Services Provided by the HMO

1. Chiropractic Services. Treatment of NJ licensed chiropractor for treatment using manual manipulation of the spine.
   
   
2. Dental Services. Includes preventive, diagnostic, major and minor restorative, endodontic, surgical and adjunctive services, orthodontia, periodontia and prosthodontia, provided by a licensed dentist.
   
   
3. Durable Medical Equipment. Assistive Technology Devices in accordance with existing Medicaid regulations.
   
   
4. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Services.
   
   
5. Emergency Medical Care. 24 hours/day, 7 days/week.
   
   
6. Family Planning Services and Supplies.
   
   
7. Hearing Aid Services. Provision of hearing aids, accessories, ear mold impressions, routine follow-ups and adjustments, and repairs after warranty expiration.
   
   
8. Home Health Agency Services. Provided to enrollee at his/her home and on his/her physician’s orders as part of a written plan that physician reviews every 60 days. Includes nursing services by an R.N. and/or licensed practical nurse; home health aid service, medical supplies and equipment, appropriate appliances for the home and audiology services.
   
   
9. Hospice Agency Services. By an agency that meets Medicare certification requirements.
   
   
10. Inpatient Hospital Services. These include acute care hospitals, rehabilitation hospitals and special hospitals. HMO responsible for inpatient costs of enrollees with dual diagnosis (physical plus mental health/substance abuse condition) whose primary diagnosis is not mental health or substance abuse related.
    
    
11. Inpatient Rehabilitation Services.
    
    
12. Laboratory Services. (Except routine testing related to the administration of Clozapine and the other psychotropic drugs listed under fee for service coverage.)
    
    
13. Medical Supplies.
    
    
14. Mental Health/Substance Abuse Services. Provided by HMO for enrollees who are clients of Division of Developmental Disabilities.
    
    
15. Optical Appliances. Artificial eyes, lenses, frames, and other aids to vision prescribed by a physician skilled in diseases of the eye or an optometrist.
    
    
16. Optometrist Services. By a state-licensed optometrist.
    
    
17. Organ Transplants. Medically necessary transplants including liver, lung, heart, heart-lung, pancreas, kidney, cornea, intestine, and bone marrow including autologous bone marrow transplants.
    
    
18. Outpatient Hospital Services. Preventive, diagnostic, therapeutic or palliative services under the direction of a physician or dentist.
    
    
19. Outpatient Rehabilitation Services - 60 days per therapy per contract year:
    • physical therapy;
    • occupational therapy;
    • audiology services; and
    • speech/language therapy.
      
      
20. Podiatrist Services. Excludes routine hygienic care of the feet, including treatment of corns and calluses, trimming of nails, and other hygienic care, in the absence of a pathological condition.
    
    
21. Post-acute care. Rendered at an acute care hospital or nursing facility for 30 days or less for inpatient rehabilitation services.
    
    
22. Primary and Specialty Care. Provided by physicians, Certified Nurse Midwives, Certified Nurse Practitioners, Clinical Nurse Specialists, and Physician Assistants.
    
    
23. Prescription Drugs.
    
    
24. Preventive Health Care and Counseling and Health Promotion. Includes referrals to WIC programs.
    
    
25. Prosthetics and Orthotics. Includes certified shoe provider services. “Prosthetic devices” means replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner. “Orthotic appliances” means a device or brace prescribed by a physician or licensed practitioner. A brace includes rigid and semi-rigid devices to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body.
    
    
26. Radiology Services. Diagnostic and therapeutic.
    
    
27. Transportation Services. For any HMO covered service or non-HMO covered service including ambulance, mobile intensive care units (MICUs) and invalid coach (including lift-equipped vehicles).

Services Remaining in the Fee for Service Program

The following services will remain under the fee for service program but the enrollee may be required to have a medical order from his/her PCP to access these services.

1. Personal Care Assistant Services
   
   
2. Medical Day Care
   
   
3. Outpatient Rehab – physical therapy, occupational therapy, and speech pathology services
   
   
4. Abortions and related services (detailed related services in contract)
   
   
5. Transportation – lower mode
   
   
6. Sex abuse examinations performed at DYFS contracted Child Abuse Regional Centers or by DYFS contracted physicians
   
   
7. Services provided by NJ Mental Health/Substance Abuse and DYFS Residential Treatment facilities, Group Homes or Assisted Living Facilities
   
   
8. Family planning services and supplies may be accessed through the HMO or fee
   for service.
   
   
9. Home health services for the non-dually eligible ABD population
   
   
10. Mental Health services (for all non-DDD beneficiaries)
    
    
11. Substance Abuse (for all non-DDD beneficiaries)
    
    
12. Costs for methadone and its administration
    
    
13. Clozapine, risperridone, olanzapine, quetiapine, methadone, and generically-equivalent drug products
    
    
14. Up to 12 hospital days required for social necessity
    
    
15. Donor and beneficiary inpatient costs for organ transplants

Institutional Fee for Service Benefits

1. Nursing Facility Care (Exception - admission to a nursing facility solely for inpatient rehabilitation services: up to 30 days will be paid by HMO, after which member must be disenrolled from the Plan.)
   
   
2. Inpatient psychiatric services (excluding residential treatment centers) for individuals under the age of 21 and over 65. The member is to be disenrolled from the HMO on the date of admission.
   
   
3. Intermediate Care Facility/Mental Retardation Services: the member is to be disenrolled from the HMO upon the date of admission.
   
   
4. Waiver and demonstration programs (excluding DDD/CCW).

Services not Covered by Medicaid/Plan A

1. All services not medically necessary.
   
   
2. Cosmetic surgery except when medically necessary and approved.
   
   
3. Experimental organ transplants.
   
   
4. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals.
   
   
5. Rest cures, personal comfort and convenience items, services and supplies not directly related to the care of the patient.
   
   
6. Services involving use of equipment in facilities when the equipment’s purchase, rental or construction not approved by state law.
   
   
7. All claims arising from services provided in federally owned or operated institutions (e.g., VA hospitals).
   
   
8. Services provided in an inpatient psychiatric institution, that is not an acute care hospital, to individuals under 65 and over 21 years of age.
   
   
9. Services provided to all persons without charge.
   
   
10. Services furnished while individual is on active duty in the military.
    
    
11. Services provided outside the U.S.
    
    
12. Services arising from condition or accidental injury arising out of or in the course of employment.
    
    
13. That part of any benefit that is covered or payable by a third party.
    
    
14. Services provided by an immediate member of the individual’s family.
    
    
15. Services billed without adequate records to support claim.

Last legal review 3/10/05.