New Jersey Children with Medicaid Struggle to Get the Care They Need

UPDATE – August 3, 2021:  The legislation that will ensure that all New Jersey kids have access to the healthcare they need has passed out of the New Jersey legislature and is headed to Governor Phil Murphy for his signature.

Your voice and support are still needed! Please click HERE to let Governor Murphy know that you support this legislation and that it is a priority for New Jersey families.

Below, please find additional background on this issue.

Right now, thousands of New Jersey’s kids are struggling to access the comprehensive and integrated pediatric care they need. Many of these children have complex or rare medical conditions. Many others just need a specialist close to home.

This applies to all children whose health coverage is through a NJ Medicaid managed care plan. At the current time, there is no NJ Managed Medicaid health plan with Children’s Hospital of Philadelphia (CHOP) in its network. While some of these children might ultimately receive approval for the specialized care CHOP provides, the process for obtaining this approval is challenging, especially for vulnerable populations, and places hurdles between children and the care their providers know they need. We believe that physicians should be able to refer families to pediatric specialty care, and children should be able to receive that care, based on the type and level of care a child needs, not based on the form of insurance a child has.

There should be no barriers to children getting necessary care, regardless of income. For that reason, we have aggressively pursued in-network agreements with every NJ Medicaid managed care plan. At this moment, no NJ Medicaid plan has CHOP in-network.

What CHOP is doing to help children

At CHOP, in addition to continuing our push to be in-network with NJ Medicaid plans, our Government Affairs team and many teams across the CHOP Care Network are working together to find other solutions for these New Jersey families. We are advocating for a legislative solution to ensure that all of New Jersey’s kids who have Medicaid managed health plans have in-network access to pediatric specialists within easy distance of their homes. This will help all of these kids, and especially those with complex or rare conditions, by ensuring they can more easily get care without burdensome travel. We hope it will enable CHOP to be in plan networks, enabling these children to access CHOP without unnecessary barriers, but what matters most is that kids get the care they need without unnecessary hurdles.

Key points for understanding S300

• S3000 does require Medicaid managed care organizations to include the full range of pediatric services in-network, which means no time-consuming special agreement is needed for families to access care; just the normal referral process establishing a need for the care;
• S3000 does require that the care be within certain time-and-distance guidelines from the family. These standards do differentiate based on the county where the family lives;
• S3000 does establish a 30-day grievance process through which families or providers can raise concerns that the required care, within the required time and distance, is not being provided as required by the legislation;
• S3000 does create a process under which Medicaid managed care organizations can establish that, despite a good faith effort, the care cannot be provided in-network and/or within the established time-and-distance requirements, allowing the Medicaid managed care organization to rely on a single case agreement, or similar arrangement, to approve the care in a timely fashion similar to that of an in-network provider;
• S3000 does require the state to establish an oversight process (AND PROMISE BY SENATE AND ASSEMBLY TO OVERSEE ENFORCEMENT) for ensuring that Medicaid managed care organizations follow the requirements established by the legislation;
• S3000 does not require that a Medicaid managed care organization include Children’s Hospital of Philadelphia or any particular provider in-network to meet its obligations under the law;
• S3000 does not permit that a provider or family insist on care with a particular provider unless that care is not otherwise available within the limits defined in the legislation;
• S3000 does not provide all of the detail necessary for the legislation to be implemented; instead, all stakeholders will have to work with the Administration on more detailed regulations necessary for implementation;
• S3000 does not take immediate effect; instead, if signed this summer, the soonest the law could be implemented is January 2022.

Download key points for understanding Senate Bill S300.

What you can do to help

Please click HERE to let Governor Murphy know that you support this legislation and that it is a priority for New Jersey families.

For more information about this important initiative, please reach out to CHOP’s Government Affairs Department at GOVTAffairs@chop.edu.

Thank you so much for your time and support. Please know every message counts.