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A 4485

Establishes minimum Medicaid reimbursement rate for structured day program services provided to beneficiary eligible for brain injury services.

2026-2027 Regular Session Introduced by Rosy Bagolie and 8 co-sponsors

Establishes minimum per diem rates for Structured Day Program Services aligned to Day Habilitation rates to ensure predictable, adequate Medicaid reimbursement for brain injury pro

Reported and Referred to Assembly Appropriations Committee
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Bill Summary · A 4485

Summary of New Jersey A 4485 (Session 222)

Purpose and Intent

A 4485 seeks to establish a minimum Medicaid reimbursement rate for structured day program services provided to Medicaid beneficiaries eligible for brain injury services. The bill extends existing minimum reimbursement requirements (which currently cover community residential services) to include Structured Day Program Services. The overall aim is to ensure that structured day programs receive a predictable, adequate per diem/encounter rate comparable to other brain injury-related services.

Key Provisions

  • Minimum Reimbursement Rates Established
    The bill amends P.L.2022, c.78 to set minimum per diem or encounter reimbursement rates for brain injury services, specifically adding Structured Day Program Services to the list. The rate structure is tied to comparable rates within the Division of Developmental Disabilities (DDD) system:

    • Community Residential Services - Low Supervision: Equal to the rate for Individuals Supports Services – Tier B (DDD-based).
    • Community Residential Services - Moderate Supervision: Equal to the rate for Individuals Supports Services – Tier C (DDD-based).
    • Community Residential Services - High Supervision: Equal to the average of the Day Habilitation Services – Tiers D and E (DDD-based).
    • Structured Day Program Services: Equal to the average of Day Habilitation Services – Tiers D and E (DDD-based). The current reference rate for this average is $9.89 per 15 minutes.

  • Definitions (as part of Section 2):

    • Clarifies what constitutes a brain injury service, brain injury service providers, and the scope of Medicaid delivery systems (fee-for-service or managed care).
    • Distinguishes between traumatic and non-traumatic brain injuries and defines relevant terms.

  • Regulatory Authority
    The Commissioner of Human Services would adopt rules and regulations necessary to implement the act, in accordance with the Administrative Procedure Act.

  • Effective Date and Application
    The act takes effect 30 days after enactment and applies to:

    • Services provided on or after the effective date.
    • Medicaid managed care contracts executed or renewed on or after the effective date.

Who Is Affected

  • Beneficiaries: Medicaid beneficiaries requiring treatment for brain injuries who access structured day programs.
  • Brain Injury Service Providers: Approved providers delivering structured day programs and other brain injury services.
  • State Agencies: Department of Human Services (and the Division of Disability Services), which administers Medicaid brain injury services and sets related rates; the Commissioner would implement regulations.

Procedural and Timeline Aspects

  • Legislative Path: Introduced in the Assembly on February 24, 2026, referred to the Assembly Aging and Human Services Committee. Co-sponsors include multiple Assembly members.
  • Effective Date: 30 days after enactment.
  • Implementation Scope: Applies to services and to new or renewed Medicaid managed care contracts from the effective date forward.

Practical Impact

  • Provides a defined, minimum payment floor for Structured Day Program Services, aligning these rates with established DDD-based Day Habilitation rate structures.
  • Aims to improve compensation adequacy for structured day programs serving brain injury beneficiaries, potentially influencing program viability, service availability, and long-term sustainability of brain injury-related supports within Medicaid.
  • Creates a more uniform, predictable reimbursement framework across different levels of supervision and service intensity.

Compiled from official sources — confirm details with the bill’s official record.

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