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生活文摘 Notify me of new comments Author Thread: NEW JERSEY MEDICAID COVERED SERVICES slu NEW JERSEY MEDICAID COVERED SERVICES Posted: Friday, December 07, 2007 12:26 PM (EST) NEW JERSEY MEDICAID COVERED SERVICES Service M/O Process Special Considerations Payment Information Outpatient Services M Includes preventive, diagnostic, therapeutic or palliative services. Services must be furnished under the direction of a physician or dentist, except nurse-midwife services. Certain procedures require precertification under managed care. PT, OT and Speech Therapy are covered under FFS. Reimbursed in FFS according to fee schedule. For FFS, Ambulatory Surgery Centers are paid a facility fee based on Medicare levels 1-9. NJ FamilyCare Plans C and D require a $5 copayment per visit. Rural Health Clinic (RHC) M There are no RHC’s (according to federal definition) in New Jersey. Federally Qualified Health Centers (FQHC) M Services covered are preventive, diagnostic, therapeutic, rehabilitative or palliative services that are furnished by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients.  Includes: §         Services furnished at the clinic by or under the direction of a physician or dentist; §         Services furnished outside the clinic, by the clinic personnel under the direction of a physician, to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address; §         Services furnished at the clinic that are nurse-midwife services.   For FFS, FQHCs are paid using the physician fee schedule. HMOs must reimburse FQHCs an amount that is at least equivalent to the amount that the HMO would make to a non-FQHC provider for similar services. HMOs may pay FQHCs on a FFS or capitated basis.  HMO payments to FQHCs for primary care must be equal to or greater than payments to other primary care providers.  Non-primary care services may be included if mutually agreeable between the HMO and FQHC.  For non-primary care services, payments must be equal to or greater than the average amounts paid to other non-primary care providers for equivalent services. FQHCs are reimbursed reasonable costs (FFS).  DMAHS reimburses for the difference between reasonable costs and HMO payments on an annual basis.  DMAHS also recoups payments from FQHCs in excess of reasonable costs. Laboratory/X-ray M Professional and technical laboratory services must be ordered and provided by or under the direction of a physician or other licensed practitioner. Lab services must be provided by a laboratory that meets the requirements of CLIA and the requirements for participation in Medicare. Radiology covered services include: §         Routine x-rays, EKG, EEG, §         MRI, MRA, CAT scan, PET scan and all other DT4 tests, and §         All other diagnostic tests. Routine testing related to administration of Clozapine, Risperidone, Olanzapine, Quetiapine, and Methadone is only covered under FFS. For FFS, lab is reimbursed at 80% of Medicare. Radiology is reimbursed according to the physician fee schedule. NJ FamilyCare Plan D requires a $5 copayment per visit for lab tests if not part of an office visit. Nursing Home M All nursing homes are required to provide services to meet the total needs of their patients. Services to be provided include: (a) medical and nursing, (b) diagnostic, 8 dental, (d) pharmaceutical, (e) rehabilitative, (f) dietary, (g) recreational and social, and (h) religious. Nursing homes are required to maintain a bed for a period of up to ten days for any resident receiving Medicaid payments who is absent from the facility due to hospital admission. In addition, such a person shall continue to be covered by Medicaid for the number of days (up to ten) that the nursing home maintains his/her bed. Should a resident not be able to return to the nursing home before the end of the ten-day period, he/she will have priority for the next available bed in the facility.   For therapeutic leave, residents are allowed 24 overnights per year (this must be authorized by a physician). New Jersey uses a prospective payment method that adjusts for case mix.  Payments are based on facility-specific base-year costs, trended to the rate year and adjusted for seven patient acuity levels.  The state re-bases projections every year.  Payments are reduced where base-year costs exceed percentile screens within three peer groupings for each of numerous cost centers. Physician Services M Primary care as well as specialty care are covered services. Services must provided within the scope of practice of medicine or osteopathy as defined by NJ state law. For primary care, HMO enrollees must see in-network providers (PCPs) unless enrollee is referred to an out-of-network provider by an in-network provider. HMO enrollees must have authorization from PCP to see specialists.  PCPs must notify HMO of referrals to specialists. Physicians not under contract with an HMO are reimbursed according to Medicaid FFS physician fee schedule. NJ FamilyCare Plan C requires a $5 copayment per visit. NJ FamilyCare Plan D requires a $5 copayment per visit during office hours and $10 copayment per visit during non-office hours. Early and Periodic Screening Diagnosis and Treatment (EPSDT) Program M Services are covered in accordance with federal requirements. Physical exams and preventive health care at appropriate ages through age 20, including: §         Vision and hearing screening; §         Dental inspection; §         Nutritional assessment; §         Lab tests for hemoglobin/hematocrit/ EP, urinalysis, tuberculin, and lead screening. When other services are indicated as a result of screening, services are covered with precertification under managed care. For children eligible solely through NJ FamilyCare Plans B and C (SCHIP programs), coverage includes all preventive screening and diagnostic services, medical examinations, immunizations, dental, vision, lead screening and hearing services.  Only those treatment services identified through the examination that are included under an HMO’s benefit package or specified services through the FFS program are covered. For FFS, EPSDT services are reimbursed using the physician fee schedule. All providers who furnish EPSDT services should enroll in the VFC program. HMOs are paid separately, $10 for every documented encounter record for an EPSDT screening examination.  HMOs are required to pass the $10 amount directly to the screening provider. There are no copayments under any of the managed care plans. Family Planning Services and Supplies O Covered services include: §         Pregnancy prevention; §         Pregnancy testing; §         Counseling; §         Follow-up care for complications associated with contraceptives; and §         Sterilization. Treatment for infertility is not covered. HMO enrollees may obtain family planning services and supplies from either the HMO’s contracted providers or from any other qualified Medicaid family planning provider. Abortion is only covered through FFS, but HMOs must pay for lab tests, etc. in preparation for abortion. New Jersey follows federal guidelines with regard to sterilization (such as 30-day waiting period). DMAHS reimburses family planning services provided by FFS providers based on the physician fee schedule. NJ FamilyCare Plans C and D (SCHIP) require $5 copayment per visit. Clinic Services O Services covered are preventive, diagnostic, therapeutic, rehabilitative or palliative services that are furnished by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients.  Includes: §         Services furnished at the clinic by or under the direction of a physician or dentist; §         Services furnished outside the clinic, by the clinic personnel under the direction of a physician, to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address; §         Services furnished at the clinic that are nurse-midwife services.   Reimbursement for clinic services is provided under FFS is made according to the physician fee schedule. Prescription Drugs O Covers non-experimental, FDA-approved, physician-prescribed drugs. For EPSDT, some over the counter drugs are covered, if ordered by prescription. Some drugs require pre-authorization and there are exclusions (see Provider Administrative Manual). General versions are dispensed unless prescribing provider indicates (in handwritten note) Brand Medically Necessary. HMOs may use formularies as long as certain minimum requirements are met (see HMO Contract Vol. 1, IV-20). As of July 1, 2002, the rules will change with regard to protease inhibitors – For NJ FamilyCare Plan A adults without dependent children, HMOs will refer them to the AIDS Drug Distribution Program (ADDP).  For Plan D adults without dependent children, protease inhibitors will be covered through FFS.  HMOs will be required to pay for protease inhibitors for other Plan A and D clients as well as all Plan B and C clients. The following drugs are only covered through FFS: Clozapine, Risperidone, Olanzapine, Quetiapine and Methadone.  This may be changing in the near future. Reimbursed according to a 10% discount off of AWP. NJ FamilyCare Plan C requires a $1 copayment for generic drugs and $5 copayment for brand. NJ FamilyCare Plan D requires a $5 copayment for generic and brand name for less than 34 day supply ($10 for more than 34 day supply). Case Management Services O Called “Care Management” services. Specific care management services include: §         Pregnancy services including HealthStart program, §         EPSDT services and coordination for children with elevated blood lead levels, §         Mental health/substance abuse services coordination, §         HIV/AIDS services coordination, and §         Dental services for enrollees with developmental disabilities. §         Other diagnoses where appropriate or requested by provider or patient. HMOs must have a case/care management component. HMOs must establish linkages with Ryan White CARE Act grantees for care management services either through a contract, MOA or other cooperative working agreement approved DMAHS. Reimbursement for case management services not provided under managed care is provided according to the Medicaid physician fee schedule. Necessary Medical Transportation O Services covered: §         Emergency transport such as ambulance, medical intensive care units (MICUs) and invalid coach ; §         Routine transportation to medical appointments, with approval by individual County Social Services/Welfare Agencies; Medicaid covers routine transportation to medical appointments (NJ FamilyCare Plan A) but there is no coverage for individuals enrolled in NJ FamilyCare Plans B, C and D (SCHIP).  Transportation is arranged through County Social Services/Welfare Agencies. For managed care enrollees, HMOs are responsible for/contract for ambulance, MICU and invalid coach.  HMOs also pay for “lower mode” services but the County Boards of Social Services provide them. For FFS clients, Medicaid pays for ambulance, MICU and invalid coach according to the fee schedule.  For lower mode services, the County Boards of Social Services have annual budgets established by Medicaid based on the previous year’s costs.  Some County Boards have their own transportation services but many contract them out. Services Provided By Nurse Midwife, Certified Pediatric Nurse Practitioner, and Certified Family Nurse Practitioner O Services furnished by these providers are covered. May provide primary care in accordance with HMO requirements. Certified nurse midwifes must be licensed to practice in NJ as a registered professional nurse, must have completed a program of study as specified by the State, and must be legally authorized to practice under NJ state law. Certified Nurse Practitioners must be licensed professional nurses who meet NJ’s advanced educational and clinical practice requirements and must certified by the State Board of Nursing. These providers are reimbursed directly under FFS and have their own manual.  They use physician codes but with the AV modifier. Extended Services to Pregnant Women O Program is called “HealthStart” and has two major components: medical and health support services.  The medical component includes obstetrical prenatal, intrapartum and postpartum care services.  The health support services include case coordination, health education, nutrition, social/psychological services and home visits. HealthStart is a Medicaid program, however, the planning and implementation of HealthStart is a joint effort of the Department of Health and Senior Services and the Department of Human Services. HMOs and DHAHS require HealthStart documentation and summary data within 90 days after the last contact. These services can be provided under the managed care contract. They are reimbursed in FFS using local “W” codes, which are found in the physician fee schedule. Ambulatory Prenatal Care O Managed care services include all prenatal office visits, 2 routine sonograms, lab work, pregnancy testing, NSTs performed in OB office, inpatient delivery service and all inpatient care.  Additional pregnancy related services including diagnostic testing and perinatology consults are also covered when notification is provided by primary OB physician.   Package described provided under cap rate. Providers who furnish these services to women not enrolled in managed care are reimbursed FFS according to the Medicaid fee schedule. NJ FamilyCare Plan C requires a $5 copayment per visit. NJ FamilyCare Plan D requires a $5 copayment per visit during office hours and a $10 copayment per visit during non-office hours. Current through 4/2002 Back to: Technical Assistance Materials

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