Medicaid Managed Care for Children
with Special Needs in New Jersey

Fact Sheet 1: What's covered, what's not?

When we talk about Medicaid managed care, some unfamiliar words may come up.  Go to the “Important Terms” fact sheet  to look up highlighted words.  This will help you learn how to “speak the language” of managed care.

What is Medicaid Managed Care?

Medicaid is a government program that provides free medical assistance for qualified beneficiaries.  New Jersey’s new Medicaid program, New Jersey Care 2000+, also known as “Medicaid Managed Care,” requires most Medicaid-eligible children with special needs to receive their health care from managed care organizations.

Families of Medicaid-eligible children with special health care needs and/or disabilities must select for their child one of 5 HMOs that have contracted with the State of New Jersey to provide Medicaid Managed Care services. If they don't, thier child will eventually be assigned to one of the HMOs.

What’s new in the Medicaid Managed Care system?

You work with a state-contracted Health Benefits Coordinator (HBC) to identify and enroll in the best plan for your child among the 5 HMO choices. 

Once your child is signed up with an HMO,

• you receive an identification card, a member handbook, and a provider directory from the HMO (and maybe a separate prescription card)

• you select a Primary Care Provider (PCP) from that plan’s provider list. If you don’t, the HMO assigns one to you.

• the HMO assigns a Care Manager (usually a nurse or social worker) to your child.

You also choose a Primary Care Dentist (PCD). You don't need a referral from your PCP.

You must get a referral from your child’s PCP for most non-emergency services (specialist visits, lab, hospital, equipment, therapies) before your child receives those services.  Otherwise, the HMO can refuse to pay for the services.  Some services must be pre-approved at the HMO, a process called prior authorization, which is initiated by your PCP.

If you, as a prudent layperson, decide that your child has an emergency medical condition, the HMO pays for treatment of emergencies without need for a referral or pre-approval.  Just call 911 or go to the nearest emergency room.  But do not use the emergency room for any routine care; it won’t be paid for

If you think your child has an emergency but aren't sure and can't reach your PCP, your child can be screened at the emergency room at no cost to you even if he isn't treated there.

Call your HMO 24-hour toll free number if your child develops a need for urgent care (attention needed within 24 hours; but not an immediate emergency).  Your PCP will provide or arrange for this care.

With Medicaid managed care, you will see providers in the HMO’s Provider Network, with few exceptions.  If there is no one in the HMO’s network who can provide a covered service your child needs, you may get a referral outside the network.  If you decide to see a non-network provider on your own, without a referral, you will have to pay that provider out of your own pocket.

Your child’s Care Manager works with you and your child to develop (and modify as needs change) an Individual Health Care Plan to monitor all the services (even those provided outside the HMO) your child receives.

Medicaid beneficiaries with complex medical or mental health needs may be allowed to continue with their fee-for-service providers and not enroll in an HMO.  This is called an exemption.  Each exemption request is reviewed and, if denied, may be appealed through the Medicaid Fair Hearing process.  Call the HBC to apply for an exemption.

Once you get used to Medicaid Managed Care, you may find that you experience easier access to Medicaid services and providers, and better coordination of services to meet your child's needs.

If you follow correct HMO procedures, you should never receive a bill.  If you do, take it immediately to your care manager for resolution.

What’s the same about the new system?

You continue to receive your monthly Medicaid eligibility letter, though now you also have the HMO’s identification (ID) card.

Bring your current Medicaid eligibility letter with your HMO ID card to all visits.

Your child is still eligible under Medicaid managed care for the services (Benefits Package) she has always received under the traditional Medicaid fee-for-service system.  She receives HMO excluded services (also called “carve-out” services), such as physical, speech, and occupational therapies, and some transportation services on a fee-for-service basis outside your HMO plan.  Coordinate all services with your HMO Care Manager, and be sure they are part of your child’s Individual Health Care Plan.  They will be paid for by Medicaid.

Some Medicaid services are not provided by your HMO.  Medicaid still pays for them.

REMEMBER!!!

IN AN EMERGENCY, CALL 911 OR GO TO NEAREST EMERGENCY ROOM!
Check with your PCP next day.

GET A REFERRAL FROM YOUR PCP BEFORE SEEKING ANY NON-EMERGENCY SERVICES!

USE ONLY PROVIDERS IN YOUR HMO'S NETWORK PROVIDER DIRECTORY!

Medicaid Managed Care Services

Benefits Package:

Primary and Specialty Care
Preventive Health Care and Counseling
Health Promotion
EPSDT (Early and Periodic Screening, Diagnosis, and Treatment)
Emergency Medical Care
Inpatient Hospital (acute, rehab, and specialty)
Outpatient Hospital
Laboratory
Radiology
Prescription Drugs
Family Planning Services and Supplies
Audiology
Inpatient Rehabilitation
Podiatrist
Chiropractor
Optometrist
Optical Appliances
Hearing Aid Services
Home Health (with limits)
Hospice
Durable Medical Equipment
Medical Supplies
Prosthetics and Orthotics (including shoe)
Dental
Organ Transplants
Transportation (some)
Post-acute Care

Mental Health/Substance Abuse (for DDD clients only; non-DDD clients receive mental health services on a fee-for-service
basis just as they did in the past.  Read about “carve out” or excluded services on page 4).

See also your HMO member handbook

Call the Health Benefits Coordinator (HBC) with questions about HMO enrollment, transfers, and exemptions.

1-800-701-0710

(Translation Services Available)

TTY: 1-800-701-0720

USING MEDICAID MANAGED CARE

• Call the HBC to enroll in an HMO

• Read your HMO Member Handbook

• Select and work with your PCP

• Get referrals for other services

• Work with your Care Manager

• Use network providers

• Use emergency rooms only for emergencies