Bill Text: NJ A5209 | 2026-2027 | Regular Session | Introduced
Bill Title: Requires health insurers to provide reason for denial of coverage for private duty nursing.
Sponsorship: Partisan Bill (Democrat 1)
Status: (Introduced) 2026-06-04 - Introduced, Referred to Assembly Oversight, Reform and Federal Relations Committee [A5209 Detail]
Download: New_Jersey-2026-A5209-Introduced.html
Sponsored by:
Assemblyman ALEXANDER "AVI" SCHNALL
District 30 (Monmouth and Ocean)
SYNOPSIS
Requires health insurers to provide reason for denial of coverage for private duty nursing.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health insurance coverage and private duty nursing and supplementing P.L.2023, c.296 (C.17B:30-55.1 et seq.).
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. If a payer denies a prior authorization request for private duty nursing services that has been determined to be medically necessary by the covered person's physician, the payer shall provide a full description of the reason for the denial. If the denial is based on a finding that the private duty nursing services are not medically necessary, the payer shall provide, in addition to its reason for that finding, an explanation of why the determination of the covered person's physician is invalid. The explanation shall include the criteria the payer uses in evaluating prior authorization requests for private duty nursing services and shall provide examples of when prior authorization requests for private duty nursing are approved, including the submitted documentation necessary for those approvals.
2. This act shall take effect on the 90th day next following the date of enactment.
STATEMENT
This bill requires health insurers to provide a reason for the denial of coverage for private duty nursing services.
Specifically, if a payer denies a prior authorization request for private duty nursing services that has been determined to be medically necessary by the covered person's physician, the bill requires the payer to provide a full description of the reason for the denial. If the denial is based on a finding that the private duty nursing services are not medically necessary, the payer is required to provide its rationale for that finding, including an explanation of why the determination of the covered person's physician is invalid. The payer is also required to provide examples of when prior authorization requests for private duty nursing are approved, including the submitted documentation necessary for those approvals.
