Member Benefits
To view benefit information, look under the column in the NJ FamilyCare chart that matches the type of plan noted on the member’s ID card. If there is no plan listed on the card, the member is in NJ FamilyCare A or NJ FamilyCare ABP. If the member receives MLTSS benefits, please view the MLTSS benefit chart.
NJ FamilyCare MLTSS
Dental Care for Children
Children should see a dentist for the first time at the eruption of their first tooth, but no later than age 1 year old. Encourage parents of young children to schedule routine dental visits for their children with a pedodontist or a general dentist who treats children younger than 3 years old.
Physicians who have completed the required training, and have received approval from us to do so, may apply fluoride varnish to children’s teeth during well-child visits or up to every three months for children under the age of 4 years. Pediatricians and PCPs will receive $15 for each fluoride varnish application up to every three months and an additional $10 if the child has a dental encounter within 30 days, or $5 if within 60 days.
Providers should use the following procedure and diagnosis codes when submitting medical claims for fluoride varnish applications: 99188, Z41.8 (ICD-10).
Disease Management Programs – Care Management/Special Programs
We provide disease management programs to assist patients who have experienced a critical event or diagnosis that requires the extensive use of resources and/or who need help navigating the system.
The program involves comprehensive assessment of the member’s condition, determination of available resources and benefits, and development and implementation of a case management plan with performance goals, monitoring and follow up. To enroll your patient in a disease management program, call 1-800-682-9094, ext. 89634.
Horizon Healthy Journey Program
The Horizon Health Journey Program helps members manage their wellness and prevention services as outlined by HEDIS specifications. This program includes:
- Member engagement – reminders and education for members to close gaps in care for all stages of life — infancy through adulthood — such as immunizations, wellness visits, preventive screenings and chronic disease monitoring.
- Provider engagement – education and guidance on HEDIS specifications, performance reporting and quality transformation support.
To contact the Horizon Healthy Journey program, call 1-844-754-2451.
ModivCare
Eligible homebound members can receive transportation services for routine medical care through ModivCare, a Medicaid transportation vendor. To set up transportation, members can call ModivCare at 1-866-527-9933. ModivCare requires scheduling by noon at least two days in advance.
Family Planning
Family planning services are services that prevent or delay pregnancy.
- Members are entitled to receive family planning services. Some plans have limited coverage.
- Members may self-refer to family planning providers.
We are responsible for payment of all claims related to family planning services when rendered by a participating physician.
All family planning services and supplies providers must enroll in the 21st Century Cures Act to receive reimbursement for services.
Sterilization Authorization is required for sterilization. In accordance with Title 42 Code of Federal Regulations (CFR) 50, Subpart B, all sterilizations require a valid consent form (Spanish form).
The consent form must be completed and signed by the member in advance of the sterilization procedure being performed. We require that all Consent for Sterilization Forms be submitted to the Health Services Department by faxing the form to 1-609-583-3047. Recipients must be at least 21 years of age when the consent form is signed. There must be at least 30 calendar days between the date the recipient signs the consent form and the date of the surgery.
The Consent for Sterilization Form will generate an authorization for payment, so the form does not need to be submitted again with the claim. The initiating professional or facility can advise all other practitioners participating in this procedure of the authorization number so they do not need to submit a separate HHS-687 form in order to be reimbursed for their services. Sterilization claims cannot be submitted electronically. Sterilization reversals are not covered.
Office Based Addiction Treatment (OBAT) Program
The Division of Medical Assistance and Health Services, in collaboration with the Division of Mental Health and Addiction Services, launched a program to cover and support Medication Assisted Treatment (MAT) and OBAT. This program coordinates the delivery of multiple reimbursable services provided by Primary Care Physicians and community behavioral health specialists to NJ FamilyCare members with an addiction diagnosis.
The program reimburses physicians and physician extenders for OBAT services through their managed care contracts. Any contracted provider who is Data 2000 waivered for prescribing buprenorphine may participate. To participate, you must be Data 2000 certified. Contact your Provider Representative if you would like to participate.
For more information on the OBAT program, please contact your Provider Representative or Provider Services at 1-800-682-9091.
Behavioral Health (Mental Health and Substance Use Disorder) Services
We have a dedicated team to help ensure that behavioral health services, including mental health and Substance Use Disorder treatment is integrated into the overall care provided to our members. Review our Behavioral Health Program page for more information.
Doula Services
A doula is a trained professional who provides continuous physical, emotional and informational support throughout the perinatal period. The services include the following:
- Prenatal visits
- Labor and delivery support
- Postpartum visits
There will be two levels of doula services: standard care and enhanced care for members age 19 or younger.
For more information, visit Section 13.16 of the Provider Administrative Manual.