New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES › Subchapter 3 - BENEFITS › Section 10:74-3.3 - Managed care organization (MCO) benefits for Medicaid/NJ FamilyCare-Plans A, B, C, and D enrollees

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The MCO shall
				provide all services required by the managed care contract, including, but not
				limited to, the services listed in (a)1 through 29 below and at N.J.A.C.
				10:49-5, for all Medicaid/NJ FamilyCare-Plans A, B, C, and D enrollees, with
				the exception of those services identified as fee-for-service (see
				N.J.A.C.
				10:74-3.4) or excluded from the specific
				service package under
				N.J.A.C.
				10:74-3.5:
1. Primary and specialty care by physicians,
				dentists, certified nurse midwives, advanced practice nurses and physician
				assistants, within the scope of their practice and in accordance with all
				applicable state certification/licensure requirements;
2. Preventive health care and counseling and
				health promotion;
3. Early and
				Periodic Screening, Diagnosis, and Treatment (EPSDT) Program services:
i. For NJ FamilyCare-Plans B, C, and D
				participants, coverage shall include EPSDT: medical examinations, dental,
				vision, hearing, and lead screening services. Coverage includes only those
				treatment services identified through the examination that are available under
				the MCO's benefits package for Plans B, C, and D enrollees or as services
				specified under the FFS program;
4. Emergency medical care;
5. Inpatient hospital services including
				acute care hospitals, rehabilitation hospitals and special hospitals;
6. Outpatient hospital services;
7. Laboratory services, not including routine
				testing related to administration of Clozapine and other specified atypical
				antipsychotic drugs listed in the managed care contract for non-DDD
				clients;
8. Radiology services,
				diagnostic and therapeutic;
9.
				Prescription drugs, including legend drugs and non-legend drugs that are
				covered by the Medicaid/NJ FamilyCare program and indicated in the managed care
				contract;
10. Family planning
				services and supplies;
11.
				Audiology services;
12. Inpatient
				rehabilitation services;
13.
				Podiatrist services;
14.
				Chiropractor services;
15.
				Optometrist services;
16. Optical
				appliances;
17. Hearing aid
				services;
18. Home health agency
				services, except that home health agency services for aged, blind and disabled
				(ABD) beneficiaries are covered fee-for-service and not by the MCO;
19. Hospice services, in the community and in
				institutional settings. Room and board services are included only when services
				are delivered in an institutional (non-private residence) setting;
20. Durable medical equipment (DME)/assistive
				technology devices in accordance with existing Medicaid/NJ FamilyCare rules
				(see N.J.A.C. 10:59);
21. Medical
				supplies;
22. Prosthetics and
				orthotics, including certified shoe provider services;
23. Dental services;
24. Organ transplants, which include donor
				and recipient costs, except that the Medicaid/NJ FamilyCare fee-for-service
				program will reimburse for transplant-related donor and recipient inpatient
				hospital costs for an individual placed on a transplant list while in the
				fee-for-service Medicaid/NJ FamilyCare program prior to initial enrollment into
				an MCO;
25. Transportation services
				to and from any MCO-covered service and any service covered by the
				fee-for-service program as specified in this chapter, including ambulance,
				mobile intensive care units (MICUs) and mobile assistive vehicles (MAVs)
				(including lift-equipped vehicles);
26. Nursing Facility/Special Care Nursing
				Facility (NF/SCNF) Services--NF/SCNF services shall be covered for all
				Medicaid, NJ FamilyCare-Plan A, and NJ FamilyCare Alternative Benefit Plan
				(ABP) enrollees. This covered benefit is limited to rehabilitation services for
				NJ FamilyCare -Plan B, C, and D enrollees;
27. Mental health/substance use disorder
				services only for MLTSS enrollees and those enrollees who are clients of the
				Division of Developmental Disabilities (DDD) or a Fully Integrated Dual Special
				Needs Program (FIDE-SNP) program;
28. Partial care and partial hospitalization
				services (except for DDD clients); and
29. Inpatient mental health and substance use
				disorder treatment services.