New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 49 - ADMINISTRATION MANUAL › Subchapter 5 - SERVICES COVERED BY MEDICAID AND THE NJ FAMILYCARE PROGRAMS › Section 10:49-5.7 - Services available and unavailable to beneficiaries eligible for NJ FamilyCare-Plan D and Plan D for adults

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as
				indicated at
				10:79-2.5, which concerns services
				for newborns enrolling into NJ FamilyCare-Plan C and D, the services listed
				below are available to beneficiaries eligible for NJ FamilyCare-Plan D and Plan
				D for Adults, when medically necessary and provided through the network of an
				HMO selected by the NJ FamilyCare-Plan D beneficiary.
1. Advanced practice nurses;
2. Clinic services (services in an
				independent outpatient health care facility, other than hospital, that provides
				covered ambulatory care services);
3. Dental services for individuals under the
				age of 19 years that are necessary to prevent disease, promote oral health, and
				restore oral structures to health and function, including the treatment of
				emergency conditions;
4. Emergency
				room services;
5. Family planning
				services, including medical history and physical examination (including pelvic
				and breast), diagnostic and laboratory tests, drugs and biologicals, medical
				supplies and devices, counseling, continuing medical supervision, continuity of
				care and genetic counseling.
i. Services
				provided primarily for the diagnosis and treatment of infertility, including
				sterilization reversals, and related office (medical and clinic) visits, drugs,
				laboratory services, radiological and diagnostic services and surgical
				procedures are not covered by the NJ FamilyCare program;
6. Federally qualified health center primary
				care services;
7. Home health care
				services, limited to skilled nursing for a home bound beneficiary, which is
				provided or supervised by a registered nurse, and home health aide when the
				purpose of the treatment is skilled care, medical social services, which are
				necessary for the treatment of the beneficiary's medical condition;
i. Personal care assistant services are not
				covered;
8. Hospice
				services;
9. Hospital
				services--inpatient;
10. Hospital
				services--outpatient;
11.
				Laboratory (clinical);
12.
				Nurse-midwifery services;
13.
				Optometric services, including one routine eye examination per year;
14. Optical appliances, limited to one pair
				of glasses or contact lenses per 24 month period;
15. Organ transplant services which are
				non-experimental or non-investigational;
16. Prescription drug services;
i. Exception: Over-the-counter drugs are not
				covered;
17. Physician
				services;
18. Podiatric services;
i. Exception: Coverage excludes routine foot
				care;
19. Prosthetic
				appliances, limited to initial provision of prosthetic device that temporarily
				or permanently replaces all or part of an external body part lost or impaired
				as a result of disease or injury or congenital defect;
i. Coverage includes repair and replacement
				when due to congenital growth;
20. Private duty nursing care, only when
				authorized by the HMO;
21.
				Radiological services;
22.
				Inpatient rehabilitative services, including physical, occupational and speech
				therapy for non-chronic conditions and acute illnesses and injuries;
23. Transportation services, limited to
				ambulance for medical emergency only;
24. Well child care including immunizations,
				lead screening and treatments;
25.
				Maternity and related newborn care; and
26. Diabetic supplies and
				equipment.