Current through Register Vol. 56, No. 18, September 16, 2024
(a) Effective for
dates of service on or after July 1, 2007, all beneficiaries previously covered
under Plan H are covered under NJ FamilyCare Plan D. The information in (b)
through (g) below applies only to claims for former NJ FamilyCare Plan H
beneficiaries with dates of service prior to July 1, 2007.
(b) Childless adults whose income is below
100 percent of the Federal poverty level and who do not qualify for WFNJ/GA and
who were enrolled in NJ FamilyCare on July 1, 2002 shall be eligible to receive
the NJ FamilyCare Plan H service package.
(c) Restricted alien parents who are enrolled
in NJ FamilyCare on November 1, 2003, shall receive the Plan H service
package.
(d) Out-of-plan
community-based mental health services shall be limited to 60 service days per
calendar year and shall be eligible for payment on a fee-for-service basis.
1. Adult mental health rehabilitation
services provided in/by community residence programs (see N.J.A.C. 10:77A)
shall not be eligible for payment under NJ FamilyCare-Plan H.
2. NJ FamilyCare-Plan H beneficiaries under
age 21 who are receiving services under the Division of Child Behavioral Health
Services may secure additional mental health services if the services are
authorized by the Contracted Systems Administrator or other agent authorized by
the Department of Human Services and included in a plan of care.
(e) No behavioral health
out-of-plan service of any kind, where the place of service is a hospital,
shall be a covered service, unless provided in an approved psychiatric hospital
to a beneficiary who is receiving services under the Division of Child
Behavioral Health Services.
(f) The
services listed below shall be available to beneficiaries eligible for NJ
FamilyCare-Plan H, when medically necessary and when provided through the
network of an HMO selected by the beneficiary.
1. Advanced practice nurse
services;
2. Ambulance--medical
emergency only;
3. Ambulatory
surgery in an outpatient hospital setting only;
4. Clinic services (free
standing)--ambulatory;
5. Diabetic
supplies/equipment;
6. Durable
Medical equipment-limited benefit, only covered when a medically necessary part
of the beneficiary's inpatient hospital discharge plan;
7. Emergency room services;
8. Federally qualified health centers (FQHC)
primary care services;
9. Home
health care services (limited benefits);
10. Inpatient hospital (non-behavioral health
related);
11. Laboratory
services;
12. Outpatient hospital
(non-mental health related);
13.
Physician services;
14.
Prescription drugs (excludes over the counter medications); and
15. Radiological services.
(g) The following services shall
be available to NJ FamilyCare-Plan H beneficiaries on a fee-for-service basis:
1. Abortion (elective/induced); and
2. Mental health services in the community,
including psychological services, up to a maximum of 60 days per calendar year;
i. Adult mental health rehabilitation
services provided in/by community residence programs (see N.J.A.C. 10:77A) are
not eligible for payment under NJ FamilyCare-Plan H.
ii. NJ FamilyCare-Plan H beneficiaries under
age 21 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.
(See 10:49-5.8(d)
).
(h)
Additional mental health and mental health rehabilitation services as listed
below may be available to beneficiaries under age 21 who are eligible for NJ
FamilyCare-Plan H under fee-for-service receiving services from the Division of
Child Behavioral Health Services. All services shall first be authorized by the
Contracted Systems Administrator, the Division of Medical Assistance and Health
Services 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. Psychiatric services provided in an
inpatient psychiatric hospital setting (see N.J.A.C. 10:52);
3. 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);
4. Behavioral assistance services for
children, youth or young adults (see N.J.A.C. 10:77-4);
5. Mobil response and stabilization
management services for children, youth or young adults under EPSDT (see
N.J.A.C. 10:77-6); and
6.
Intensive in-community mental health rehabilitation services for children,
youth or young adults under EPSDT (see N.J.A.C. 10:77-5).
