Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

Practitioner Services

Prescription Drugs

Physical Therapy and Other Services

Products and Devices

Transportation Services

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Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: New Jersey (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes				Fee for service, using an all-inclusive payment per episode of care	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes			1 Psych service/day with some exceptions up to $6,000/year	Fee for service	CN & MN
Federally Qualified Health Center Services
Yes				Prospective cost based rate/visit	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes		Admissions for specified procedures and LOS	Specified procedures require a second opinion	Prospective payment/discharge using DRG	CN & MN - See state-specific FN
Outpatient Hospital Services
Yes			Non-emergency services in ER not covered	Cost based payment	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes				Fee for service	CN & MN
Rural Health Clinic Services
No
Practitioner Services
Certified Registered Nurse Anesthetist Services
No
Chiropractor Services
Yes				Fee for service	CN & MN - See state-specific FN
Dental Services
Yes		Specified services	Exam and cleaning 2/year, frequency of x-rays limited by type	Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes		Specified services, x-ray services costing more than $35	Specified procedures require a second opinion	Fee for service	CN & MN
Nurse Midwife Services
Yes				Fee for service at 70% of specialist physician fee	CN & MN
Nurse Practitioner Services
Yes				Fee for service at 95% of non-specialist physician fee	CN & MN
Optometrist Services
Yes		Visual testing and training	Visual aids covered when visual acuity criteria met	Fee for service	CN & MN
Physician Services
Yes			Psych services up to $900/year or $400 for nursing facility residents	Fee for service, cost based payment for vaccines	CN & MN
Podiatrist Services
Yes		Post-fracture or surgical care, orthopedic shoes and appliances	Routine foot care covered only for specified systemic conditions, 1 debridement of toenails/2 months, treatment of flat feet and subluxations not covered	Fee for service	CN & MN - See state-specific FN
Psychologist Services
Yes			Psychotherapy services up to $900/year or $400 for nursing facility residents	Fee for service	CN & MN
Prescription Drugs
Prescription Drugs
Yes		Specified drugs including nutritional supplements and methadone		AWP-12.5%, plus pharmacy specific dispensing fee of $3.73-$4.07 depending on services provided, non-traditional pharmacies receive a capitated dispensing fee	CN & MN - See state-specific FN
Physical Therapy and Other Services
Occupational Therapy Services
No
Physical Therapy Services
No
Services for Speech, Hearing and Language Disorders
No
Products and Devices
Dentures
Yes		Yes	Dentures covered if specified occlusal criteria met, 1 full upper and/or lower denture/7.5 years	Fee for service	CN & MN
Eyeglasses
Yes			1 pair eyeglasses/year for over age 59, 1 pair/2 years for age 19-59	Acquisition cost with ceilings	CN & MN
Hearing Aids
Yes				Acquisition cost plus dispensing fee	CN & MN
Medical Equipment and Supplies
Yes		Specified med equipment and med supply items		Fee for service, some items paid invoice cost plus percentage	CN & MN
Prosthetic and Orthotic Devices
Yes		Yes	Limited to post-trauma care or to treat gross deformities, orthopedic shoes must be attached to brace, 3 home visits to fit appliance	Fee for service	CN & MN
Transportation Services
Ambulance Services
Yes				Fee for service	CN & MN
Non-Emergency Medical Transportation Services
Yes		Yes		See service-specific FN	CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes			Specified services only	Dependent upon service and billing provider	CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes			Portable x-ray services only in nursing facilities or as emergency	Fee for service	CN & MN
Targeted Case Management
Yes				Fee for service	CN & MN - See state-specific FN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes		Services for the following populations: 1, 2, 4, 5, 6 & 8 - See service-specific FN	Dependent upon the services provided	CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes	Care after initial visit	Plan of care required, cost of care for 6 months must be less than in nursing facility	Cost based payment per time unit, med supplies paid fee for service	CN & MN
Hospice Care
Yes		Two 90-day periods and one 30-day period with additional periods as necessary, 24 therapeutic leave days per year	Prospective rates based on Medicare methodology	CN
Personal Care Services
Yes	Yes	Plan of care required, personal care assistant 25 hours/week, Community Mental Health-supervised care 8 hours/day up to 35 hours/week	Fee for service using hourly rates	CN & MN
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes		10 hosp leave days/hospitalization, 24 therapeutic leave days/year	Prospective cost based per diem	CN
Inpatient Psychiatric Services, under age 21
Yes			Cost based payment	CN
Intermediate Care Facility Services for the Mentally Retarded
Yes		10 hosp leave days/hospitalization, 24 therapeutic leave days/year	Cost based payment	CN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes		10 hosp leave days/hospitalization, 24 therapeutic leave days/year if in plan of care	Prospective per diem based on cost with incentives for high occupancy, hosp leave days paid at 50% of per diem rate	CN
Religious Non-Medical Health Care Institution and Practitioner Services
Yes	Admissions for specified procedures and LOS	Specified procedures require second opinion, practitioner services not covered	Cost based payment	CN

Notes: This State has an approved Section 1115 Waiver from CMS, funded by both Title XIX and Title XXI, under which it extended healthcare coverage to parents and caretaker relatives of Medicaid and SCHIP-eligible children with income at or below 200 percent of the federal poverty level (FPL), although this was subsequently reduced to 115 percent of the FPL. The waiver also extended coverage to pregnant women with income between 185 percent and 200 percent of the FPL. The program is called NJ FamilyCare. Under the waiver, pregnant women receive full Medicaid benefits and the parents and caretaker relatives receive a reduced benefit package modeled after a standard commercial plan, which is not reflected on the tables. Benefits available to this State’s Medically Needy population are also limited, as follows. Services in a nursing facility, inpatient psychiatric hospital for persons under age 21, institution for mental diseases, intermediate care facility for the mentally retarded (developmentally disabled) and religious non-medical health care institution are not covered at all, nor is hospice care. Services in the inpatient general hospital setting, as well as chiropractor services and targeted case management are limited to pregnant women. Podiatrist services are limited to pregnant women and the aged, blind and disabled. Prescription drug coverage is available only to pregnant women and children. This State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA) in a program called NJ WorkAbility. These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits, if their income is at or below 500 percent of the FPL, however an income-based monthly premium is charged based on income above 150 percent of the FPL.