in the news

UPDATE:  GOVERNOR MURPHY’S NJ STATE FISCAL YEAR 2026 BUDGET 

I attended in person, the Governor’s Budget Message and the Commissioner of Human Services, Medicaid Briefing.

For now, the proposed $58.1 billion budget is presented “status quo” without large programmatic cuts. However, the Governor did not rule out a “break the glass” emergency.

As you can see from the news coming out of Washington, DC, the House and US Senate passed different budget bills. There are also varying statements concerning the Medicaid/Medicare funding.

The Federal Medicaid funding is in danger, and everyone was encouraged to stay in contact with their representatives in Congress. New Jersey currently receives 50% federal match on Medicaid spending from the federal government. March 14 will be a pivotal day in Washington, DC as the final Congressional Resolution (CR) to fund the government as well as the debt ceiling must be re-authorized by Congress.

This state budget provides $6.3 billion for Medicaidmich for which we receive the same amount in federal matching funds. Currently, 1.8 million individuals utilize these programs.

Ambulatory Surgery Center Tax Changes

There are changes to the Ambulatory Surgery Center Tax that will negatively impact the owners of larger centers. Governor Murphy is proposing aligning the ASC tax rates with federal Medicaid Provider taxes allowing a reduction in the nominal rate from 2.95% to 2.5% but eliminating the cap. This is estimated to raise more than $60 million in new state revenues.

Primary Care Funding for Medicaid/Medicare Parity

An increase in current Medicaid Reimbursement for Primary Care. Including a new $49 million appropriation.

Attracting more OB-GYN’s

A new program to attract more OB-GYNs to New Jersey and retain the existing workforce is accomplished by increasing reimbursement rates.

Hospital Funding

Hospitals will receive $3.6 billion in direct state funding under this proposed budget. This represents $2.9 billion in increased funding since Governor Murphy took office.

Graduate Medical Education Funding

The proposed budget includes $336 million in funding including the supplemental and trauma components

This a partial list of some of the major healthcare components of the proposed budget. More will be provided in the next update. The Legislative review of the budget begins now. We will be fighting all elements of the budget that negatively impact on patient care….

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New Jersey State Legislative Update

Laurie Clark – Legislative Counsel to NJSIPP

February 13, 2025

We started the New Year with positive news on the legislative and regulatory fronts!

Telemedicine Parity Extension Signed into Law

Bill Was Signed on December 31

On December 19, both Houses of the Legislature voted to pass S2988/A3853 sponsored by Senator Vin Gopal and Assemblyman Herb Conaway.

This bill amends section 11 of P.L.2021, c.310 to extend the end date from December 31, 2024 to July 1, 2026 during which time a health benefits plan in this State is to provide coverage and payment for health care services delivered to a covered person through telemedicine or tele-health at a provider reimbursement rate that equals the provider reimbursement rate that is applicable, when the services are delivered through in-person contact and consultation in New Jersey, provided the services are otherwise covered by the health benefits plan when delivered through in-person contact and consultation in New Jersey.

The bills were signed into law on December 31. The law became effective immediately and extends the pay parity regulations for New Jersey Insurance Coverage until July 1, 2026.

Please note that Medicare Regulations on Telehealth Pay Parity have been extended until March of 2025. We await further Congressional action in the new session which begins tomorrow.

New Jersey Department of Banking and Insurance Issues Bulletin on Prior Authorization Law

On December 31, 2024, the New Jersey Department of Banking and Insurance issued several key bulletins effectuating the provisions of laws signed in the previous legislative session (2023). These Bulletins have the full force of law and are mandatory for compliance by insurance carriers operating in New Jersey beginning on January 1, 2025.

Please review the bulletin concerning prior authorization at the link below.

We are especially happy about the provisions that require a physician of the same specialty be directly involved with the internal appeal. Our society worked very hard on those provisions.

Personal Injury Protection Auto Insurance Reforms Underway

On Monday, the Senate Commerce Committee chaired by Senator Joseph Lagana reported favorably and with committee amendments Senate Bill No. 1473 (Lagana/Bramnick).

 As amended, this bill revises the personal injury protection coverage for basic automobile insurance policies from $15,000 to $20,000 and requires a minimum personal injury protection coverage of $50,000 for standard automobile liability insurance policies.  Under the bill, every basic automobile insurance policy will be required to provide personal injury protection coverage in an amount not to exceed $20,000 per person per accident, and every standard automobile liability insurance policy will be required to provide personal injury protection coverage that shall be no less than $50,000 per person per accident.  Current law requires basic automobile insurance policies to provide personal injury protection coverage in an amount not to exceed $15,000 per person per accident, with no minimums required for standard automobile liability insurance policies.  Additionally, the bill requires insurers to inform a named insured that policy limits for the insured’s standard automobile liability insurance policy or basic automobile insurance policy have increased during the renewal period of the policy but exempts insurers from needing a signed coverage selection form before increasing these limits.

 This bill was pre-filed for introduction in the 2024-2025 session pending technical review.  As reported, the bill includes the changes required by technical review, which has been performed.

COMMITTEE AMENDMENTS:

 The committee has amended the bill to:

 (1)  revise personal injury protection coverages for basic automobile insurance policies from $50,000 to $20,000; 

 (2)  require insurers to inform a named insured that policy limits have increased when the named insured has renewed a policy of insurance and exempt insurers from receiving a signed coverage selection form before increasing a policy’s limits;

 (3)  update current law reviewing personal injury protection options for standard automobile liability insurance policies;

 (4)  revise the effective date to require that the revised personal injury protection coverages for basic automobile insurance policies be implemented on the first day of the 18th month after the date of enactment of this bill; and

 (5)  make certain technical changes.

The bill is now on second reading and ready for a Senate floor vote.

In addition, work on a new PIP Fee Schedule is in progress. The goal is to have it in place by the end of 2025.

NJSIPP Executive Director Andy Kaufman, MD was a featured panelist at BioNJ’s Patient Advocacy Forum on December 13. The topic of the panel was “The Impact of Pharmacy Benefit Management Practices on Patients”

Dr. Kaufman ‘s participation was highly acclaimed and of great assistance to the patient advocates in attendance.

Dr. Woska being honored for his service to our society as the Executive Director for the past 5 years. We congratulate him for all the time and effort that he put forth and the excellent job that he did.

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• Proposed Medicare National Coverage Determination for Epidural Steroid Injection

  Effective 12/05/2021

  The link to the policy is available here:

  https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38994&ver=7&bc=0

   

  Covered Indications

• History, physical examination, and concordant radiological image-based diagnostic testing and supporting one of the following:

  Cervical, Thoracic, or Lumbar radiculopathy, radicular pain and/or neurogenic claudication due to central disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis.

  OR

  Post-laminectomy syndrome

  Acute herpes zoster associated pain

  AND

  Symptoms severe enough to impact quality of life or function. An objective pain scale or functional assessment must be performed prior and repeated following intervention to assess response.

  AND

  Pain duration of at least 4 weeks, and in the inability to tolerate noninvasive conservative care or failure to respond to 4 weeks of noninvasive conservative care.

  *Acute herpes zoster pain refractory to conservative care, 4 week wait is not required

• 2. ESI must be performed under CT or fluoroscopy image guidance with contrast,unless the patient has a documented contrast allergy or pregnancy where ultrasound guidance without contrast may be considered.

• 3. Transforaminal EPIDURAL steroid injections (TFESIs) involving a maximum of two (2) levels in one spinal region are considered medically reasonable and necessary. It is important to recognize that most conditions would not ordinarily require ESI at two (2) levels in one spinal region.

• 4. Caudal EPIDURAL steroid injections (CESIs) and interlaminar EPIDURAL steroid injections (ILESIs) involving a maximum of one level are considered medically reasonable and necessary.

• 5.  It is medically reasonable and necessary to perform TFESIs bilaterally only when clinically indicated.

• 6. Repeat ESI when the first injection:

7.   An initial injection of contrast is required to confirm epidural placement unless the patient has a contraindication to contrast. The subsequent epidural steroid injections should include corticosteroids and may be combined with anesthetics or saline.

8.   The ESIs should be performed in conjunction with conservative treatments.

9.   Patients should be part of an active rehabilitation program, home exercise program or functional restoration program. 

3.   It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic blocks, facet blocks, trigger point injections etc.) during the same session as ESIs, with the exception of a facet synovial cyst and ESI performed in the same session

 4.     Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore not considered medically reasonable and necessary.Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific patient.

5.   ESIs to treat non-specific low back pain (LBP), axial spine pain, complex regional pain syndrome, widespread diffuse pain, pain from neuropathy from other causes, cervicogenic headaches are considered investigational and therefore are not considered medically reasonable and necessary.

6.   ESIs are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period.

7.   It is not considered medically reasonable and necessary for more than one spinal region to be injected in the same session.

8.   It is not considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve root levels during the same session.

9.   It is not considered medically reasonable and necessary to perform CESIs or ILESIs at more than one (1) level during the same session.

10.   It is not medically reasonable and necessary to perform CESIs or ILESIs bilaterally.

11.   It is not medically reasonable and necessary to prescribe a predetermined series of ESIs.

12. Steroid dosing should be the lowest effective amount, it is recommended not to exceed 80mg of triamcinolone, 12 mg of betamethasone, 15 mg of dexamethasone per session.

13. It generally would not be considered medically reasonable and necessary for treatment with ESI to extend beyond 12 months.Frequent continuation of epidural steroid injections over 12 months may trigger a focused medical review. Use beyond twelve months requires the following:

a.   Pain is severe enough to cause a significant degree of functional disability or vocational disability.

b.   ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline).

c.   Rationale for the continuation of ESIs including but not limited to patient is high-risk surgical candidates, the patient does not desire surgery, recurrence of pain in the same location relieved with ESIs for at least three months

d.   The primary care provider must be notified regarding continuation of procedures and prolonged repeat steroid use.

14. ESIs should not be performed when contraindicated including but not limited to: suspected or active localized spinal infection, significant systemic infection, compressive lesions of the spinal cord, conus medullaris or cauda equina, suspicion or major risk factors for cancer.

Update on New Medicare Facet Rules

Dr. Steve Aydin created this informative presentation that was shared during the NJSIPP Annual Fall Meeting.  We thank him for sharing his slides below.

OPEN PRESENTATION