Effective October 1, 2013, NJ FamilyCare became the single program for all public medical assistance in New Jersey, including all adults and children eligible for services under any state or federal authority. The Department of Human Services' Division of Medical Assistance and Health Services (DMAHS) administers the state- and federally-funded NJ FamilyCare program for over 1 million low- to moderate-income adults and children. NJ FamilyCare provides health insurance to parents/caretakers and dependent children, pregnant women, and people who are aged, blind or disabled and/or those requiring long-term services and supports. NJ FamilyCare pays for hospital services, doctor visits, prescriptions, nursing home care, home and community-based services and other healthcare needs.
While NJ FamilyCare offers a few services through traditional fee-for-service arrangements, the majority of Medicaid benefits are provided through contracts with managed care health plans, also commonly referred to as HMOs. Today, the majority of NJ FamilyCare beneficiaries are enrolled in managed care plans that provide most health care benefits in exchange for a per member, per month payment. DMAHS has been providing mandatory managed care services for eligible beneficiaries since 1995. Health plans ensure quality and cost-effective care by emphasizing prevention and coordination of care. Their care and case management programs help ensure clients have continuity of care and receive services that are appropriate for their condition. Health plans also provide enabling services such as language translation, community outreach, and health educational programs that facilitate effective communication and access to appropriate and timely care.
The provider community is an integral part in the health care of our beneficiaries. We invite you to learn more about specific prescription drug services, information pertaining to HMO prior authorization, the care management program, specific preventive programs, the AIDS Drug Distribution Program (ADDP) and much more by viewing the NJ FamilyCare Managed Care Contract, and the D-SNP Contract.
To assure that you can continue to provide services to your patients who are required to enroll, or who may elect to enroll, in an NJ FamilyCare-contracted HMO, please let your patients know in which HMOs you participate. You must be a part of the provider network of an NJ FamilyCare-contracted HMO in order to provide services to your patients who are enrolled in that organization. Patients may select their HMO based on whether a specific provider is in that network.
Call the provider services telephone number of any of the NJ FamilyCare-contracted HMOs for information regarding provider applications. Patients may call the member services telephone number of any of the NJ FamilyCare-contracted HMOs with questions they may have, such as questions about changes in enrollment or primary care provider selection.
Any questions regarding the auto-assignment process, or Medicaid managed care should be directed to NJ FamilyCare's Mediciad Hotline at 1-800-356-1561 (TTY: 1-800-701-0720)
Note: The Medicaid Hotline is not accessible when New Jersey State government offices are closed.
Frequently, the Division of Medical Assistance and Health Services distributes Provider Newsletters regarding important contract information and updates. To view previous Provider Newsletters, visit www.njmmis.com.
The 1965 federal law, Social Security Act Section 1905(a), prohibits Medicaid federal financial participation (FFP) for medical care or services for inmates in a public institution, except as a patient in a medical institution. State law also prohibits the use of state Medicaid funds to cover inmate care as referenced in NJSA 30:4D-6 (e) and 42 CFR §435.101 whereby incarcerated individuals who are expected to be hospitalized for a 24-hour period, or longer, at a medical institution are not considered to be an inmate during that time and can be covered by Medicaid, if otherwise eligible. The State Fiscal Year 2015 Appropriations Act requires that the NJ Department of Human Services work with the county corrections agencies to promote NJ FamilyCare enrollment of all eligible inmates requiring inpatient hospitalization.
NJ FamilyCare Presumptive Eligibility provides temporary NJ FamilyCare health coverage while full NJ FamilyCare eligibility is being determined. NJ FamilyCare Presumptive Eligibility (PE) training for hospital PE providers, county welfare agency directors, and county correctional staff was held on August 11, 2014. The Division of Medical Assistance and Health Services presented solutions for paying hospitalization expenses for eligible inmates beginning September 1, 2014.
Presumptive Eligibility for Inmates Resources:
Training Presentation: NJ FamilyCare and Hosptalized Inmates
Frequently Asked Questions (FAQs) about NJ FamilyCare Presumptive Eligibility for Inmates