New Jersey

In New Jersey:
  • As of July 1, 2011, there were 1,098,608 beneficiaries enrolled in the state’s Medicaid program, 853,645 of whom were enrolled four Medicaid-only MCOs (as of September 2014, five MCOs participate in the state’s Medicaid program).
  • Physical, behavioral, and oral health benefits are provided to Medicaid beneficiaries through the state’s Family Care managed care program. Outpatient substance abuse serves are carved out of managed care and provided on a fee-for-service basis.
  • Transportation benefits are provided to 853,645 Medicaid enrollees through a Prepaid Ambulatory Health Plan.
  • In 2012, New Jersey received approval for a Section 1115 Demonstration that consolidated its existing managed care programs, as well as four existing home and community-based service waivers.
As of 2013, 782,311 individuals were eligible for New Jersey’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT). According to 416 data from 2013, the state achieved an EPSDT screening ratio of 90% and a participant ratio of 64%. 353,364 children received dental services of any kind, with 329,795 receiving preventive dental services.
Last updated September 2014
Medical Necessity
New Jersey defaults to the federal definition of medical necessity for the EPSDT benefit. The state does not have a formal state-level medical necessity definition for Medicaid, deferring to clinical judgment and industry best practices. In discussing Medicaid-covered services, the New Jersey Administrative Code (N.J.A.C. 10:49-5.1) notes that:
“Any service limitations imposed will be consistent with the medical necessity of the patient’s condition as determined by the attending physician or other practitioner and in accordance with standards generally recognized by health professionals and promulgated through the New Jersey Medicaid program.”
Initiatives to Improve Access
Providers in New Jersey are paid a $10 incentive payment for each documented EPSDT screening examination.
Reporting & Data Collection
New Jersey has in place a performance-based incentive program for managed care organizations (MCOs). MCOs earn back an amount withheld from their capitation payment based on performance on maternity care and prevention screening measures; the latter category includes a measure of the percentage of Medicaid enrollees aged 3-17 who have evidence of a body mass index percentile documentation.
MCOs must also report annually on a set of HEDIS performance measures that include:
  • Childhood Immunization Status (requires Member Level Data)
  • Immunizations for Adolescents
  • Well-Child Visits in First 15 Months of Life
  • Well-Child Visits in the 3rd , 4th , 5th and 6th Years of Life
  • Appropriate Testing for Children with Pharyngitis
  • Adolescent Well-Care Visits
  • Follow-Up Care for Children Prescribed ADHD Medication
  • Child and Adolescent Access to Primary Care Practitioners
  • Lead Screening in Children
Behavioral Health
Children receive behavioral health assessments as part of well-child visits. The New Jersey Department of Human Services provides an approved screening tool (Section B.4.9 of the managed care contract appendices) to be used on children when an indication of a potential behavioral health issue is uncovered.
Support to Providers and Families
Support to Families
Managed care organizations are required to notify families of upcoming well-child visits according to the state periodicity schedule. They are also responsible for conducting outreach to families if appointments are missed and notifying primary care providers when children are overdue for well-child visits.
Support to Providers
Medicaid provider communications on policy changes and policy manuals are collected on the state Medicaid agency’s website.
Care Coordination
New Jersey has in place a Medicaid medical home demonstration project. Managed care organizations (MCOs) are required to participate in the project, which includes the use of multi-disciplinary teams to coordinate care for Medicaid beneficiaries. The Medicaid agency provides flexibility in the payment methodology used by MCOs to support the medical homes but require that the MCOs “submit payment methodologies for review … that support care coordination and reward quality and improved patient outcomes.”
MCOs are also tasked with coordinating care and service delivery with a variety of community-based organizations and agencies, including:
  • State agencies, local health departments, Head Start and WIC programs;
  • Schools;
  • Social service organizations;
  • Consumer organizations, and
  • Civic/community groups.
MCOs must also maintain systems dedicated to coordinating physical and behavioral health services for enrollees.
New Jersey is also launching a Medicaid Accountable Care Organization (ACOs) demonstration that will allow regional ACOs to participate in a shared savings model and coordinate services for Medicaid beneficiaries, including children.
Oral Health
Managed care organizations must develop dental provider networks that include safety net dental providers, including:
  • Dental education institutions,
  • Hospital-based dental programs, and
  • “Dental clinics sponsored by governmental agencies as well as dental clinics sponsored by private organizations in urban/under-served areas.”