Current through Register Vol. 56, No. 18, September 16, 2024
(a) Except for the
exceptions at
10:79-6.5, which concern services
for newborns enrolling into NJ FamilyCare-Plan C, the services listed below are
available to beneficiaries eligible for NJ FamilyCare-Plan B or C, through an
HMO selected by the NJ FamilyCare-Plan B or C beneficiary.
1. Advance practice nurse services;
2. Audiology services;
3. Chiropractic services;
4. Clinic services (services in an
independent outpatient health care facility, other than hospital, that provides
services such as, dental, optometric, ambulatory surgery, etc.);
5. Clinical nurse specialist
services;
6. Dental
services;
7. Durable medical
equipment;
8. Early and periodic
screening, and diagnosis medical examinations, dental, vision and hearing
services, and lead screening services. Includes only those treatment services
identified through the examination that are available under the HMO contract or
covered fee-for-service program;
9.
Emergency room services;
10. Family
planning services including medical history and physical examination (including
pelvic and breast), diagnostic and laboratory tests, drugs and biologicals,
medical supplies and devices, counseling, continuing medical supervision,
continuity of care and genetic counseling;
i.
Services provided primarily for the diagnosis and treatment of infertility,
including sterilization reversals, and related office (medical and clinic)
visits, drugs, laboratory services, radiological and diagnostic services and
surgical procedures are not covered by the New Jersey Medicaid or NJ FamilyCare
program.
11. Federally
qualified health center primary care services;
12. Hearing aid services;
13. Home health care services;
i. Exception: personal care assistant
services;
14. Hospice
services;
15. Hospital
services--inpatient:
i. General
hospitals;
ii. Special hospitals;
and
iii. Rehabilitation
hospitals;
16. Hospital
services--outpatient;
17.
Laboratory (clinical);
18. Medical
supplies and equipment;
19.
Nurse-midwifery services;
20.
Optometric services;
21. Optical
appliances;
22. Organ transplant
services, donor and recipient costs;
23. Prescription drug services;
24. Physician services;
25. Podiatric services;
26. Prosthetic and orthotic
devices;
27. Private duty
nursing;
28. Radiological services;
and
29. Transportation services,
limited to ambulance, MICU's and invalid coach.
(b) The services listed below are available
to beneficiaries eligible for NJ FamilyCare-Plan B or C under fee-for-service:
1. Religious non-medical health care
institution care and services;
2.
Clinic services (services in an independent outpatient health care facility,
other than hospital) for family planning services, mental health or substance
abuse treatment services;
3.
Elective/induced abortion services;
4. Emergency room services for treatment of
mental health disorder or for substance abuse;
5. Family planning services including medical
history and physical examination (including pelvic and breast), diagnostic and
laboratory tests, drugs and biologicals, medical supplies and devices,
counseling, continuing medical supervision, continuity of care and genetic
counseling;
i. Services provided primarily
for the diagnosis and treatment of infertility, including sterilization
reversals, and related office (medical and clinic) visits, drugs, laboratory
services, radiological and diagnostic services and surgical procedures are not
covered;
6. Hospital
services--inpatient, for:
i. Psychiatric
hospitals;
ii. Inpatient
psychiatric programs for children 19 years of age and under; and
iii. Acute care or special hospital services
if provided for mental health or substance abuse services;
7. Mental health services provided by
practitioners, such as physicians, psychologists, and certified nurse
practitioners/clinical nurse specialists;
i.
NJ FamilyCare-Plan B and C beneficiaries under age 19 who are receiving
services under the Division of Child Behavioral Health Services may be eligible
for additional mental health and mental health rehabilitation services as
authorized by the Contracted Systems Administrator (CSA). (See
10:49-5.6(d).)
8. Outpatient hospital services
for family planning, mental health and substance abuse treatment
services;
9. Rehabilitative
services, including physical, occupational and speech therapy, limited to 60
days per type of therapy per year;
10. Sex abuse examinations;
11. Substance abuse services provided by
practitioners, including physicians, psychologists, advanced practice nurses;
and
12. Targeted case management
services for the chronically ill.
(c) Services not covered under Plan B and C
shall be as follows:
1. Unless listed in (a)
and (b) above, no other services are covered by NJ FamilyCare-Plan B or
C.
2. Services not covered shall
include, but shall not be limited to:
i.
Nursing facility services, except the Medicare Part A copayments for the first
30 days of skilled nursing care;
ii. Intermediate care facilities for mental
retardation (ICFs/MR);
iii.
Personal care services;
iv. Medical
day care services;
v. Lower mode
transportation;
vi. Any item or
service (other than an emergency item or service, not including items or
services furnished in an emergency room of a hospital) furnished at the
direction or on the prescription of a physician, individual or entity, during
the period when such physician, individual or entity is excluded from
participation in the Medicaid and NJ FamilyCare programs, and when the
physician, individual or entity furnishing such item or service has received
written notice from the Division that the physician, individual or entity has
been excluded from participation in the Medicaid and NJ FamilyCare
programs;
vii. Programs for
Assertive Community Treatment (PACT) services; and
viii. Adult mental health rehabilitation
services provided in/by community residence programs (see N.J.A.C. 10:37A and
10:77A).
(d)
Additional mental health and mental health rehabilitation services as listed
below may be available to beneficiaries under age 19 who are eligible for NJ
FamilyCare-Plan B or C under fee-for-service who are receiving services from
the Division of Child Behavioral Health Services. All services shall first be
authorized by the CSA or other agent authorized by the Department of Human
Services and shall be included in an approved plan of care.
1. Care coordination by a care management
organization (CMO) (see N.J.A.C. 10:73);
2. Mental health rehabilitation services
provided in residential childcare facilities (as defined in N.J.A.C. 10:127 and
licensed by DHS/DYFS), children's group homes (as defined in N.J.A.C. 10:128
and licensed by DHS/DYFS), or psychiatric community residences for youth (as
defined in N.J.A.C. 10:37B and licensed by DHS/DMHS);
3. Behavioral assistance services for
children, youth or young adults under EPSDT (see N.J.A.C. 10:77-4);
4. Mobil response and stabilization
management services for children, youth or young adults under EPSDT (see
N.J.A.C. 10:77-6); and
5.
Intensive in-community mental health rehabilitation services for children,
youth or young adults (see N.J.A.C. 10:77-5).
(e) All presumptively eligible NJ
FamilyCare-Plan B and C beneficiaries shall be eligible to receive all the
services specified in (a) and (b) above for fee-for-service during the
presumptive eligibility period, which shall include the services that are
otherwise only available through the managed care organizations. The provision
of the managed care services fee-for-service shall be limited to the
presumptive eligibility period. The additional mental health services listed in
(d) above may be available to children, youth or young adults under the age of
19 who are receiving services from the Division of Child Behavioral Health
Services during their period of presumptive eligibility.
