N.J. Admin. Code § 10:49-21.4

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:49-21.4 - Medicaid/NJ FamilyCare Managed Care Program services

(a) The following services are provided under the Medicaid/NJ FamilyCare Managed Care Program:

1. Primary and specialist care;

2. Preventive health care and counseling;

3. Early and Periodic Screening, Diagnostic and Treatment (EPSDT);

4. Audiology Services;

5. Organ transplants, donor and recipient costs;

6. Inpatient and outpatient hospital services;

7. Emergency medical care;

8. Laboratory and radiology services;

9. Prescription drugs (Legend and non-legend drugs);

10. Family planning services

11. Podiatrist services;

12. Chiropractor services;

13. Optometrist services;

14. Optical and hearing appliances;

15. Home health agency services;

16. Medical supplies and durable medical equipment;

17. Dental services;

18. Ambulance, Mobile Intensive Care Unit (MICU) and invalid coach transportation services;

19. Prosthetic and orthotic services;

20. Hospice services; and

21. Private duty nursing agency services.

(b) The following services are not covered by an HMO, but are available to beneficiaries and are payable by the Medicaid program on a traditional fee-for-service basis:

1. Medical day care;

2. Elective/induced abortion services;

3. Lower mode transportation;

4. Psychiatric inpatient hospital services;

5. Residential treatment center care services;

6. Intermediate care facility/mental retardation services;

7. Outpatient rehabilitation services; these services for NJ FamilyCare Plan B and C beneficiaries are limited to 60 days per year;

8. Services to beneficiaries participating in waiver or demonstration programs;

9. Personal care assistant services;

10. Nursing facility care;

11. Substance abuse services--diagnosis, treatment and detoxification costs for methadone, suboxone and subutex maintenance and their administration;

12. Mental health services (except that these services are covered by the HMO for DDD clients);

13. Partial care and partial hospitalization services;

14. Sex abuse examinations;

15. Home health agency services for the Aged, Blind and Disabled (ABD) population; and

16. Prescription drugs for the ABD population and dual-eligible beneficiaries eligible for Medicaid and Medicare.

(c) Certain services provided to beneficiaries who are enrolled in an HMO will no longer be reimbursed on a fee-for-services basis. If the beneficiary is enrolled in an HMO, and the HMO restricts payment to providers who have agreed to contract with it, a provider who is not a contractor with the HMO, or who fails to obtain authorization from the HMO, may not be reimbursed. It is therefore incumbent upon the provider to check the identification card of the Medicaid beneficiary prior to the provision of any service, even if the provider has received prior authorization from a Medical Assistance Customer Center (MACC) or the Medicaid/NJ FamilyCare Central Dental Services Unit. Failure to do so could result in a claim being rejected by both the Division's fiscal agent, Unisys, and the member's HMO.

(d) Persons in Home or Community-based Waiver Programs, those who are in demonstration programs, those who are in long-term care facilities or residential placement facilities and those in the Medically Needy program, or presumptive eligibility program, are excluded from enrolling in an HMO. Other persons, including pregnant women past the first trimester who have an existing relationship with an obstetrician, those persons who have chronic debilitating illnesses who are under the care of a physician who will coordinate their health care needs; and individuals who are terminally ill with an established relationship with a physician or enrolled under the Hospice program, may be exempted from mandatory managed care under certain circumstances. See N.J.A.C. 10:74-8 for further information on excluded or exempted persons.

(e) A beneficiary may elect to obtain family planning services either through the HMO or through a Medicaid-participating family planning provider on a fee-for-service basis.

(f) Reimbursement for any and all drugs prescribed for the treatment of mental health and substance abuse are the responsibility of the HMO with the exception of methadone, suboxone, subutex for treatment of substance abuse and atypical antipsychotics (see 10:49-21.4(b)9 ). A pharmacist dispensing these drugs shall participate in the pharmacy network of the Medicaid/NJ FamilyCare beneficiary's HMO. In addition, any ambulance, MICU or invalid coach transportation provided for behavioral health services also remain the responsibility of the HMO. A transportation provider providing ambulance, MICU or invalid coach services shall participate in the transportation network of the Medicaid member's HMO.

N.J. Admin. Code § 10:49-21.4

Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
Section was "Medicaid Managed Care Program--New Jersey Care 2000 Services". In the introductory paragraph of (a), inserted "/NJ FamilyCare" and deleted "--New Jersey Care 2000" following "Program"; in (a)1, deleted "(Preventive health care and counseling, EPSDT)" from the end; added new (a)2 through (a)5; recodified former (a)2 through (a)15 as new (a)6 through (a)19; deleted former (a)16; recodified former (a)17 and (a)18 as (a)20 and (a)21; in the introductory paragraph of (b), substituted a colon for a period at the end; rewrote (b)7; (b)11 and (b)12; added (b)13 through (b)16; in (c), substituted "Medical Assistance Customer Center (MACC)" for "Medicaid District Office" and "the Medicaid/NJ FamilyCare" for "Medicaid's"; and in (f), inserted ", suboxone, subutex for treatment of substance abuse and atypical antipsychotics" and "/NJ FamilyCare".