Health Care Through HMO and Fee-For-Service Providers
The NJ FamilyCare program for free and reduced-cost health insurance covers the costs of approved and medically necessary health care services for their beneficiaries in two ways: (1) by contracting with large HMOs (health maintenance organizations) that pay a network of providers to care for beneficiaries, and (2) by contracting directly with individual health care providers to pay them a set fee for each approved service they provide for beneficiaries, known as fee-for-service care.
Most Plan B and C beneficiaries are enrolled in one of the six approved HMOs in New Jersey that provide most of their health care. See Choosing an HMO form the FamilyCare Web site. They must use a health care provider who is part of their HMO’s provider network to have the care paid for by NJ FamilyCare. But there are some covered health care services that the HMOs do not provide, and those are paid for by NJ FamilyCare when provided by a fee-for-service Medicaid/NJ FamilyCare provider.
Who Has Plan B and Plan C NJ FamilyCare benefits?
NJ FamilyCare Plans B and C cover benefits for children only. There are no adults in either plan. NJ FamilyCare determines the benefit plans based mostly on a family’s income in relation to the federal poverty level (fpl). But there are also several non-financial requirements for NJ FamilyCare eligibility, such as residency, citizenship, uninsured status, and more. (Please see the NJ FamilyCare Web site for details.)
If they have satisfied all other eligibility requirements, the following children have Plan B or Plan C benefits.
NJ FamilyCare Plan B: Children with family income between 134% fpl and 150% fpl.
Examples:
Family of 3 = Annual income between $24,353 and $27,465
Family of 4 = Annual income between $29,327 and $33,075
NJ FamilyCare Plan C: Children with family income between 151% fpl and 200% fpl.
Examples:
Family of 3 = Annual income between $27,465 and $36,620
Family of 4 = Annual income between $33,075 and $44,100
Covered Services in NJ FamilyCare Plans B and C
The following lists the health care services that are covered in NJ FamilyCare Plan B 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
- Audiology services
- 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
- Clinical nurse specialist services
- Dental services
- Durable medical equipment
- Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for under age 21
- Emergency room services
- 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)
- Federally qualified health center primary care
- Hearing aid services
- Home health care except personal care assistance services
- Hospice services
- Hospital inpatient services in general acute care, special, and rehabilitation hospitals
- Hospital outpatient services
- Laboratory services
- Medical supplies and equipment
- Nurse-midwifery services
- Optometry services
- Optical appliances
- Organ transplants, recipient and donor costs
- Prescription drugs
- Physician services
- Podiatry services
- Prosthetic and orthotic services
- Private duty nursing with exceptions
- Radiology services
- Non-lower mode transportation (not buses or taxis), including ambulance, mobility assistance vehicle, and mobile intensive care units.
Services Provided Fee-for-Service
- Religious, non-medical health care services
- Clinic services in non-hospital outpatient facility for family planning services, mental health and substance abuse treatment services
- Elective/induced abortion services
- Emergency room services for treatment of mental health and substance abuse
- Family planning services, including physical exams by non-HMO Medicaid/NJ FamilyCare provider
- Inpatient hospital services for psychiatric hospitals; inpatient psychiatric programs for children 19 years of age and younger; and acute care or special hospital services if provided for mental health or substance abuse services
- Additional mental health services may be available for children receiving services from the Division of Child Behavioral Health Services when authorized
- Mental health services provided by such practitioners as physicians, psychologists, and certified nurse practitioners/clinical nurse specialists
- Outpatient hospital services for family planning, mental health, and substance abuse treatment services
- Rehabilitative services, including physical, occupational and speech therapy, limited to 60 days per type of therapy per year
- Sex abuse examinations
- Substance abuse services provided by such practitioners as physicians, psychologists, and advanced practice nurses
- Targets case management services for the chronically ill.
Services Not Covered by Medicaid/NJ FamilyCare Plan B or Plan C Include:
- All services not medically necessary
- Nursing facility services, except the Medicare Part A copayments for the first 30 days of skilled nursing care
- Intermediate care facilities for mental retardation
- Personal care services
- Medical day care services
- Lower mode transportation (buses and taxis)
- Programs for Assertive Community Treatment (PACT) services
- Adult mental health rehabilitation services provided in/by community residence programs.
If you are denied eligibility or terminated wrongly for Medicaid/NJ FamilyCare, or you have been denied a medically necessary covered service, you have a right to a Grievance 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 1/8/10. |
