New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES
Subchapter 3 - BENEFITS
Section 10:74-3.3 - Managed care organization (MCO) benefits for Medicaid/NJ FamilyCare-Plans A, B, C, and D enrollees

Universal Citation: NJ Admin Code 10:74-3.3

Current through Register Vol. 56, No. 18, September 16, 2024

(a) The MCO shall provide all services required by the managed care contract, including, but not limited to, the services listed in (a)1 through 29 below and at N.J.A.C. 10:49-5, for all Medicaid/NJ FamilyCare-Plans A, B, C, and D enrollees, with the exception of those services identified as fee-for-service (see N.J.A.C. 10:74-3.4) or excluded from the specific service package under N.J.A.C. 10:74-3.5:

1. Primary and specialty care by physicians, dentists, certified nurse midwives, advanced practice nurses and physician assistants, within the scope of their practice and in accordance with all applicable state certification/licensure requirements;

2. Preventive health care and counseling and health promotion;

3. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program services:
i. For NJ FamilyCare-Plans B, C, and D participants, coverage shall include EPSDT: medical examinations, dental, vision, hearing, and lead screening services. Coverage includes only those treatment services identified through the examination that are available under the MCO's benefits package for Plans B, C, and D enrollees or as services specified under the FFS program;

4. Emergency medical care;

5. Inpatient hospital services including acute care hospitals, rehabilitation hospitals and special hospitals;

6. Outpatient hospital services;

7. Laboratory services, not including routine testing related to administration of Clozapine and other specified atypical antipsychotic drugs listed in the managed care contract for non-DDD clients;

8. Radiology services, diagnostic and therapeutic;

9. Prescription drugs, including legend drugs and non-legend drugs that are covered by the Medicaid/NJ FamilyCare program and indicated in the managed care contract;

10. Family planning services and supplies;

11. Audiology services;

12. Inpatient rehabilitation services;

13. Podiatrist services;

14. Chiropractor services;

15. Optometrist services;

16. Optical appliances;

17. Hearing aid services;

18. Home health agency services, except that home health agency services for aged, blind and disabled (ABD) beneficiaries are covered fee-for-service and not by the MCO;

19. Hospice services, in the community and in institutional settings. Room and board services are included only when services are delivered in an institutional (non-private residence) setting;

20. Durable medical equipment (DME)/assistive technology devices in accordance with existing Medicaid/NJ FamilyCare rules (see N.J.A.C. 10:59);

21. Medical supplies;

22. Prosthetics and orthotics, including certified shoe provider services;

23. Dental services;

24. Organ transplants, which include donor and recipient costs, except that the Medicaid/NJ FamilyCare fee-for-service program will reimburse for transplant-related donor and recipient inpatient hospital costs for an individual placed on a transplant list while in the fee-for-service Medicaid/NJ FamilyCare program prior to initial enrollment into an MCO;

25. Transportation services to and from any MCO-covered service and any service covered by the fee-for-service program as specified in this chapter, including ambulance, mobile intensive care units (MICUs) and mobile assistive vehicles (MAVs) (including lift-equipped vehicles);

26. Nursing Facility/Special Care Nursing Facility (NF/SCNF) Services--NF/SCNF services shall be covered for all Medicaid, NJ FamilyCare-Plan A, and NJ FamilyCare Alternative Benefit Plan (ABP) enrollees. This covered benefit is limited to rehabilitation services for NJ FamilyCare -Plan B, C, and D enrollees;

27. Mental health/substance use disorder services only for MLTSS enrollees and those enrollees who are clients of the Division of Developmental Disabilities (DDD) or a Fully Integrated Dual Special Needs Program (FIDE-SNP) program;

28. Partial care and partial hospitalization services (except for DDD clients); and

29. Inpatient mental health and substance use disorder treatment services.

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