All Insurance Policy Changes (Page 857)

Continuing from page 856. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
Newsletter Vol. 33, No.12
New Jersey Medicaid·Effective Jul 1, 2023
New Jersey Medicaid/NJ FamilyCare now requires Electronic Visit Verification (EVV) data submission for all home health care services (skilled nursing, private duty nursing, and therapy services) delivered at place of service 12/Home, effective immediately. All home health providers must submit six required EVV data elements (service type, recipient, date, location, provider, start/end times) for claims to be processed. Prior authorization remains required for all listed services.
High impact
Newsletter Vol. 33, No.13
New Jersey Medicaid·Effective Jul 1, 2023
Effective July 1, 2023, New Jersey Medicaid/NJ FamilyCare has restricted synchronous teledentistry (CDT code D9995) to only three patient populations: individuals with intellectual and developmental disabilities, those enrolled in MLTSS, and homebound individuals. Teledentistry must now be billed with CDT code D0140 (limited oral evaluation – problem focused) on the same claim, and requires strict compliance with technology standards (minimum 384 kbps bandwidth, real-time audio/video), patient authentication, and provider availability protocols.
High impact
Medicaid Alert MA-2023-05
New Jersey Medicaid·Effective Jul 1, 2023
New Jersey Medicaid has increased reimbursement rates for behavioral health services effective July 1, 2023. The policy provides updated payment rates for psychiatric evaluations, psychotherapy, medication monitoring, and substance abuse treatment services with different rates for specialists vs non-specialists and child-specific services.
High impact
Newsletter Vol. 33, No.14
New Jersey Medicaid·Effective Jan 1, 2023
New Jersey implemented Electronic Visit Verification (EVV) compliance requirements for home health care services, personal care assistance, and developmental disabilities services effective January 1, 2023. Providers must capture and report six required data elements (service type, recipient, date, location, provider, start/end times) through HHAeXchange, CareBridge, or approved third-party EVV systems. Claims will not be paid without EVV compliance; providers must track compliance metrics for each payer separately.
Medium impact
Newsletter Vol. 33, No.15
New Jersey Medicaid·Effective Sep 1, 2023
New Jersey is restarting Medicaid/NJ FamilyCare eligibility reviews after the public health emergency pause. Healthcare providers must help patients maintain coverage by sharing key messages about updating contact information and responding to renewal mail to prevent coverage loss.
Medium impact
Medicaid Alert MA-2023-06
New Jersey Medicaid·Identified Jun 20, 2026
New Jersey Medicaid has adopted CPT code G0330 for Ambulatory Surgical Centers (ASC) to bill when dental services are provided under general anesthesia, with reimbursement of $861.22. This applies to Medicaid beneficiaries with intellectual disabilities, developmental disabilities, early childhood caries, or chronic medical conditions requiring general anesthesia for dental care.
Medium impact
Newsletter Vol 33, No.16
New Jersey Medicaid·Effective Sep 1, 2023
New Jersey Medicaid/NJ FamilyCare providers must comply with SUPPORT Act requirements by checking the New Jersey Prescription Monitoring Program (NJPMP) before prescribing or dispensing Controlled Dangerous Substances (CDS), gabapentin, and Human Growth Hormone (HGH). The state will conduct routine compliance reviews to validate proper NJPMP usage. This is a reminder/enforcement notification of existing obligations rather than a new requirement.
Medium impact
Newsletter Vol. 33, No.17
New Jersey Medicaid·Effective Oct 1, 2023
New Jersey's Naloxone365 program now covers both FDA-approved legend and over-the-counter (OTC) naloxone 4 mg nasal spray for any NJ resident age 14 or older, regardless of Medicaid eligibility. Pharmacies can now use their pharmacy NPI in the prescriber ID field for OTC naloxone claims since no standing order exists. Reimbursement is based on the lowest of NADAC, WAC minus 2%, or SUL plus a $10.92 dispensing fee, or usual and customary charge.
High impact
Newsletter Vol. 33, No.19
New Jersey Medicaid·Effective Jul 1, 2023
New Jersey has implemented a tiered reimbursement rate structure for Assisted Living Residences (ALR) and Comprehensive Personal Care Homes (CPCH) based on the percentage of Medicaid/NJ FamilyCare beneficiaries served. Rates increase from $0-$35 per diem for ALR and $0-$35 for CPCH depending on facility Medicaid census tier (0%-100%). New Medicaid Partner Communities with land use restrictions can access the highest tier immediately upon enrollment.
Medium impact
Senior Services News Vol. 26, No. 01
New Jersey Medicaid·Effective Jan 1, 2024
New Jersey raised income eligibility limits for pharmaceutical assistance programs (PAAD, Lifeline, HAAAD, Senior Gold) effective January 1, 2024. PAAD eligibility increased to less than $52,142 for single persons and less than $59,209 for married couples (up $10,000). Senior Gold now covers incomes between $52,142–$62,142 (single) and $59,209–$69,209 (married). Billing teams must verify patient eligibility against these new thresholds to ensure proper program enrollment and avoid claim denials.
Medium impact
Newsletter Vol. 33, No.20
New Jersey Medicaid·Effective Jan 1, 2024
New Jersey is removing contract requirements for MCOs to conduct 72-hour continued stay medical necessity reviews for inpatient admissions and authorize ancillary services when continued stay is denied. This removes administrative burdens on hospitals and MCO plans that were causing increased costs.
Medium impact
Medicaid Alert MA-2023-07
New Jersey Medicaid·Identified Jun 20, 2026
New Jersey Medicaid now accepts HIPAA 5010 276/277 Inquiry Transaction Set for electronic eligibility verification and claims status inquiries. This provides an additional standardized method for billing teams to check patient eligibility and claim status electronically.
High impact
Senior Services News Vol. 26, No. 02
New Jersey Medicaid·Effective Jan 1, 2024
Effective January 1, 2024, GlaxoSmithKline (GSK) and Eli Lilly have terminated their rebate agreements with New Jersey's PAAD and Senior Gold prescription assistance programs. These programs will no longer cover copays for GSK or Eli Lilly products (except insulin) for eligible seniors and disabled beneficiaries. Claims for non-insulin drugs from these manufacturers will be rejected with REJECT CODE 570, and patients will be responsible for full out-of-pocket costs.
High impact
Newsletter Vol. 33, No.18
New Jersey Medicaid·Effective Dec 1, 2023
NJ FamilyCare is implementing stricter discharge planning requirements for nursing facility members whose prior authorizations are ending due to failure to meet nursing facility level of care. Facilities must now provide proper notice, conduct 30-day discharge planning with MCO collaboration, and follow formal involuntary discharge procedures. Billing teams must ensure claims are not submitted after authorization expiration and that proper appeal processes are followed before payment ceases.
Medium impact
Newsletter Vol. 34, No.01
New Jersey Medicaid·Effective Mar 1, 2024
New Jersey updated its Morphine Milligram Equivalent (MME) conversion factors for opioid prescribing based on CDC 2022 guidelines. Eight medications were removed from the conversion table (meperidine, dihydrocodeine, pentazocine, opium, heroin, levorphanol, buprenorphine TD patch, and buprenorphine SL/buccal), and four conversion factors changed (tramadol, hydromorphone, methadone, and fentanyl transdermal). Providers must use updated MME guidelines when prescribing opioids, limiting doses to ≤50 MME for opioid-naïve patients and ≤90 MME for opioid-tolerant patients, or document medical necessity.
High impact
Newsletter Vol. 34, No.02
New Jersey Medicaid·Effective Mar 1, 2024
New Jersey Medicaid/NJ FamilyCare continues coverage of Paxlovid® (nirmatrelvir/ritonavir) for beneficiaries aged 12+ at no cost through December 31, 2024. Lagevrio® (molnupiravir) coverage continues through September 30, 2024 but now requires prior authorization. Critical billing rule: pharmacies must NOT submit Medicaid claims when dispensing from 340B drug inventory; 340B claims will be denied with edit code 2296.
High impact
Newsletter Vol. 34, No.03
New Jersey Medicaid·Effective Apr 1, 2024
New Jersey Medicaid/NJ FamilyCare now covers tympanostomy tube insertion using the Tula System as an office-based procedure under local anesthesia. ENT providers instructed in the Tula System may bill CPT 0583T (unilateral) or 0583T50 (bilateral) effective immediately, with specific reimbursement rates ($1,362.12 and $1,678.62 respectively). These codes cannot be billed with nine other related CPT codes on the same date of service.
Medium impact
Newsletter Vol. 34, No.04
New Jersey Medicaid·Effective May 1, 2024
New Jersey updated its Fair Hearing appeal process for Permedion inpatient utilization review determinations. Hospitals now have the right to request a second-level Fair Hearing within 60 days of receiving an upheld adverse determination. All Fair Hearing requests must be submitted in writing to both DMAHS and Permedion and will undergo peer-to-peer physician review before submission to the Office of Administrative Law.
Medium impact
Newsletter Vol. 34, No.05
New Jersey Medicaid·Effective Jun 1, 2024
New Jersey now allows certified family members to provide homemaker-home health aide (CHHA) and personal care services to Medicaid/NJ FamilyCare beneficiaries under age 21, effective immediately. Family members must be certified by the NJ Board of Nursing, employed through a home health agency or health care service firm, and work under registered nurse supervision. Services are billed using standard PCA billing codes and require prior authorization through MACC or the member's MCO.
Medium impact
Senior Services News Vol. 27, No. 01
New Jersey Medicaid·Effective Jun 17, 2024
Effective June 17, 2024, ViiV Healthcare products are no longer covered by New Jersey's PAAD and Senior Gold pharmaceutical assistance programs due to terminated rebate agreements. All ViiV drugs (labeler code 49702) will be rejected with code 570. Affected patients must seek alternative copay assistance through ADDP, their primary insurance, or manufacturer programs.
High impact
Newsletter Vol. 34, No.08
New Jersey Medicaid·Effective Jul 15, 2024
Effective July 15, 2024, NJ FamilyCare/Medicaid Community Support Services (CSS) providers must submit prior authorization requests with complete procedure codes and applicable modifiers instead of band codes only. Claims will be paid only if billed procedure/modifier codes exactly match those approved on the prior authorization. Band codes are now for IRP documentation only.
Low impact
Newsletter Vol. 34, No.07
New Jersey Medicaid·Effective Jul 1, 2024
New Jersey Medicaid/FamilyCare will now reimburse pharmacies an additional $20.60 administration fee for providing education and consultation when dispensing hormonal contraceptives under a standing order (without individual prescriptions). Pharmacies must use specific billing codes and the standing order NPI to receive this additional reimbursement.
High impact
Newsletter Vol. 34, No.09
New Jersey Medicaid·Effective Aug 1, 2024
New Jersey FamilyCare now covers Acute Hospital Care at Home (AHCaH) services delivered in patients' homes by eligible hospitals with CMS approval and NJ DOH authorization. Hospitals must use specific revenue codes (0161) and occurrence span codes (82) for billing, and will be reimbursed at inpatient facility rates in FFS programs. This policy is effective immediately and applies to all NJ FamilyCare members approved for acute home-based care.
High impact
Medicaid Alert MA-2024-01
New Jersey Medicaid·Effective Jul 1, 2024
Effective July 1, 2024, New Jersey Medicaid requires FQHCs to use new HCPCS codes combined with specific modifiers (AJHE for mental health psychotherapy, AJHF for substance use counseling) when billing for Licensed Clinical Social Worker (LCSW) services. These modifier combinations must be used alongside existing PPS encounter codes (T1015HE for individual therapy, G0470HQ for group services) to allow the state to track LCSW service utilization.
Medium impact
Newsletter Vol. 34, No.10
New Jersey Medicaid·Effective Sep 1, 2024
New Jersey expanded coverage for Hepatitis C Direct Acting Antivirals (DAAs) with simplified prior authorization. Treatment-naïve members no longer need prior auth if proper diagnosis codes are documented, while treatment-experienced members still require prior authorization with detectable virus levels within 90 days.

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Archive by year

2023 2024 2025 2026

Newsletter Vol. 33, No.12

Newsletter Vol. 33, No.13

Medicaid Alert MA-2023-05

Newsletter Vol. 33, No.14

Newsletter Vol. 33, No.15

Medicaid Alert MA-2023-06

Newsletter Vol 33, No.16

Newsletter Vol. 33, No.17

Newsletter Vol. 33, No.19

Senior Services News Vol. 26, No. 01

Newsletter Vol. 33, No.20

Medicaid Alert MA-2023-07

Senior Services News Vol. 26, No. 02

Newsletter Vol. 33, No.18

Newsletter Vol. 34, No.01

Newsletter Vol. 34, No.02

Newsletter Vol. 34, No.03

Newsletter Vol. 34, No.04

Newsletter Vol. 34, No.05

Senior Services News Vol. 27, No. 01

Newsletter Vol. 34, No.08

Newsletter Vol. 34, No.07

Newsletter Vol. 34, No.09

Medicaid Alert MA-2024-01

Newsletter Vol. 34, No.10