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LAW Home > Legal Topics > Health Care > NJ FamilyCare/Medicaid > Medicaid Program in NJ

Medicaid Services and Managed Care


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Comprehensive Services through NJ FamilyCare

Medicaid in New Jersey is considered part of NJ FamilyCare. This includes the many different programs that fall under Medicaid. Once enrolled in a Medicaid program, you have a right to receive all medically necessary services. NJ Medicaid provides a full range of services, including doctor, hospital, mental health, dental, physical therapy, family planning, prescription drugs, and others. Services available to children are particularly comprehensive because of requirements under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. As a NJ Medicaid recipient, you cannot be charged a deductible, co-pay, or other cost for services.

Choosing your Medicaid Insurance Plan

If you have Medicaid in NJ, your care will generally be managed by a private health insurance company that has a contract with the NJ Medicaid agency. Currently, five companies provide Medicaid coverage in New Jersey in the form of a Managed Care Organization (MCO), often referred to as an HMO (Health Maintenance Organization). They are:

Aetna Better Health
Horizon NJ Health
United Healthcare Community Plan

Your MCO coverage should start on the first day of the month after you are approved for Medicaid.

You can choose your plan when you first sign up for Medicaid. If you are already established with a doctor, call their office and ask which Medicaid MCO (HMO) plans they accept. You can also review the plan’s provider directory (described in more detail below) to help you choose the plan that is best for you. If you do not choose a plan, you will be assigned to one.

You have the right to change your plan at any time for cause. You also have a right to change your plan without cause within 90 days of initial enrollment and every 12 months thereafter. If you want to switch plans, call NJ FamilyCare at 1-800-701-0710.

Medicaid Cards

Once you are enrolled in Medicaid, you should receive a blue and white Health Benefits Identification (HBID) card from the State of New Jersey (sample Health Benefits Identification Card) with your Medicaid number. You should keep this in a safe place, but you will not usually need this card to get care. In addition, once you are enrolled in a Medicaid MCO, you should receive a card in the mail from that company, which you must present any time you seek medical care, including doctor’s visits, lab or radiology testing, hospital care, etc.

There may be a gap between the effective date of your Medicaid eligibility and when you are covered by the MCO. There may be other times when you remain eligible for Medicaid, but you lose your MCO coverage for some reason. If you have medical costs during these time periods—for example, emergency room visit or prescriptions—and you have your HBID card, ask your provider to bill Medicaid on a “fee for service” (FFS) basis. If you don’t have your card with you and are not otherwise able to persuade the provider to bill FFS, you may still be able to get any costs you pay reimbursed to you. If the provider is a Medicaid FFS provider, and you present later with your HBID card, they must reprocess your charges through Medicaid and pay you back for what you spent.

Using your Medicaid Insurance Plan

When you make a medical appointment, be careful to use the specific name of the insurance plan you have. Doctors who take Horizon Blue Cross Blue Shield insurance, for example, may not take the Medicaid equivalent Horizon NJ Health. It is frustrating to show up for an appointment only to be told that the doctor does not participate with that insurance plan.

Making it clear that that you are in a Medicaid HMO also protects you from being “balance billed” by the doctor. If a physician’s office knows at the time of your visit that you have a Medicaid plan, then they cannot bill you even if the plan does not pay all of their charges. Sometimes a doctor’s office may mistakenly bill you. You should call the billing office and explain that you have Medicaid. If they refuse to adjust the bill, call the member services number for your MCO and they will contact the physician’s office on your behalf.

Finding Doctors who Accept Your Medicaid Insurance Plan

All of the Medicaid MCOs ask you to select a primary care physician, usually in the specialties of family medicine, internal medicine (adults only), or pediatrics (children only). You have the right to choose your primary care physician. If you do not choose, one will be assigned to you. You can change your primary care physician at any time, even mid-month. If you go to a different primary care physician than the one assigned (usually printed on your insurance card), that provider will not be paid for the visit. They may refuse to see you for this reason. However, you can call the member services department from the doctor’s office, and change your assignment. Write down the reference number for your call, so you have proof that you made it.

To choose a primary care provider, it is helpful to review’s the list of participating providers that each plan is required to maintain. The list includes primary care and all other providers that participate in the plan’s network. Links for each plan are at the end of this article. However, these lists are not always accurate, so it is best to call the provider listed to confirm they currently participate in your Medicaid MCO’s plan and are accepting new patients.

When you need a specialist, you must first see if there is an appropriate one that participates in your plan. Your primary care provider can help you to find the right specialist and tell you if a referral is necessary. Sometimes, the specialist you need might not be a participating provider. This may be because there is no participating specialist you need located close enough to you or because there is no specialist in the plan’s network that has the required skill and knowledge to treat your condition

In that event, your MCO is still required to provide you with care through an out-of-network provider. Your primary care office should be able to call the insurance company to help you find an appropriate specialist. The insurance company may agree for you to see a specialist not on their list, if you get pre-approval for the care; but if your insurance company refuses to do so, you have the right to challenge that decision

Medicaid MCO Provider Directories

Aetna Better Health: Online search tool, Directories by county
Amerigroup: Online search tool
Horizon NJ Health: Online search tool
United Healthcare Community Plan: Online search tool
WellCare: Online search tool

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