Chiropractic: A Science-Based Legal Perspective

Chiropractic: A Science-Based Legal Perspective

by | Jul 14, 2026 | Consumer Advocacy

Chiropractic is one of the most widely used — and most litigated — forms of alternative medicine in the United States. In New Jersey alone, there are roughly 2,000 licensed chiropractors, and the industry has fought aggressively in courtrooms and legislatures to expand its legal status, secure insurance reimbursement, and position itself on equal footing with medical doctors. In a previous post, I examined the legal status of homeopathy in New Jersey. Chiropractic raises many of the same questions — and some that are uniquely its own.

This post examines what the science actually says about chiropractic, why it remains legal and insurance-covered despite persistent scientific controversy, and how New Jersey courts and regulators have shaped the profession’s reach over the years.

Origins of Chiropractic

Chiropractic was founded in 1895 by Daniel David Palmer, a magnetic healer from Iowa who claimed he received the practice’s core principles from the spirit of a deceased physician. Palmer’s central theory was that nearly all disease originates from “vertebral subluxations” — misalignments of the spinal vertebrae that he believed interfered with the body’s “innate intelligence” flowing through the nervous system. Adjust the spine, the theory went, and you restore the body’s natural healing power.

The problem is that the chiropractic subluxation, as defined by Palmer and his followers, has never been demonstrated to exist. It is distinct from the orthopedic concept of a subluxation — which refers to a partial dislocation of a joint that is visible, measurable, and clinically meaningful. The chiropractic subluxation is a metaphysical concept rooted in vitalism, not anatomy. No peer-reviewed study has ever established that spinal “nerve interference” from a subluxated vertebra causes organic disease.

This foundational problem has never been resolved. The chiropractic profession remains deeply divided between “straight” chiropractors who still adhere to Palmer’s subluxation theory and “reform” or evidence-based chiropractors who limit their practice to neuromusculoskeletal conditions like back pain and neck pain.

What the Evidence Actually Shows

To be fair to the evidence-based faction of the chiropractic profession, there is legitimate support for spinal manipulation as a treatment for specific musculoskeletal complaints. Some studies have found spinal manipulation to be a reasonable option with modest benefit for low back pain in some patients. That is a significant but narrow finding. It does not validate chiropractic as a system of medicine. It does not support the claim that spinal manipulation treats asthma, ear infections, colic, high blood pressure, or any of the other conditions that many chiropractors continue to market for treatment. Systematic reviews have consistently found no reliable evidence that chiropractic care is effective for conditions other than certain types of back and neck pain — and even there, the benefit is modest and comparable to physical therapy.

More concerning is the safety profile. High-velocity neck manipulation — the kind involving a rapid twisting motion of the cervical spine — carries a known risk of vertebral artery dissection, a tear in the artery wall that can cause stroke. The risk is low in absolute terms but not negligible, and the potential modest benefit does not outweigh the significant risk of injury.

Chiropractic Versus the American Medical Association

The same question I asked about homeopathy applies here: if the foundational science is so contested, why is chiropractic not only legal but actively reimbursed by health insurance and Medicare?

The answer is largely historical and political. Chiropractic has been licensed in all 50 states since the 1970s, the result of sustained lobbying over nearly a century. In 1972, Congress amended the Social Security Act to include chiropractic services under Medicare — but only for spinal manipulation for back conditions, a limitation that chiropractors have fought to expand ever since. The American Medical Association declared chiropractic an “unscientific cult” in 1966 and advised its members that associating with chiropractors was unethical. That posture backfired legally when, in 1987, a federal court found in Wilk v. American Medical Association that the AMA had engaged in an unlawful conspiracy to restrain trade — essentially, an illegal boycott of a competitor. The AMA’s aggressive opposition to chiropractic, whatever its scientific merit, had crossed the line into an antitrust violation as far as the court was concerned. The Wilk case is a stark reminder that scientific fact and consensus versus the search for truth in a courtroom are vastly different concepts. In other words, the legal merit of the Wilk case did not depend on whether chiropractic was a scientifically sound medical discipline. Rather the case turned on varying factors that have nothing to do with the scientific method, including US antitrust law, the ability of the lawyers involved, the biases and ability of the few judges involved, the burden of proof in a civil case (often described as “more likely than not”), the law and court rules governing expert testimony (which has created “experts” that only exist in courtrooms), the rules of evidence, and the truthfulness and likeability of the witnesses.    

To summarize, the Wilk decision did not validate chiropractic science. It simply established that the AMA could not use coordinated institutional pressure to drive chiropractors out of business. The practical effect, however, was to legitimize chiropractic further in the eyes of insurers, regulators, and the public.

New Jersey: The Fight for Insurance Reimbursement

New Jersey has been a significant battleground for chiropractic insurance reimbursement. The state’s largest health insurer, Horizon Blue Cross Blue Shield of New Jersey, became the target of a class action lawsuit brought on behalf of thousands of NJ chiropractors.

The case, DeMaria et al. v. Horizon Healthcare Services, Inc., centered on Horizon’s practice of “bundling” chiropractic claims. When a chiropractor provided chiropractic manipulative therapy (CMT) together with evaluation and management services (E/M) or physical therapy (PT) during the same visit, Horizon automatically denied payment for the E/M and PT, folding everything into a single global fee for the CMT — regardless of what services were actually rendered.

In 2009, following a regulatory complaint by the Association of New Jersey Chiropractors (ANJC), the New Jersey Department of Banking and Insurance (DOBI) declared Horizon’s bundling practice a violation of New Jersey’s Unfair Claim Settlement Practices Act, and issued a cease and desist order effective 2010. The class action lawsuit, filed in 2011, sought damages for the period before the DOBI order — from December 2005 through April 2010.

In June 2015, a federal court certified two classes of chiropractors — an ERISA class and a non-ERISA class — covering over 9,500 practitioners whose claims had been systematically denied. In 2016, Horizon agreed to a $33 million settlement, one of the largest ERISA benefit class action settlements involving healthcare providers in the country at that time.

DeMaria was not an isolated case. New Jersey chiropractors also obtained a significant settlement against CIGNA Insurance and American Specialty Health Network (ASHN) over out-of-network reimbursement practices. That matter resulted in an $11.75 million settlement, with a former president of the Association of New Jersey Chiropractors serving as the lead out-of-network plaintiff.

The DeMaria case established an important precedent: an insurer’s systematic denial of provider claims based on an undisclosed internal bundling policy can be challenged as a class action under both ERISA and New Jersey contract law. As with the Wilk case, it is important to keep in mind that DeMaria the CIGNA cases had nothing to do with the scientific merit of chiropractic.

Are Chiropractors Equal to Medical Doctors Under New Jersey Law?

Chiropractors have long sought to be treated as equivalent to physicians under the law — particularly in the context of expert witness testimony, scope of practice, and professional titles. New Jersey law draws a clear but sometimes contested line.

Under N.J.S.A. 45:9-14.5, the practice of chiropractic in New Jersey is defined as a philosophy, science, and healing art focused on the reduction of chiropractic subluxation and the examination, adjustment, and treatment of the articulations and soft tissue of the body. Chiropractors in New Jersey may use the title “doctor” but it must be qualified with the words “doctor of chiropractic,” “chiropractor,” or “chiropractic physician,” or the abbreviation D.C. Critically, chiropractors cannot prescribe medications, perform surgery, or conduct endoscopy. When a patient’s condition falls outside the scope of chiropractic, the chiropractor is required to refer the patient to a licensed physician.

Chiropractors as Expert Witnesses: The Permanency Certification Problem

The question of whether a chiropractor qualifies as a “physician” under New Jersey law is not merely academic. It has significant practical consequences in personal injury litigation — particularly in automobile accident cases governed by the Automobile Insurance Cost Reduction Act (AICRA), N.J.S.A. 39:6A-8.

Under AICRA’s verbal threshold provision, a plaintiff who has selected the limitation on lawsuit option cannot sue for pain and suffering unless they can demonstrate, among other things, that they have sustained a permanent injury. To survive a defense motion for summary judgment on that issue, the plaintiff must provide a certification from a “licensed, treating physician” asserting that a permanent injury was sustained. The question of whether a chiropractor qualifies as a “physician” for that purpose produced a sustained split in the New Jersey courts.

Early opinions struggled with the definitional ambiguity. In Pensabene v. Straus, 342 N.J. Super. 196 (Law Div. 2001), the court noted that the definitional portion of the verbal threshold statute is confusing and relied on how other courts had construed “physician” in other statutory contexts — concluding that it would be unjust to deprive an injured plaintiff of their claim simply because they chose to treat with a chiropractor rather than a medical doctor. Olarte v. Crocker, 380 N.J. Super. 203 (Law Div. 2002), reached the same conclusion by reasoning that since chiropractors were not specifically excluded from the statutory definition, the legislature must have intended to include them.

Those conclusions were challenged in subsequent unpublished opinions by a trial judge who took a more textually rigorous approach. In Afram v. Heller, the trial judge reasoned that chiropractors are not permitted to diagnose or treat the systems and conditions that physicians are trained and licensed to address, and that they lack the authority to administer the objective diagnostic tests — such as MRI interpretation — that the AICRA statute requires before a permanency opinion can be rendered. A chiropractor, on that view, cannot produce the foundational clinical work that a permanency certification is supposed to represent.

The Appellate Division resolved the split by siding with the more permissive line of cases, holding in Afram v. Heller that a chiropractor’s permanency certification is sufficient to survive a summary judgment motion under AICRA. That holding, combined with the Supreme Court’s decisions in Serrano and DiProspero — which reduced the plaintiff’s burden on the subjective impact element of the verbal threshold — significantly shifted the balance in favor of plaintiffs in automobile injury litigation.

The Accutane Problem: Why the Science Should Matter in Court

The Afram holding sits in uncomfortable tension with a more fundamental question that the court never confronted: what is the scientific basis for treating a chiropractor’s opinion on permanent injury as reliable expert testimony in the first place?

In the case In re Accutane Litigation, 234 N.J. 340 (2018), the New Jersey Supreme Court adopted Daubert-based reliability principles for expert testimony in civil cases. Under that standard, a trial court acts as a gatekeeper whose responsibility is to assess whether an expert’s opinion is grounded in “sound, adequately-founded scientific methodology involving data and information of the type reasonably relied on by experts in the scientific field.” Mere credentials are not enough. The methodology itself must be reliable. Where it is not, the expert opinion is inadmissible.

That standard creates a serious problem for chiropractic expert testimony that courts have largely chosen to ignore. Consider what the scientific record actually establishes. The foundational theory of chiropractic — that vertebral subluxations interfere with the body’s innate intelligence and cause disease — has no support in peer-reviewed science. The best available evidence for the practice’s most defensible application, spinal manipulation for back and neck pain, shows efficacy roughly comparable to physical therapy. That is not a fringe critique of chiropractic; it is the mainstream scientific consensus.

Now apply the Accutane standard to that baseline. If a physical therapist were to take the stand in a personal injury case and offer an opinion that a car accident caused a plaintiff’s permanent spinal injury, that testimony would not survive a gatekeeping motion. Physical therapists are not licensed to diagnose, cannot interpret imaging studies, and are not trained in the clinical evaluation of permanent impairment. No plaintiff’s attorney would seriously propose calling a physical therapist for that purpose, and no court would permit it. The evidentiary logic is straightforward: the witness’s training and methodology do not support the opinion being offered.

If chiropractic’s evidence base is genuinely comparable to physical therapy for the conditions at issue — and the scientific literature says it is — then there is no principled reason to reach a different conclusion for a chiropractor’s permanency opinion. A chiropractor in New Jersey cannot interpret MRI films, cannot prescribe medications, and cannot perform the diagnostic workup that a meaningful permanency evaluation requires. The opinion rests on a clinical foundation that is, at best, no more rigorous than what a physical therapist could offer.

The Afram court did not engage with this problem because it was resolving a question of statutory interpretation, not evidentiary reliability. The question before it was whether the AICRA statute’s use of the word “physician” included chiropractors — and the court answered that question yes, largely on the grounds that excluding chiropractors would be unjust to plaintiffs who chose to treat with one. That is a pragmatic policy judgment, not a scientific one. And it has the effect of bypassing the gatekeeping function that Accutane subsequently demanded.

The result is a structural inconsistency in New Jersey civil litigation. In a toxic tort or product liability case, plaintiffs’ experts must demonstrate that their methodology meets a rigorous reliability standard or face exclusion. In an automobile personal injury case, a chiropractor’s certification of permanent injury — resting on a professional framework whose foundational theory has no scientific validity — is treated as legally sufficient to defeat summary judgment. The same New Jersey court system that demands sound scientific methodology in one context has, in another, institutionalized a workaround that insulates chiropractic opinions from that scrutiny entirely.

That inconsistency has real consequences. Defense attorneys in automobile injury cases would be well-served by exploring whether Accutane’s reliability principles can be used to challenge the admissibility of chiropractic expert testimony at the trial level, even where Afram controls the certification question at summary judgment. The two analyses are not the same: Afram addresses whether a chiropractor’s certification is sufficient under AICRA as a matter of statutory interpretation; Accutane addresses whether the underlying expert opinion is scientifically reliable enough to be placed before a jury.

The Ongoing Push to Expand Scope of Practice

The chiropractic industry in New Jersey has pursued legislative expansion of its scope of practice over the years. A significant legislative effort, led over a five-year period by the ANJC’s legislative chairman, resulted in an expanded Chiropractic Practice Act signed into law by Governor Jon Corzine — the first expansion of the scope of chiropractic practice in New Jersey in 57 years. The same effort produced the first Licensed Chiropractic Assistant legislation in the United States, later signed into law by Governor Chris Christie.

These expansions are significant because they reflect the chiropractic profession’s sustained political strategy: use the legislature and the courts to steadily widen the boundaries of what chiropractors are permitted to do, regardless of whether the underlying science supports those expanded claims.

Final Thoughts

Chiropractic occupies an unusual position in American healthcare: a profession with a pseudoscientific foundation that has nonetheless secured legal standing, insurance coverage, and political influence through a century of determined advocacy. Some of what chiropractors do — spinal manipulation for back pain — has legitimate, if modest, evidence behind it. Much of what the profession claims beyond that does not.

New Jersey’s legal landscape reflects this tension at every level. Courts and regulators have pushed back against insurance abuse while simultaneously expanding the profession’s legal footprint through legislation. And in the personal injury context, the courts have allowed a statutory interpretation decision — Afram — to effectively shield chiropractic expert opinions from the scientific reliability scrutiny that In re Accutane demands of every other category of expert testimony in civil litigation. A profession whose best-supported application is comparable in efficacy to physical therapy has been granted, through a combination of statutory ambiguity and judicial pragmatism, an expert witness status that the science does not justify.

Consumers are best served by approaching chiropractic with the same critical eye they would apply to any healthcare decision: ask what the evidence says, understand the limits of the treatment, and consult a licensed physician for any condition that may require diagnosis or medical management.

Medicaid Eligibility for Lawfully Present Immigrants in New Jersey: What the New Federal Law Means for NJ FamilyCare

Medicaid Eligibility for Lawfully Present Immigrants in New Jersey: What the New Federal Law Means for NJ FamilyCare

by | Jun 9, 2026 | Consumer Advocacy, Legal Bulletin, Medicaid, Medicaid Updates

Federal law is changing who qualifies for NJ FamilyCare. Beginning October 1, 2026, many lawfully present immigrants may lose their coverage. Congress passed the One Big Beautiful Bill Act, which President Trump signed into law in 2025. Among its many provisions is a significant restriction on Medicaid eligibility for non-citizen immigrants. Starting October 1, 2026, certain lawfully present immigrants who are currently enrolled in NJ FamilyCare — New Jersey's name for its Medicaid program — may no longer qualify.

This is not a future concern. NJ has already begun mailing letters to potentially affected members to gather information and assess eligibility before the October 1 deadline. If you or someone you know receives one of these letters, the worst thing to do is ignore it.

Who Is Affected

The changes target a specific set of immigration categories. The following groups of lawfully present non-citizens may lose NJ FamilyCare coverage on October 1, 2026:

  • Refugees;

  • Asylees;

  • Certified victims of trafficking and their spouse, child, sibling, or parents;

  • Veterans or active-duty military and spouses or unmarried dependents who also have qualified non-citizen status;

  • Iraqi and Afghani parolees;

  • Individuals who were paroled into the U.S. between February 24, 2022 and September 30, 2024 under the Ukrainian Humanitarian Parole (UHP) program; and

  • People whose deportation is being withheld.

What these categories share is that they represent people who entered the United States through humanitarian or protection-based pathways — people who, in many cases, fled violence or persecution. Under existing rules, federal law treated many of them as eligible for Medicaid. The new law removes that eligibility for those who have not taken a specific additional step: transitioning to Lawful Permanent Resident (LPR) status.

The Green Card Exception

Adjusting to LPR status — becoming a permanent resident with a green card — does not automatically solve the problem. The law imposes a five-year waiting period. If you transitioned to LPR status less than five years ago, you may still be ineligible. The five-year clock runs from the date the immigrant obtains qualified alien status.

There are, however, carve-outs to the five-year rule. If you originally arrived in one of the affected categories and you have since transitioned to LPR status, you may still qualify even if it has been less than five years. These categories include:

  • Refugees;

  • Asylees;

  • Certified victims of trafficking and their spouse, child, sibling, or parents;

  • Veterans or active-duty military and spouses or unmarried dependents who also have qualified non-citizen status;

  • Amerasian immigrants;

  • Iraqi and Afghani special immigrants and parolees;

  • Individuals who were paroled into the U.S. between February 24, 2022 and September 30, 2024 under the Ukrainian Humanitarian Parole (UHP) program; and

  • People whose deportation is being withheld.

The state has been directed to treat those individuals more favorably than others in the LPR-under-five-years category.

If that sounds complicated, it is. The intersection of immigration status and Medicaid eligibility has never been simple, and the new law adds another layer of complexity. If you are uncertain whether these changes apply to you, do not try to figure it out alone.

Who Is Not Affected

Not every non-citizen is at risk. In addition to the categories noted above, several groups will continue to qualify under the new rules including:

  • Lawful Permanent Residents of at least 5 years (calculated from date on green card);

  • Lawfully present non-citizens who are pregnant, or under the age of 21;

  • Cuban/Haitian Entrants;

  • Compact of Free Association (COFA) migrants, including individuals from Micronesia, Marshall Islands, and Palau; and

  • Children under 19, regardless of their immigration status.

These populations are protected by separate statutory provisions and should not see a change in their eligibility on October 1.

What New Jersey Is Already Doing

NJ FamilyCare is not waiting until October. The state has begun sending outreach letters to members whose immigration status may bring them within the affected categories. These letters are not yet termination notices — they are requests for information to help the state determine who remains eligible and who does not.

If NJ FamilyCare already has what it needs to confirm your continued eligibility, you will receive a letter telling you your coverage has been renewed. If it needs more, you will receive a request for documentation or a renewal packet. The critical thing is to respond promptly. Failing to respond can result in a gap or termination of coverage, even if you are actually still eligible.

Members should also make sure their contact information is current. If your address or phone number has changed, call NJ FamilyCare Customer Service at 1-800-701-0710 (TTY: 711) now, before any letter goes undelivered.

The Broader Picture

These changes do not exist in isolation. The same legislation that is cutting Medicaid eligibility for immigrants also introduces work and community engagement requirements for certain adult enrollees beginning January 1, 2027, and shortens the renewal period from annually to every six months for those in certain plans. The cumulative effect of these changes is a significant increase in administrative burden on the states and more paperwork for some of the most vulnerable Medicaid enrollees in the state.

New Jersey has historically taken steps to extend coverage to immigrant populations beyond what federal law requires but those programs cost money. Whether New Jersey will maintain state funded coverage options is an open question.

Learn More

For a detailed explanation of how immigration status affects NJ Medicaid eligibility under existing rules, see our guide: NJ Medicaid and Immigration Status — What You Need to Know.

For a broader overview of the federal Medicaid cuts in the One Big Beautiful Bill Act affecting New Jersey residents, see: Federal Medicaid Cuts: What New Jersey Residents Need to Know.

The official NJ DMAHS information page on these changes is available at nj.gov/humanservices/dmahs/obbba/medicaid-federal-changes.shtml. The state has indicated it will update that page as additional guidance becomes available.

Personal Care Assistant Services in New Jersey: What You’re Entitled To — and What Insurance Companies Aren’t Telling You

Personal Care Assistant Services in New Jersey: What You’re Entitled To — and What Insurance Companies Aren’t Telling You

by | May 26, 2026 | Consumer Advocacy, Medicaid

Many New Jersey Medicaid recipients who need help with daily activities — bathing, dressing, toileting, mobility — are entitled to Personal Care Assistant (PCA) services. These are in-home, hands-on services paid for by Medicaid and delivered through a managed care organization. They can make the difference between living independently at home and moving to a facility.

What most people don’t know is that PCA services are available under all New Jersey Medicaid plans — not just MLTSS. This post explains how PCA eligibility works, how hours are determined, and what New Jersey consumers should know before agreeing to switch their Medicaid plan.

What Are PCA Services?

Personal Care Assistant services are non-emergent, health-related services provided in the home of an eligible NJ FamilyCare (Medicaid) beneficiary. They are intended to help people with disabilities and chronic conditions maintain independence and remain in the community rather than moving to a nursing facility or assisted living.

PCA services cover hands-on assistance with Activities of Daily Living or ADLs. PCA services do not cover skilled nursing, medication administration, or medical procedures. They are personal care — the kind of hands-on daily assistance that allows someone to function safely at home when they can no longer do so independently.

Who Is Eligible?

📌 Key Point: PCA services are available to ALL New Jersey Medicaid beneficiaries who meet the functional criteria — not just those enrolled in MLTSS.

Eligibility for PCA services is governed by N.J.A.C. 10:60-3.1. A beneficiary qualifies if they require either a) moderate or greater hands-on assistance in at least one ADL, or b) minimal assistance or greater in at least three different ADLs, at least one of which must require hands-on assistance.

A diagnosis alone is not sufficient. The functional limitations must be documented through a face-to-face assessment using the State's standardized PCA Assessment Tool.

            Activities of Daily Living (ADLs) are defined as:

  1. Oral hygiene and care of teeth and mouth

  2. Grooming — care of hair, shampooing, shaving, nail care where upper extremity function or cognitive impairment requires assistance

  3. Bathing — in bed, tub, or shower

  4. Toileting and use of bedpan

  5. Changing bed linens with the beneficiary in bed

  6. Ambulation indoors and outdoors

  7. Transfers — moving from bed to chair or wheelchair, in and out of tub or shower

  8. Assistance with eating, including placing food and liquids into the mouth and assisting with swallowing difficulties

  9. Dressing

  10. Accompanying the beneficiary to physician visits, clinics, or other trips for medical diagnosis, treatment, or therapeutic purposes

            Instrumental Activities of Daily Living (IADLs) are defined as:

  1. Sweeping, vacuuming, and dusting of the beneficiary's room and areas used by the beneficiary

  2. Care of kitchen — maintaining cleanliness of refrigerator, stove, sink, and floor; dishwashing

  3. Care of bathroom — maintaining cleanliness of toilet, tub, shower, sink, and floor

  4. Care of the beneficiary's personal laundry and bed linen, including necessary ironing and mending

  5. Bed-making and changing of bed linen

  6. Rearranging furniture to enable the beneficiary to move about more easily

  7. Listing, shopping for, and storing food and essential household supplies

  8. Planning, preparing, and serving meals, including special therapeutic diets

  9. Relearning household skills

One of the most misunderstood aspects of the PCA benefit is the fact that it is not available to every senior or person with a disability who may need some assistance at home. It is important to know that IADL assistance alone — no matter how significant — does not establish eligibility for PCA services. A beneficiary who needs help with meal preparation, housekeeping, laundry, and shopping but does not meet the ADL threshold above does not qualify for PCA. IADLs are authorized only in conjunction with ADL services, as a supplement to hands-on personal care.

IADLs for Shared Households

It is also crucial to understand that when a beneficiary lives with a legally responsible relative, that relative is expected to handle IADL tasks that benefit the household generally — cleaning shared spaces, shared laundry, shared meal preparation, and shopping for items used by all household members. PCA IADL coverage is limited to tasks that specifically serve the beneficiary's personal needs.

Finally, it is important to know that PCA services do not include the following:

  • Supervision as a standalone service

  • Companionship

  • Services limited to non-hands-on personal care needs only

  • Services for conditions with no functional limitations (e.g., high cholesterol)

  • Services for acute short-term diagnoses expected to heal (e.g., a fracture)

How PCA Hours Are Determined

PCA hours are not self-reported or set by a doctor’s prescription. They are determined by a professional who conducts a clinical assessment in the applicant’s home using New Jersey’s standardized PCA Assessment Tool. The assessment evaluates the individual’s functional status across each ADL category and determines how many hours per week of PCA services are medically necessary.

Prior authorization from the MCO is required. The MCO reviews the nurse’s assessment and the plan of care before authorizing hours. Under New Jersey administrative code, PCA hours are authorized on a weekly basis. Unused hours cannot be banked or carried over to the following week — even if the beneficiary or aide was ill or hospitalized.

The current weekly cap on PCA services is 40 hours. If a beneficiary disagrees with the number of hours authorized, they have the right to appeal through their MCO and, if necessary, through a Fair Hearing before an Administrative Law Judge.

The Personal Preference Program: Self-Directing Your PCA Services

New Jersey offers an alternative to agency-provided PCA services through the Personal Preference Program (PPP). Under the PPP, eligible Medicaid beneficiaries receive a monthly budget based on their authorized PCA hours and can use that budget to hire their own caregiver directly, including a family member, friend, neighbor, or spouse.

Any Medicaid beneficiary who qualifies for PCA services and chooses to self-direct can participate. The authorized representative who manages the budget cannot be the same person who provides the care. A fiscal intermediary handles payroll, taxes, and withholding on behalf of the participant.

To switch from agency-provided PCA services to the PPP, contact your MCO and request enrollment. A reassessment of hours may or may not be required depending on the MCO.

The MLTSS Misconception — and Why It Matters

⚠️ Consumer Alert: PCA services are a benefit of all NJ Medicaid programs — not exclusively an MLTSS benefit. Consumers who are told they must switch to MLTSS to receive PCA services are being misinformed.

A widespread misconception among New Jersey Medicaid recipients — and sometimes among their families and care coordinators — is that PCA services are only available through MLTSS. This is incorrect. PCA services are a New Jersey State Plan benefit, meaning they are available to all NJ FamilyCare beneficiaries who meet the functional criteria, regardless of which Medicaid plan they are enrolled in.

MLTSS is a different and more comprehensive program designed for individuals who meet nursing facility level of care. MLTSS covers a broader array of services than standard Medicaid, including assisted living, case management, home modifications, and personal emergency response systems. For consumers who genuinely need that level of service coordination, MLTSS may be the right choice.

But not every Medicaid recipient who needs PCA services needs MLTSS. A person who needs 15 hours of weekly PCA assistance but is otherwise managing well at home may have their needs fully met by standard Medicaid with PCA services. Enrolling in MLTSS when it is not necessary adds administrative complexity, may change the consumer’s provider network, and is not required to access PCA benefits.

Why MCOs May Encourage MLTSS Enrollment

Understanding why MCOs sometimes steer consumers toward MLTSS requires a basic understanding of how managed care financing works. Medicaid pays MCOs a capitation rate — a fixed monthly payment per enrollee. The capitation rate for MLTSS enrollees is significantly higher than the rate for standard ABD Medicaid enrollees, reflecting the greater expected cost of serving a population with nursing facility-level needs.

This creates a financial incentive structure worth understanding. As long as an MCO’s actual cost of serving an MLTSS enrollee remains below the capitation rate, the MCO retains the difference. Enrolling a consumer in MLTSS who could be adequately served under standard ABD Medicaid generates a higher capitation payment for the MCO for what may be a comparable cost of services. This is not a hypothetical concern — federal Medicaid policy documents on New Jersey’s MLTSS program have explicitly acknowledged that MCOs have financial incentives to enroll additional participants in MLTSS as long as their costs remain below the capitation rate.

None of this means that every MCO recommendation to enroll in MLTSS is financially motivated or that MLTSS is the wrong choice for a given consumer. For many New Jersey residents with complex long-term care needs, MLTSS is the appropriate program. The point is that consumers should make this decision based on their own needs and circumstances — not based on a recommendation from an entity that has a financial stake in the outcome.

What Consumers Should Ask Before Switching

If you or a family member is currently enrolled in standard ABD Medicaid and is being encouraged to switch to MLTSS, ask these questions before agreeing:

  • Am I eligible for PCA services under my current ABD Medicaid plan?

  • What specific services does MLTSS provide that I cannot receive under my current plan?

  • What are the clinical eligibility requirements for MLTSS, and do I actually meet them?

  • What are the financial eligibility requirements for MLTSS, and how will this impact me going forward?

  • What impact will this have on my Estate since Medicaid is entitled to be paid back after I pass away?

Consumers have the right to remain in their current Medicaid plan. A recommendation to switch — however well-intentioned it may be presented — is not a requirement.

Final Thoughts

PCA services are one of the most valuable benefits available to New Jersey Medicaid recipients. They allow people with significant functional limitations to remain in their homes and communities rather than moving to institutional care. Knowing that this benefit is available under standard Medicaid plans — and understanding how hours are assessed and authorized — puts consumers in a much stronger position to advocate for themselves.

Living With Family and Losing Medicaid: How In-Kind Support and Maintenance Works — and How a Simple Lease Can Fix It

Living With Family and Losing Medicaid: How In-Kind Support and Maintenance Works — and How a Simple Lease Can Fix It

by | Apr 28, 2026 | Consumer Advocacy, Medicaid, Medicaid Planning

A 70-year-old woman moves in with her adult son after a stroke. Her only income is $1,200 a month in Social Security. She applies for ABD Medicaid — New Jersey’s Medicaid program for the aged, blind, and disabled — and is told she is over the income limit, which in 2026 is $1,330 for a single person. But she earns only $1,200 a month. How is she over income?

The answer is a rule called In-Kind Support and Maintenance, or ISM. It is one of the most commonly misapplied rules in the Medicaid and SSI world, and one of the most fixable. In many cases, a written lease and a monthly rent payment is all it takes to bring an otherwise-qualifying applicant into eligibility. The problem is that many New Jersey counties are still applying an old version of the rule — even though federal regulations changed nationwide in September 2024 to become significantly more favorable to applicants.

What Is In-Kind Support and Maintenance?

ISM is the Social Security Administration’s term for non-cash assistance provided to an SSI or Medicaid recipient in the form of shelter. When someone else provides or pays for your housing — rent, mortgage payments, utilities, real property taxes, garbage collection — SSA treats that assistance as a form of income, even though no money actually changes hands. That imputed income counts against program income limits.

Food was also part of ISM calculations until September 30, 2024, when SSA eliminated it. Food assistance from any source — whether a family member buys groceries, takes someone to dinner, or otherwise provides meals — is no longer counted as income for SSI or Medicaid purposes. Only shelter remains.

ISM is relevant to both SSI and ABD Medicaid in New Jersey. SSI recipients are automatically eligible for NJ Medicaid. But individuals who do not receive SSI — those whose Social Security income exceeds the SSI limit but who are still below the ABD Medicaid income threshold — can be knocked over that threshold by ISM, even though their actual cash income is within the limit. For more background on how SSI and ABD Medicaid interact in New Jersey, see my post on SSI and Medicaid Eligibility in New Jersey.

How ISM Is Valued: The VTR and PMV

ISM is valued using one of two methods, depending on the living arrangement.

The Value of the One-Third Reduction (VTR) applies when the applicant lives in another person’s household and receives both shelter and all meals from the household. Under the VTR, SSA reduces the SSI benefit by exactly one-third of the Federal Benefit Rate — a flat reduction regardless of what the support is actually worth.

In all other shelter-related ISM situations, SSA uses the Presumed Maximum Value (PMV) rule. The PMV is a cap on the amount of ISM that can be imputed — for 2026, it is $351.33 per month (one-third of the federal SSI benefit rate plus $20). Even if a person receives more in free rent, the maximum income SSA will impute is the PMV. For an ABD Medicaid applicant who is not on SSI, the PMV is added to their actual cash income for purposes of the eligibility calculation.

📋 Example:   Maria, age 70, lives with her son and pays no rent. Her only income is $1,200/month in Social Security.   Without a lease: SSA imputes $351.33 in ISM shelter. Maria’s countable income = $1,551.33. She is over the 2026 ABD Medicaid income limit despite having no additional cash income.   With a qualifying lease: No ISM is imputed. Maria’s countable income remains $1,200/month — within the ABD Medicaid limit.

The Fix: The Business Arrangement Rule

This is where the 2024 rule change matters most. Under the revised federal regulation effective September 30, 2024, SSA will not charge ISM in the form of room or rent if the applicant pays rent under a “business arrangement.”

📌 2024 Rule Change (20 CFR 416.1130(b)):   A business arrangement now exists — and no ISM is charged — when the monthly rent required under the lease equals or exceeds the Presumed Maximum Value (PMV).   This standard applies nationwide, to all applicants and recipients, regardless of who the landlord is — including a family member. The PMV for 2026 is $351.33/month.

The practical consequence is significant. Before September 30, 2024, a New Jersey applicant living with a family member needed to pay their fair share of full market rent to avoid ISM — which could easily be $1,500 or more per month in many NJ markets. Under the current rule, rent at or above the PMV — currently $351.33 — is sufficient to establish a business arrangement and eliminate ISM entirely, regardless of what the market rent would be.

The rent must be paid under a genuine written lease and must actually be paid each month. SSA will verify the arrangement. A paper lease with no money changing hands will not survive scrutiny.

Why NJ Counties Are Still Getting This Wrong

⚠️ Important: Many NJ counties are still applying the pre-September 2024 ISM rules — requiring a fair share of rent at full market value rather than the PMV. This is denying benefits to applicants who are legally entitled to them.

The September 30, 2024 changes are federal regulatory changes that apply uniformly in New Jersey. Common errors being made post-2024 include: 1) continuing to require evidence of the applicant’s payment of their fair share of housing expenses, rather than the PMV, 2) continuing to request utility bills when that documentation is irrelevant, and 3) rejecting rental agreements. These are not technical errors with minor consequences. They result in real people being wrongly denied ABD Medicaid coverage they are legally entitled to.

What to Do If You Are Denied Based on ISM

If an ABD Medicaid application is denied — or an existing benefit is terminated — on the basis of ISM, the first step is to review the denial notice. New Jersey is required to explain the basis for the denial and the calculation used. If ISM was applied incorrectly, the applicant has the right to request a fair hearing.

What the Lease Needs to Include

To establish a business arrangement and eliminate ISM, the rental agreement should be in writing and reflect a genuine arrangement. At minimum, the lease should include:

  • The names of the landlord and tenant

  • The address and description of the space being rented

  • The monthly rent amount — at or above the PMV ($351.33 in 2026)

  • The lease term (month-to-month is acceptable)

  • A statement on whether it is inclusive of utilities including gas, electric, water, garbage, etc.

  • Signatures of both parties and the date of execution

Rent must actually be paid each month and documented. Payment by check or money order with a clear notation that it is a rent payment is recommended. Electronic transfers through Zelle, Venmo, or PayPal may be accepted but should include a note identifying the payment as rent for the relevant period. Such payments should be consistent (made around the same date each month) and partial payments should be avoided. Cash payments without documentation create evidentiary problems and should be avoided.

Final Thoughts

The ISM rules affect some of the most financially vulnerable people in New Jersey — elderly individuals and people with disabilities living on fixed incomes in family households. For this population, ABD Medicaid is not a secondary benefit. It covers their medical care, prescriptions, and often their long-term care services. The fix — a written lease with documented monthly rent at or above the PMV — is one of the simplest solutions in elder law and benefits planning.

Medicaid and Immigration in New Jersey: What a Medicaid Lawyer Wants You to Know

Medicaid and Immigration in New Jersey: What a Medicaid Lawyer Wants You to Know

by | Mar 1, 2026 | Consumer Advocacy, Legal Bulletin, Medicaid, Medicaid Updates

As a New Jersey Medicaid lawyer, I’m often asked whether immigrants—especially those who are undocumented—can qualify for Medicaid or other forms of public health coverage. The answer is complicated, because eligibility depends on a mix of federal law, state initiatives, and funding streams that shift with each legislative cycle. The short answer is that New Jersey offers more inclusive health coverage than most states, but many immigrants still face limits depending on their immigration status.

Lawfully Present vs. Undocumented: A Crucial Distinction

Federal Medicaid law draws a sharp line between immigrants who are “lawfully present” and those who are “undocumented.” Lawfully present immigrants include lawful permanent residents (green card holders), refugees, asylees, victims of trafficking, certain humanitarian parolees, and others permitted to live in the U.S. under federal immigration law.

Many of these immigrants can qualify for Medicaid, though most must first wait five years after obtaining status before they become eligible. Historically, refugees, asylees, and trafficking victims were exempt from that five-year bar and could access coverage immediately. As explained below, the One Big Beautiful Bill Act (OBBBA) has significantly changed this going forward, with major provisions taking effect October 1, 2026.

By contrast, undocumented immigrants—those without lawful status—cannot enroll in full Medicaid coverage under federal law. But in New Jersey, there are exceptions and state-funded programs that fill some of the gaps.

New Jersey’s State Initiatives: Expanding Coverage for Children and Families

One of the most significant New Jersey state programs is Cover All Kids. Enacted into law in 2021, the program was implemented in phases, with full coverage for undocumented children taking effect on January 1, 2023, under Governor Murphy’s administration. It allows all children under 19 to receive NJ FamilyCare coverage regardless of immigration status, as long as they meet the income and residency rules. It is a groundbreaking policy that recognizes every child’s need for health care, no matter where they were born. It’s important to understand how it’s funded. Because federal Medicaid and Children’s Health Insurance Program (CHIP) funds cannot be used for undocumented children, Cover All Kids is paid for entirely by New Jersey.

New Jersey also provides coverage for pregnant women, though the scope depends on immigration status. U.S. citizens and lawfully present immigrants with low are eligible for full NJ FamilyCare/Medicaid coverage during pregnancy, with postpartum coverage continuing for 12 months after delivery. Undocumented women who do not qualify for full Medicaid may be eligible for the NJ Supplemental Prenatal and Contraceptive Program (NJSPCP), which covers outpatient prenatal and family planning services. Emergency labor and delivery for undocumented women may be covered separately under Emergency Medicaid, described below.

Emergency Coverage for All

Even for those who don’t qualify for Medicaid benefits, emergency medical care remains available. Through the Medical Emergency Payment Program (commonly called Emergency Medicaid), immigrants—regardless of status—can receive coverage for treatment of life-threatening conditions, including labor and delivery.

This program is not purely state-funded. Federal law allows states to receive federal Medicaid matching funds for emergency services provided to individuals who are otherwise Medicaid-eligible but not lawfully present. New Jersey is a Medicaid expansion state, meaning it currently receives approximately 90% federal reimbursement for these emergency services, with the state covering the remainder. Hospitals remain legally required under the federal Emergency Medical Treatment and Labor Act to provide emergency stabilization to any patient regardless of immigration status or ability to pay. Only true emergencies qualify for Emergency Medicaid; any non-emergency care for undocumented immigrants must be fully funded by the state if offered at all.

The “One Big Beautiful Bill” and Its Sweeping Impact on Immigrant Coverage

The One Big Beautiful Bill Act (OBBBA), signed into law on July 4, 2025, makes the most far-reaching changes to immigrant Medicaid eligibility since the 1996 welfare reform law. While much public attention has focused on work requirements and hospital reimbursements, the OBBBA’s effects on immigrant health coverage are equally significant.

The key changes for New Jersey residents are:

  • Refugees, asylees, humanitarian parolees, and trafficking victims lose federal Medicaid and CHIP eligibility entirely (effective October 1, 2026). Under prior law, these groups were exempt from the five-year waiting period and could access Medicaid immediately upon receiving status. Under the OBBBA, they are removed from the definition of “qualified alien” for Medicaid purposes altogether. Only green card holders (lawful permanent residents), certain Cuban and Haitian entrants, and citizens of Freely Associated States remain eligible for federal Medicaid. States may still choose to cover lawfully residing children and pregnant women using their own funds.

  • Emergency Medicaid federal reimbursement is reduced (effective October 1, 2026). For undocumented immigrants who would otherwise be Medicaid-eligible, the federal matching rate for emergency services drops from New Jersey’s current 90% expansion rate to approximately 50–65%. This does not eliminate emergency coverage, but it significantly increases the financial burden on the state.

  • Cover All Kids remains intact because it is funded entirely by New Jersey for undocumented children. The OBBBA does not penalize states for using their own dollars to cover undocumented children.

These changes mean that thousands of New Jersey residents who are lawfully present in the United States—people who went through the legal process to obtain refugee, asylee, or humanitarian parole status—will lose access to federally funded health coverage starting October 2026, unless Congress acts.

What Democrats Want to Restore

In response, Democratic lawmakers in Congress have proposed measures to reverse several of these cuts. Their efforts aim to restore the federal Medicaid matching funds eliminated under the OBBBA, particularly for emergency medical services and for programs that assist lawfully present immigrants whose eligibility was stripped.

The Democratic proposals also seek to eliminate new work requirements, restore funding to rural hospitals, and extend enhanced ACA premium tax credits (topics not covered in this article). As the nonpartisan Kaiser Family Foundation has noted, these proposals do not create new eligibility for undocumented immigrants (who were already ineligible for federally funded coverage before the OBBBA). Rather, they aim to restore coverage for lawfully present immigrants like refugees and asylees, and to ensure that mixed-status families don’t lose access to care because of shifting political priorities or administrative red tape.

In addition, Democrats want to reinstate the higher federal cost-sharing for emergency services provided to immigrants without legal status—in practical terms, restoring the 90% reimbursement for states like New Jersey that maintain immigrant-inclusive safety nets.

Where Things Stand Now

New Jersey continues to be one of the more immigrant-friendly states when it comes to health coverage. Undocumented children remain protected under Cover All Kids. Lawfully present pregnant women receive full Medicaid with 12 months of postpartum coverage. Emergency care remains available to all through Emergency Medicaid, even as the federal government will cover a lower share of those costs beginning in October 2026.

However, the most significant near-term threat is to lawfully present immigrants—refugees, asylees, and humanitarian parolees—who will lose federal Medicaid eligibility entirely under the OBBBA unless that provision is reversed. Whether New Jersey chooses to bridge the gap with state dollars, as it has done for undocumented children, remains to be seen.

From a policy perspective, the direction of federal law will determine how sustainable New Jersey’s approach remains. If the state continues to shoulder the costs of inclusivity while federal funding shrinks, the long-term pressure on the state budget will grow. On the other hand, restoring the federal match for emergency and qualified immigrant coverage could stabilize the system and maintain access for some of New Jersey’s most vulnerable residents.

Final Thoughts

As a Medicaid lawyer practicing in New Jersey, I see firsthand how these laws affect real people. Families trying to navigate complex immigration and health systems often face confusion, fear, and financial strain. Understanding who qualifies—and how programs like Cover All Kids and Emergency Medicaid are funded—is essential for both residents and practitioners.

The bottom line is this: New Jersey has built a relatively compassionate model that balances legal restrictions with state-funded solutions. But that balance depends heavily on federal cooperation. With the OBBBA’s sweeping changes to lawfully present immigrant eligibility and the ongoing debate in Congress, the future of immigrant health coverage in New Jersey will likely hinge on how much support Washington is willing to restore.

Fighting Back Against Arbitrary Medicaid Denials for Failure to Respond

Fighting Back Against Arbitrary Medicaid Denials for Failure to Respond

by | Apr 10, 2025 | Consumer Advocacy, Legal Bulletin, Medicaid, Medicaid Planning, Medicaid Updates

The situation is all too common for Elder Law attorneys and their Medicaid applicant clients – a denial or termination of benefits due to supposedly insufficient documents, even when the agency is provided with everything it asked for. A recent decision, M.L. v. Essex County Division of Family Assistance and Benefits, A-0884-23 (March 18, 2025), highlights the typical scenario where the agency arbitrarily denies an application for reasons not apparent until after the fact. The court’s ruling underscores the importance of procedural fairness in Medicaid eligibility determinations and provides a summary of the law for advocates to use when pushing back on denials or terminations based on insufficient documents.

Case Background

M.L., an elderly nursing home resident, applied for Medicaid benefits on March 31, 2023. The Essex County Division of Family Assistance and Benefits initially requested additional documentation, including bank statements from Wells Fargo, to verify financial eligibility. M.L. promptly requested and obtained these records from his bank and provided copies to Essex County before the deadline. However, Essex County denied his application, claiming that he provided insufficient financial documentation and had unexplained withdrawals. M.L. promptly filed an appeal, as well as a second Medicaid application. The second application contained additional records, including records from a newly discovered Citizens Bank account. During the appeal, M.L. argued that he had substantially complied with Essex County’s requests. An administrative law judge (ALJ) agreed, ruling that M.L. had satisfied Medicaid eligibility requirements. However, the Division of Medical Assistance and Health Services (DMAHS) rejected the ALJ’s decision, affirming the original denial on the grounds that M.L. failed to provide all required documentation within the designated timeframe, including the additional statements from the Citizens Bank account.

Appellate Court’s Summary of the Law

Upon review, the Appellate Division found DMAHS’s final decision to be arbitrary, capricious, and unreasonable. The Court provided a useful review of New Jersey regulatory law that applies in these circumstances, which is summarized below.

The local County Welfare Agency (CWA) and its caseworkers “exercise direct responsibility in the application process to . . . receive applications.” N.J.A.C. 10:71-2.2(c)(2). The caseworker is charged with evaluating an applicant’s eligibility for Medicaid benefits. N.J.S.A. 30:4D-7a; N.J.A.C. 10:71-2.2(a); N.J.A.C. 10:71-3.15. “The process of establishing eligibility involves a review of the application for completeness, consistency, and reasonableness.” N.J.A.C. 10:71-2.9.

While the applicant is “the primary source of information,” the caseworker is responsible for making “the determination of eligibility and to use secondary sources when necessary, with the applicant’s knowledge and consent.” N.J.A.C. 10:71-1.6(a)(2). The caseworker is not limited in the use of secondary sources to obtain necessary verification information. N.J.A.C. 10:71-4.1(d)(3) states:

The CWA shall verify the equity value of resources through appropriate and credible sources . . . . If the applicant's resource statements are questionable, or there is reason to believe the identification of resources is incomplete, the CWA shall verify the applicant's resource statements through one or more third parties.

The applicant is responsible for cooperating fully with the verification process if the caseworker must contact a third party to verify an applicant’s resources. N.J.A.C. 10:71-4.1(d)(3)(i). The agency may perform a collateral investigation to “verify, supplement or clarify essential information.” N.J.A.C. 10:71-2.10(b).

Under N.J.A.C. 10:71-2.2, the caseworker must communicate with the applicant regarding the claimed deficiencies and then, under N.J.A.C. 10:71-2.10(b), provide an opportunity for the applicant to verify, supplement, or clarify the information before denying an application.

N.J.A.C. 10:71-2.2(e)(1) to (3) requires an applicant to:

  • Complete, with assistance from the CWA if needed, any forms required by the CWA as a part of the application process;
  • Assist the CWA in securing evidence that corroborates his or her statements; and
  • Report promptly any change affecting his or her circumstances.

N.J.A.C. 10:71-2.2(c)(1) to (5) requires a caseworker to:

  • Inform the applicants about the purpose and eligibility requirements for Medicaid Only,
  • Inform them of their rights and responsibilities under its provisions and inform applicants of their right to a fair hearing;
  • Receive applications;
  • Assist . . . applicants in exploring their eligibility for assistance;
  • Make known to . . . applicants the appropriate resources and services both within the agency and the community, and, if necessary, assist in their use; and
  • Assure the prompt and accurate submission of eligibility data to the Medicaid status files for eligible persons and prompt notification to ineligible persons of the reasons for their ineligibility.

State agencies must “turn square corners” with the public they serve in carrying out their statutory responsibilities. W.V. Pangborne & Co. v. N.J. Dep't of Transp., 116 N.J. 543, 561–62 (1989). When this bedrock principle is read together with the above regulations, the dispositive legal conclusion is that both the applicant and the County have a duty under the regulations to take affirmative steps to communicate with each other regarding a pending application. The scope of this joint duty clearly includes the parties’ efforts to clarify prior communications about a pending application.

Court’s Ruling

Based on the summary of the law, the Appellate Division found that the applicant promptly gave the County what it asked for-- namely, the Wells Fargo statements. Upon receipt, the County’s duty was to review the pending application and notify the applicant concerning what, if any, additional information was required to make an eligibility determination. The record showed that the County failed to do so. Instead, it denied the March 31 application and only then informed the applicant that his application was deficient.

It followed that DMAHS’s final administrative decision adopting the improper denial of the March 31 application was arbitrary, capricious, and unreasonable. The Appellate Division reversed DMAHS’s decision and sent the case back to the County, instructing the agency to reopen and process M.L.’s Medicaid application.

Final Thoughts

Though practitioners know it is often the exception, this case serves as a crucial reminder that government agencies must adhere to procedural fairness when assessing Medicaid applications. Applicants have a right to clear communication and a reasonable opportunity to provide necessary documentation. Furthermore, state agencies cannot deny benefits based on minor technicalities or failures in their own procedures.

For Medicaid applicants facing similar challenges, this ruling reinforces the importance of persistence and legal advocacy. If you or a loved one has been wrongfully denied Medicaid benefits, consider consulting with an experienced attorney to ensure your rights are protected.