Academy of Pediatrics; (20) Services provided by a hospice which is participating in the Medicare program

established pursuant to Title XVIII of the Social Security Act, Pub.L.89-97 ( 42 U.S.C. s.1395 et seq. ). Hospice services shall be provided subject to approval of the Secretary of the federal

Department of Health and Human Services for federal reimbursement; (21) Mammograms, subject to approval of the Secretary of the federal Department of

Health and Human Services for federal reimbursement, including one baseline mammogram

for women who are at least 35 but less than 40 years of age; one mammogram examination

every two years or more frequently, if recommended by a physician, for women who are

at least 40 but less than 50 years of age; and one mammogram examination every year

for women age 50 and over; (22) Upon referral by a physician, advanced practice nurse, or physician assistant

of a person who has been diagnosed with diabetes, gestational diabetes, or pre-diabetes,

in accordance with standards adopted by the American Diabetes Association: (a) Expenses for diabetes self-management education or training to ensure that a person

with diabetes, gestational diabetes, or pre-diabetes can optimize metabolic control,

prevent and manage complications, and maximize quality of life. Diabetes self-management education shall be provided by an in-State provider who is: (i) a licensed, registered, or certified health care professional who is certified

by the National Certification Board of Diabetes Educators as a Certified Diabetes

Educator, or certified by the American Association of Diabetes Educators with a Board

Certified-Advanced Diabetes Management credential, including, but not limited to:

a physician, an advanced practice or registered nurse, a physician assistant, a pharmacist,

a chiropractor, a dietitian registered by a nationally recognized professional association

of dietitians, or a nutritionist holding a certified nutritionist specialist (CNS)

credential from the Board for Certification of Nutrition Specialists; or (ii) an entity meeting the National Standards for Diabetes Self-Management Education

and Support, as evidenced by a recognition by the American Diabetes Association or

accreditation by the American Association of Diabetes Educators; (b) Expenses for medical nutrition therapy as an effective component of the person's

overall treatment plan upon a: diagnosis of diabetes, gestational diabetes, or pre-diabetes;

change in the beneficiary's medical condition, treatment, or diagnosis; or determination

of a physician, advanced practice nurse, or physician assistant that reeducation or

refresher education is necessary. Medical nutrition therapy shall be provided by an in-State provider who is a dietitian

registered by a nationally-recognized professional association of dietitians, or a

nutritionist holding a certified nutritionist specialist (CNS) credential from the

Board for Certification of Nutrition Specialists, who is familiar with the components

of diabetes medical nutrition therapy; (c) For a person diagnosed with pre-diabetes, items and services furnished under an

in-State diabetes prevention program that meets the standards of the National Diabetes

Prevention Program, as established by the federal Centers for Disease Control and

Prevention; and (d) Expenses for any medically appropriate and necessary supplies and equipment recommended

or prescribed by a physician, advanced practice nurse, or physician assistant for

the management and treatment of diabetes, gestational diabetes, or pre-diabetes, including,

but not limited to: equipment and supplies for self-management of blood glucose;

insulin pens; insulin pumps and related supplies; and other insulin delivery devices; (23) Expenses incurred for the provision of group prenatal services to a pregnant

woman, provided that: (a) the provider of such services, which shall include, but not be limited to, a federally

qualified health center or a community health center operating in the State: (i) is a site accredited by the Centering Healthcare Institute, or is a site engaged

in an active implementation contract with the Centering Healthcare institute, that

utilizes the Centering Pregnancy model; and (ii) incorporates the applicable information outlined in any best practices manual

for prenatal and postpartum maternal care developed by the Department of Health into

the curriculum for each group prenatal visit; (b) each group prenatal care visit is at least 1.5 hours in duration, with a. minimum

of two women and a maximum of 20 women in participation; and (c) no more than 10 group prenatal care visits occur per pregnancy. As used in this paragraph, “ group prenatal care services ” means a series of prenatal care visits provided in a group setting which are based

upon the Centering Pregnancy model developed by the Centering Healthcare Institute

and which include health assessments, social and clinical support, and educational

activities; (24) Expenses incurred for the provision of pasteurized donated human breast milk,

which shall include human milk fortifiers if indicated in a medical order provided

by a licensed medical practitioner, to an infant under the age of six months; provided

that the milk is obtained from a human milk bank that meets quality guidelines established

by the Department of Health and a licensed medical practitioner has issued a medical

order for the infant under at least one of the following circumstances: (a) the infant is medically or physically unable to receive maternal breast milk or

participate in breast feeding, or the infant's mother is medically or physically unable

to produce maternal breast milk in sufficient quantities or participate in breast

feeding despite optimal lactation support; or (b) the infant meets any of the following conditions: (i) a body weight below healthy levels, as determined by the licensed medical practitioner

issuing the medical order for the infant; (ii) the infant has a congenital or acquired condition that places the infant at a

high risk for development of necrotizing enterocolitis; or (iii) the infant has a congenital or acquired condition that may benefit from the

use of donor breast milk and human milk fortifiers, as determined by the Department

of Health; (25) Comprehensive tobacco cessation benefits to an individual who is 18 years of

age or older, or who is pregnant. Coverage shall include: brief and high intensity individual counseling, brief and

high intensity group counseling, and telemedicine as defined by section 1 of P.L.2017, c. 117 ( C.45:1-61 ); all medications approved for tobacco cessation by the U.S. Food and Drug Administration;

and other tobacco cessation counseling recommended by the Treating Tobacco Use and

Dependence Clinical Practice Guideline issued by the U.S. Public Health Service. Notwithstanding the provisions of any other law, rule, or regulation to the contrary,

and except as otherwise provided in this section: (a) Information regarding the availability of the tobacco cessation services described

in this paragraph shall be provided to all individuals authorized to receive the tobacco

cessation services pursuant to this paragraph at the following times: no later than

90 days after the effective date of P.L.2019, c. 473 : upon the establishment of an individual's eligibility for medical assistance; and

upon the redetermination of an individual's eligibility for medical assistance; (b) The following conditions shall not be imposed on any tobacco cessation services

provided pursuant to this paragraph: copayments or any other forms of cost-sharing,

including deductibles; counseling requirements for medication; stepped care therapy

or similar restrictions requiring the use of one service prior to another; limits

on the duration of services; or annual or lifetime limits on the amount, frequency,

or cost of services, including, but not limited to, annual or lifetime limits on the

number of covered attempts to quit; and (c) Prior authorization requirements shall not be imposed on any tobacco cessation

services provided pursuant to this paragraph except in the following circumstances

where prior authorization may be required: for a treatment that exceeds the duration

recommended by the most recently published United States Public Health Service clinical

practice guidelines on treating tobacco use and dependence; or for services associated

with more than two attempts to quit within a 12-month period; (26) Provided that there is federal financial participation available, benefits for

expenses incurred in conducting a colorectal cancer screening in accordance with United

States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with

the most recent published recommendations of the United States Preventive Services

Task Force and as determined medically necessary by the covered person's physician,

in consultation with the covered person. No deductible, coinsurance, copayment, or any other cost-sharing requirement shall

be imposed for a colonoscopy performed following a positive result on a non-colonoscopy,

colorectal cancer screening test recommended by the United States Preventive Services

Task Force ; and (27)(a) Within 24 months of the effective date of P.L.2023, c. 187 ( C.30:4D-6u et al.), and conditional on the receipt of all necessary federal approvals and the

securing of federal financial participation pursuant to section 2 of P.L.2023, c. 187 ( C.30:4D-6u ), community-based palliative care benefits which shall include, but not be limited

to, all of the following: (i) specialized medical care and emotional and spiritual support for beneficiaries

with serious advanced illnesses; (ii) relief of symptoms, pain, and stress of serious illness; (iii) improvement of quality of life for both the beneficiary and the beneficiary's

family; and (iv) appropriate care for any age and for any stage of serious illness, along with

curative treatment. (b) Benefits provided under this paragraph shall include, but shall not be limited

to, services provided by a hospice pursuant to paragraph (20) of subsection b. of

this section, provided that: (i) hospice services may be provided at the same time that curative treatment is available,

to the extent that services are not duplicative; (ii) hospice services may be provided to beneficiaries whose conditions may result

in death, regardless of the estimated length of the beneficiary's remaining period

of life; and (iii) the Division of Medical Assistance and Health Services in the Department of

Human Services may include any other service deemed appropriate under the benefits

provided under this paragraph. (c) Providers authorized to deliver benefits provided under this paragraph shall include

Medicaid-approved licensed hospice agencies, Medicaid-approved home health agencies

licensed to provide hospice care, and other Medicaid-approved licensed health care

providers. (d) Nothing in this paragraph shall be construed to result in the elimination or reduction

of covered benefits or services under the Medicaid program. (e) This paragraph shall not affect a beneficiary's eligibility to receive, concurrently

with services provided for in this paragraph, any services, including home health

services, for which the beneficiary would have been eligible in the absence of this

paragraph, to the extent that services are not duplicative . c. Payments for the foregoing services, goods and supplies furnished pursuant to this

act shall be made to the extent authorized by this act, the rules and regulations

promulgated pursuant thereto and, where applicable, subject to the agreement of insurance

provided for under this act. The payments shall constitute payment in full to the provider on behalf of the recipient. Every provider making a claim for payment pursuant to this act shall certify in

writing on the claim submitted that no additional amount will be charged to the recipient,

the recipient's family, the recipient's representative or others on the recipient's

behalf for the services, goods, and supplies furnished pursuant to this act. No provider whose claim for payment pursuant to this act has been denied because the

services, goods, or supplies were determined to be medically unnecessary shall seek

reimbursement form the recipient, his family, his representative or others on his

behalf for such services, goods, and supplies provided pursuant to this act; provided,

however, a provided may seek reimbursement from a recipient for services, goods, or

supplies not authorized by this act, if the recipient elected to receive the services,

goods or supplies with the knowledge that they were not authorized. d. Any individual eligible for medical assistance (including drugs) may obtain such

assistance from any person qualified to 33 perform the service or services required

(including an organization which provides such services, or arranges for their availability

on a prepayment basis), who undertakes to provide the individual such services. No copayment or other form of cost-sharing shall be imposed on any individual eligible

for medical assistance, except as mandated by federal law as a condition of federal

financial participation. e. Anything in this act to the contrary notwithstanding, no payments for medical assistance

shall be made under this act with respect to care or services for any individual who: (1) Is an inmate of a public institution (except as a patient in a medical institution);

provided, however, that an individual who is otherwise eligible may continue to receive

services for the month in which he becomes an inmate, should the commissioner determine

to expand the scope of Medicaid eligibility to include such an individual, subject

to the limitations imposed by federal law and regulations, or (2) Has not attained 65 years of age and who is a patient in an institution for mental

diseases, or (3) Is over 21 years of age and who is receiving inpatient psychiatric hospital services

in a psychiatric facility; provided, however, that an individual who was receiving

such services immediately prior to attaining age 21 may continue to receive such services

until the individual reaches age 22. Nothing in this subsection shall prohibit the commissioner from extending medical

assistance to all eligible persons receiving inpatient psychiatric services; provided

that there is federal financial participation available. f. (1) A third party as defined in section 3 of P.L.1968, c. 413 ( C.30:4D-3 ) shall not consider a person's eligibility for Medicaid in this or another state

when determining the person's eligibility for enrollment or the provision of benefits

by that third party. (2) In addition, any provision in a contract of insurance, health benefits plan, or

other health care coverage document, will, trust, agreement, court order, or other

instrument which reduces or excludes coverage or payment for health care-related goods

and services to or for an individual because of that individual's actual or potential

eligibility for or receipt of Medicaid benefits shall be null and void, and no payments

shall be made under this act as a result of any such provision. (3) Notwithstanding any provision of law to the contrary, the provisions of paragraph

(2) of this subsection shall not apply to a trust agreement that is established pursuant

to 42 U.S.C. s.1396p(d)(4)(A) or (C) to supplement and augment assistance provided by government entities to a person

who is disabled as defined in section 1614(a)(3) of the federal Social Security Act

( 42 U.S.C. s.1382c (a)(3) ). g. The following services shall be provided to eligible medically needy individuals

as follows: (1) Pregnant women shall be provided prenatal care and delivery services and postpartum

care, including the services cited in subsections a.(1), (3), and (5) of this section and subsections b.(1)-(10), (12), (15), and (17) of this section, and nursing facility services cited

in subsection b.(13) of this section. (2) Dependent children shall be provided with services cited in subsections a.(3) and (5) of this section and subsections b.(1), (2), (3), (4), (5), (6), (7), (10), (12), (15), and (17) of this section, and

nursing facility services cited in subsection b.(13) of this section. (3) Individuals who are 65 years of age or older shall be provided with services cited

in subsections a.(3) and (5) of this section and subsections b.(1)-(5), (6) excluding prescribed drugs, (7), (8), (10), (12), (15), and (17) of this

section, and nursing facility services cited in subsection b.(13) of this section. (4) Individuals who are blind or disabled shall be provided with services cited in

subsections a.(3) and (5) of this section and subsections b.(1)-(5), (6) excluding prescribed drugs, (7), (8), (10), 3 (12), (15), and (17) of

this section, and nursing facility services cited in subsection b.(13) of this section. (5)(a) Inpatient hospital services, subsection a.(1) of this section, shall only be provided to eligible medically needy individuals,

other than pregnant women, if the federal Department of Health and Human Services

discontinues the State's waiver to establish inpatient hospital reimbursement rates

for the Medicare and Medicaid programs under the authority of section 601(c)(3) of

the Social Security Act Amendments of 1983, Pub.L.98-21 ( 42 U.S.C. s.1395ww(c)(5) ). Inpatient hospital services may be extended to other eligible medically needy individuals

if the federal Department of Health and Human Services directs that these services

be included. (b) Outpatient hospital services, subsection a.(2) of this section, shall only be provided to eligible medically needy individuals

if the federal Department of Health and Human Services discontinues the State's waiver

to establish outpatient hospital reimbursement rates for the Medicare and Medicaid

programs under the authority of section 601(c)(3) of the Social Security Amendments

of 1983, Pub.L.98-21 ( 42 U.S.C. s.1395ww(c)(5) ). Outpatient hospital services may be extended to all or to certain medically needy

individuals if the federal Department of Health and Human Services directs that these

services be included. However, the use of outpatient hospital services shall be limited to clinic services

and to emergency room services for injuries and significant acute medical conditions. (c) The division shall monitor the use of inpatient and outpatient hospital services

by medically needy persons. h. In the case of a qualified disabled and working individual pursuant to section 6408 of Pub.L.101-239 ( 42 U.S.C. s.1396d ), the only medical assistance provided under this act shall be the payment of premiums

for Medicare part A under 42 U.S.C. ss.1395i-2 and 1395r. i. In the case of a specified low-income Medicare beneficiary pursuant to 42 U.S.C. s.1396a(a) 10(E) iii, the only medical assistance provided under this act shall be the payment of premiums

for Medicare part B under 42 U.S.C. s.1395r as provided for in 42 U.S.C. s.1396d(p)(3)(A)(ii) . j. In the case of a qualified individual pursuant to 42 U.S.C. s.1396a(aa) , the only medical assistance provided under this act shall be payment for authorized

services provided during the period in which the individual requires treatment for

breast or cervical cancer, in accordance with criteria established by the commissioner. k. In the case of a qualified individual pursuant to 42 U.S.C. s.1396a(ii) , the only medical assistance provided under this act shall be payment for family

planning services and supplies as described at 42 U.S.C. s.1396d(a)(4)(C) , including medical diagnosis and treatment services that are provided pursuant to

a family planning service in a family planning setting. 1

42 U.S.C.A. § 1396 et seq.