S4298

An Act concerning NJ FamilyCare reimbursement rates for pediatric dental services and supplies, and supplementing Title 30 of the Revised Statutes.

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. This act shall be known and may be cited as the “Healthy Smiles Act.”

2. The Legislature finds and declares that:

a. Oral health is a key indicator of overall health, well-being, and quality of life, and proper oral hygiene requires regular visits with a dentist as well as good oral health hygiene at home.

b. According to the American Academy of Pediatrics, the American Dental Association, the Centers for Disease Control, and many other scientific and medical institutions and experts, it is critical to begin oral health services at the age of one or when the teeth begin to erupt.

c. Because of the importance of early dental care, the NJ FamilyCare program includes regular dental care services and requires managed care organizations to assist in connecting each covered child to a dental home for a regular source of oral health services by the age of one.

d. Overall, New Jersey children have poorer dental health compared to children across the United States.

(1) New Jersey children have higher rates of untreated tooth decay, with 36 percent of third-graders experiencing tooth decay compared to the national average of 20 percent for the same age group.

(2) Low-income children fare even worse, with 24 percent of New Jersey’s Head Start children experiencing untreated tooth decay, compared to 12 percent nationwide.

(3) Disparities in dental health are also evident across race, with Black/African-American and Hispanic/Latinx children experiencing a higher prevalence of untreated tooth decay than their White, non-Hispanic counterparts.

e. In addition to physical health concerns, tooth loss can take a heavy psychological toll on individuals, causing them to feel less confident, more inhibited, and self-conscious about their appearance.

f. Despite the importance of oral health, low NJ FamilyCare reimbursement rates to providers of oral health services and supplies presents barriers to dental care for the 20 percent of New Jersey’s population enrolled in this health insurance program. Based on a national survey from 2020 by the American Dental Association, the NJ FamilyCare fee-for-service reimbursement rates for children are in the bottom 10 percent of the reimbursement rates paid in the country for dental services. These fee-for-service rates for children have not been comprehensively changed since 2007.

g. Low NJ FamilyCare reimbursement rates can significantly limit access to dental care for enrollees by reducing provider participation in the program, causing delays in securing appointments for recommended check-ups and for emergent concerns, and diminishing the quality of care delivered by network providers.

h. It is fitting and appropriate for the Legislature to address these long-standing issues before more children suffer from tooth decay and its serious consequences due to their inability to find dentists participating in NJ FamilyCare. Therefore, it is necessary for the Legislature to increase NJ FamilyCare reimbursement rates to providers of pediatric oral health services and supplies in order to ensure that the State’s most vulnerable residents can obtain the clinical care required to support proper oral hygiene and health.

3. As used in this act:

“Commissioner” means the Commissioner of Human Services.

“Division” means the Division of Medical Assistance and Health Services in the Department of Human Services.

“NJ FamilyCare” means the program established pursuant to P.L. 2005, c.156 (C.30:4J-8 et al.), which includes the Children’s Health Insurance Program and the Medicaid Program.

“Provider” means an individual or entity who, acting within the scope of its licensure pursuant to Title 45 of the Revised Statutes, renders oral health services and supplies to persons covered by NJ FamilyCare. “Provider” shall include a dentist, physician, or other health care professional licensed pursuant to Title 45 of the Revised Statutes acting within the scope of their licensure. “Provider” shall not include a dental service corporation, dental provider organization, organized delivery system, third party administrator, or similar entity.

4. a. Commencing upon July 1, 2025 or 60 days following the enactment of this act, whichever is later, the NJ FamilyCare fee-for-service reimbursement rates for covered oral health services and supplies for children under 21 years of age paid to a provider shall be increased by 20 percent from the NJ FamilyCare fee-for-service reimbursement rates in use upon the effective date of the this act for identical oral health services and supplies.

b. Commencing one year after the effective date of subsection a. of this section, and annually thereafter, the commissioner shall adjust the existing NJ FamilyCare fee-for-service reimbursement rates for covered oral health services and supplies for children under 21 years of age in direct proportion to any increase or decrease in the Consumer Price Index for All Urban Consumers as published by the United States Department of Labor for the Northeast region of the country in the previous January over the immediately preceding 12-month period.

5. a. The commissioner shall ensure that every contract entered into on and after the effective date of this act between the division and a managed care organization for the provision of health care services under NJ FamilyCare, including oral health services and supplies, provides that the reimbursement rates paid to a provider shall be equal to or greater than the NJ FamilyCare fee-for-service reimbursement rates for the identical oral health services and supplies for children under 21 years of age.

b. A managed care organization that pays a reimbursement rate to a provider in violation of subsection a. of this section shall be liable for a civil penalty of not more than $10,000 for each day that the non-compliant reimbursement rate was issued. Any penalties assessed under this section shall be collected by the commissioner in the name of the State in a summary proceeding in accordance with the “Penalty Enforcement Law of 1999,” P.L. 1999, c. 274 (C.2A:58-10 et seq.). The commissioner’s determination of a violation pursuant to this section shall be a final agency decision, subject to review by the Appellate Division of the Superior Court.

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 State NJ FamilyCare expenditures under the federal Medicaid Program and Children’s Health Insurance Program.

7. The Commissioner of Human Services, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt rules and regulations necessary to implement the provisions of this act.

8. The act shall take effect immediately.

STATEMENT

This bill makes certain adjustments to the NJ FamilyCare reimbursement rates for oral health services and supplies. The bill requires that, commencing upon July 1, 2025 or 60 days following the enactment of this bill, whichever is later, the NJ FamilyCare fee-for-service reimbursement rates for covered pediatric oral health services and supplies will be increased by 20 percent from the reimbursement rates in use for identical services at the time of the bill’s adoption.

Commencing one year after the implementation of the increased reimbursement rates, and annually thereafter, the bill directs the Commissioner of Human Services (commissioner) to adjust the existing fee-for-service reimbursement rates according to changes in the Consumer Price Index (CPI) for All Urban Consumers as published by the United States Department of Labor for the Northeast region of the country in the previous January over the immediately preceding 12-month period. For reference, in November 2024, the most recent time this data was assessed over a 12-month period, the CPI increased by 3.5 percent.

Finally, the commissioner is required to ensure that every contract entered into on and after the effective date of this bill between the State and a managed care organization (MCO) for the provision of NJ FamilyCare services provides that the reimbursement rates for pediatric oral health services and supplies are equal to or greater than the NJ FamilyCare fee-for-service reimbursement rates for the identical services and supplies.

Under the bill, an MCO in violation of this provision would be liable for a civil penalty of not more than $10,000 for each day that the non-compliant reimbursement rate was issued. Any penalties assessed are to be collected by the commissioner in the name of the State in a summary proceeding in accordance with State law. The commissioner’s determination regarding violations is the final agency decision, subject to review by the Appellate Division of the Superior Court.