Health Care Through HMO and Fee-For-Service Providers
The Medicaid/NJ FamilyCare program covers the costs of approved and medically necessary health care services in two ways:
(1) Through fee-for-service (ffs) arrangements with health care providers who agree to accept a set fee for each health care service they provide and who bill Medicaid/NJ FamilyCare directly for each approved service; and
(2) Through HMOs (health maintenance organizations) who Medicaid/NJ FamilyCare pays a set rate per HMO enrollee instead of per each health care service (capitation rate) and the HMOs then pay a negotiated rate to a network of providers to treat patients enrolled in the HMO. Each HMO’s enrollees must get most health care services from providers (doctors, hospitals, pharmacies, dentists, labs, etc.) who are in their HMO’s network of providers.
Most children and adults in the Medicaid/NJ FamilyCare program are enrolled in one of the six approved HMOs in New Jersey. See Choosing an HMO form the FamilyCare Web site. But there are some covered health care services that the HMOs do not provide. Those are paid for when provided by a fee-for-service provider.
Note: There are some Medicaid beneficiaries who are exempted from joining an HMO and some who are presumptively eligible or newly eligible for Medicaid who have not yet selected an HMO. These beneficiaries must get their health care from providers who get paid on a fee-for-service basis.
Who Has Plan A Medicaid/NJ FamilyCare Benefits?
There are non-financial requirements for Medicaid/NJ FamilyCare eligibility, such as residency, citizenship and uninsured status, and more. And there are different benefit plans/packages. If they satisfy all other eligibility requirements, the following lists most individuals who are eligible for Medicaid-Plan A covered services:
- Children under the age of 18 and their parents or caretaker relatives who are eligible for AFDC-related Medicaid
- Children and their parents or caretaker relatives who are eligible for four or 24 months of Transitional Medicaid
- Children under the age of 19 who are eligible for NJ FamilyCare with family income to 133% of the federal poverty level (fpl)
- Children under the age of one who are eligible for Medicaid
- Pregnant women with household income below 200% fpl
- Children aged 18-21 who are eligible for Medicaid Special
- Children and adults who are eligible for New Jersey Care-Aged, Blind and Disabled (ABD) Medicaid
- Adults who are eligible for NJ Workability
- Adults who are eligible for Breast and Cervical Cancer Medicaid.
Medicaid-Plan A Covered Services
The following lists the health care services that are covered in Plan A Medicaid/NJ FamilyCare through the HMOs and those that are covered when provided by a fee-for-service provider. Some services will require prior authorization or a referral from your primary care provider.
Services Provided by the HMO
- Advanced Practice Nurse
- Chiropractic services
- Clinic services in an independent (non-hospital), outpatient facility that provides family planning, dentistry, optometry, ambulatory surgery, or a Federally Qualified Health Center
- Dental services
- Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for under age 21
- Family planning services, including physical exams (including pelvic and breast), labs, supplies, and genetic counseling (services primarily for diagnosis and treatment of infertility are not covered by Medicaid/NJ FamilyCare)
- Hearing aid services
- Home health care, except for the Aged Blind and Disabled population (see Services Provided Fee-for-Service)
- Hospice services
- Hospital inpatient services in general acute care, special, and rehabilitation hospitals
- Hospital outpatient services
- Laboratory services
- Medical supplies and equipment
- Mental health services for clients of the Division of Developmental Disabilities (DDD), excluding partial care and partial hospitalization
- Nurse-midwifery services
- Optometry services
- Optical appliances
- Prescription drugs (except for ABD and dual eligible beneficiaries)
- Physician services
- Podiatry services
- Prosthetic and orthotic services
- Radiology services
- Non-lower mode transportation (not buses or taxis), including ambulance, mobility assistance vehicle, and mobile intensive care units
- Audiology services
- Organ transplants, recipient and donor costs
- Emergency medical care
- Treatment for conditions categorized as altering the mental status of an individual that are organic in nature.
Services Provided Fee-for-Service
- Case management services
- Religious, non-medical health care services
- Environmental lead inspection services-rehabilitation services
- Medical day care services
- Mental health services, including partial care and partial hospitalization services
- Mental health rehabilitation services, including
- Residential child care facilities
- Children’s group homes
- Psychiatric community residences for youth
- Behavioral assistance services for children, youth, and young adults under EPSDT
- Mobile response and stabilization management services for children, youth, or young adults under EPSDT
- Intensive in-community mental health rehabilitation services for children, youth, or young adults under EPSDT
- Programs for Assertive Community Treatment (PACT) Services
- Adult mental health rehabilitation services provided in/by community residence programs
- Nursing facility services, including intermediate care facilities (ICF) for the mentally retarded
- Rehabilitative services:
- Physical therapy
- Occupational therapy
- Speech-language therapy
- School-based rehabilitation services under EPSDT
- Personal care assistance services
- Elective and induced abortions and related services
- Lower mode transportation (buses or taxis)
- Sex-abuse examinations
- Family planning services by non-HMO Medicaid/NJ FamilyCare provider
- Home health care services for ABD beneficiaries
- Prescription drugs for ABD and dual-eligible beneficiaries
- Mental health services for non-DDD clients, including atypical antipsychotic medicines
- Substance abuse services, including diagnosis, treatment, and detoxification
- Methadone, Suboxone, and Subutex maintenance and administration for the treatment of substance abuse
- Inpatient psychiatric services, except for residential treatment centers for beneficiaries under age 21 or over age 65
- Inpatient psychiatric programs for children 21 years of age and under
- All services offered under approved waiver and demonstration programs.
Services not Covered by Plan A Medicaid/NJ FamilyCare
- All services not medically necessary
- Cosmetic surgery except when medically necessary and approved
- Experimental organ transplants
- Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals
- Rest cures, personal comfort and convenience items, services and supplies not directly related to the care of the patient
- Services involving use of equipment in facilities when the equipment’s purchase, rental, or construction is not approved by state law
- All claims arising from services provided in federally owned or operated institutions (e.g., VA hospitals)
- Services provided in an inpatient psychiatric institution, which is not an acute care hospital, to individuals under 65 and over 21 years of age
- Services provided to all persons without charge
- Services furnished while a person is on active duty in the military
- Services provided outside the U.S.
- Services arising from condition or accidental injury arising out of or in the course of employment
- That part of any benefit that is covered or payable by a third party
- Services provided by an immediate member of the individual’s family
- Services billed without adequate records to support claim.
If you are denied eligibility or terminated wrongly for Plan A Medicaid/NJ FamilyCare, or if you have been denied a medically necessary covered services, you have a right to a Fair Hearing to appeal the decision. If you need free legal assistance with any Medicaid or NJ FamilyCare issue, please contact your nearest Legal Services office or call LSNJ-LAW™, Legal Services of New Jersey’s statewide, toll-free legal hotline, at 1-888-LSNJ-LAW (1-888-576-5529) to see if you are eligible for free legal assistance. Hotline hours are Monday through Friday, 8:00 a.m. to 5:30 p.m. If you are not eligible for assistance from Legal Services, the hotline will refer you to other possible resources.
This information last reviewed 10/26/11 |
