All Insurance Policy Changes (Page 858)

Continuing from page 857. 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. 34, No.11
New Jersey Medicaid·Effective Oct 1, 2024
Effective October 1, 2024, New Jersey Medicaid reimbursement for pharmacist-administered COVID-19 vaccines changes from Medicare-aligned rates to Actual Acquisition Cost (AAC) plus a $10.92 professional fee. Pharmacies must discontinue populating three NCPDP fields (420-DK, 440-E5, 438-E3) and stop receiving incentive fee payments in Field 521-FL. Pharmacies must continue updating the New Jersey Immunization Information System (NJIIS) within 48 hours of vaccine administration.
High impact
Senior Services News Vol. 27, No. 02
New Jersey Medicaid·Effective Nov 1, 2024
Effective November 1, 2024, Merck has terminated its rebate agreement with New Jersey's PAAD and Senior Gold prescription assistance programs. All Merck-manufactured drugs (identified by labeler codes 00006, 00052, 00085, 11523) will no longer be covered by these programs, and claims will be rejected with code 570. Patients will be responsible for full copay costs unless they obtain tier reduction from primary insurance or enroll in Merck's patient assistance program.
Medium impact
Newsletter Vol. 34, No.12
New Jersey Medicaid·Effective Oct 1, 2024
Effective October 1, 2024, New Jersey Medicaid (NJFC) is reducing reimbursement rates for COVID-19 laboratory tests from Medicare rates to 80% of Medicare rates. Coverage remains without member cost-sharing, but providers will receive lower payment. This change applies to all COVID labs covered by the Division of Medical Assistance and Health Services (DMAHS).
Medium impact
Medicaid Alert MA-2024-02
New Jersey Medicaid·Effective Nov 1, 2024
New Jersey Medicaid has revised the Genetic Supporting Information Form (FD-431) to require 'Date Ordered' instead of 'Date of Service' and now allows providers to use their existing test requisition forms instead of the FD-431, provided they contain all required information elements.
High impact
Newsletter Vol. 34, No.13
New Jersey Medicaid·Effective Jan 1, 2025
New Jersey is transferring behavioral health services from Fee-for-Service to Managed Care Organizations (MCOs) starting January 1, 2025. Providers must contract and credential with MCOs by this date to continue billing for outpatient mental health and substance use disorder services.
Medium impact
Senior Services News Vol. 27, No. 03
New Jersey Medicaid·Effective Dec 1, 2024
New Jersey's PAAD and Senior Gold pharmacy assistance programs have updated claims processing procedures, requiring specific billing order when Medicare Prescription Payment Plan is involved. Pharmacies must bill Medicare Part D primary, then PAAD/SG secondary, then to Medicare Prescription Payment Plan Bank to ensure correct patient responsibility amounts.
High impact
Medicaid Alert MA-2024-03
New Jersey Medicaid·Effective Jan 1, 2025
New Jersey Medicaid (NJ FamilyCare) is transitioning from AP-DRG Version 34 to APR-DRG Version 41 for inpatient hospital reimbursement, effective January 1, 2025. This change includes implementation of national DRG weights calibrated for budget neutrality. All acute care general hospitals must update their billing systems and coding processes to reflect the new grouper and reimbursement methodology.
Medium impact
Newsletter Vol. 34, No.14
New Jersey Medicaid·Effective Dec 1, 2024
New Jersey is issuing QMB (Qualified Medicare Beneficiary) Identification Cards to help Medicare providers identify patients who cannot be balance billed for Medicare deductibles, coinsurance, or copays. The pink credit card-sized cards will be required starting June 1, 2025, replacing current 'Dear Provider' letters.
High impact
Newsletter Vol. 35, No.01
New Jersey Medicaid·Effective Jul 1, 2024
New Jersey FamilyCare now reimburses Licensed Clinical Social Workers (LCSWs) as independent billing providers and group practice members for psychotherapy and substance use counseling services. LCSWs must enroll as rendering/billing providers and use specific HCPCS modifiers (AJHE for mental health, AJHF for SUD) with designated CPT codes. This policy is effective for claims with service dates on or after July 1, 2024.
High impact
Newsletter Vol. 35, No.02
New Jersey Medicaid·Effective Jan 1, 2025
New Jersey Medicaid is implementing PERM (Payment Error Rate Measurement) audits effective January 1, 2025, requiring NJ FamilyCare Fee-For-Service providers to respond promptly to random medical records requests from a contractor. Providers must submit documentation proving claim appropriateness based on state guidelines, medical necessity, coding accuracy, and service delivery, with failure to respond resulting in potential sanctions, payment suspensions, or provider termination.
Medium impact
Newsletter Vol. 35, No.03
New Jersey Medicaid·Effective Jul 1, 2025
New Jersey is launching a Housing Supports Program effective July 1, 2025, for Medicaid/NJ FamilyCare MCO members. Providers must enroll as Housing Supports Group Providers through Gainwell Technologies by submitting required applications and documentation. This is an MCO-only service (not available under fee-for-service Medicaid) with four specialty types: Pre-tenancy Services, Tenancy Sustaining Services, Residential Modifications and Remediation, and Move-in Supports.
High impact
Newsletter Vol. 35, No.04
New Jersey Medicaid·Effective Mar 3, 2025
Effective March 3, 2025, MCORT (Mobile Crisis Outreach Response Team) providers in New Jersey must verify Medicaid eligibility for all members receiving mobile crisis services and submit claims using CMS 1500 form with procedure code H2011 and appropriate service modifiers based on provider credential level (HE HO for master's degree, HE HN for bachelor's degree) and service type (initial stabilization or follow-up management). Claims are time-based in 15-minute increments with a maximum of 14 units (3.5 hours) per service date, and separate claims must be submitted for episodes spanning multiple days.
High impact
Newsletter Vol. 35, No.05
New Jersey Medicaid·Effective Mar 1, 2025
New Jersey Medicaid (NJ FamilyCare) now allows Licensed Professional Counselors (LPCs) and Licensed Marriage and Family Counselors (LMFTs) to enroll as independent billing providers or join group practices. These providers can bill for psychotherapy and substance use disorder counseling services using specific CPT codes with HEHH modifiers (mental health) or HFHH modifiers (SUD). Practices must ensure proper enrollment of these providers and use correct modifier combinations on all claims.
High impact
Medicaid Alert MA-2025-01
New Jersey Medicaid·Identified Jun 20, 2026
New Jersey Medicaid now allows FQHCs to bill for services provided by Licensed Professional Counselors (LPCs) and Licensed Marriage and Family Therapists (LMFTs). Psychotherapy services must be billed with HEHH modifier and substance use counseling with HFHH modifier, along with specific encounter codes.
Medium impact
Newsletter Vol. 35, No.06
New Jersey Medicaid·Effective Jan 1, 2025
New Jersey Medicaid now allows Assisted Living Program (ALP) providers to bill Fee-for-Service during enrollment gaps, expanding previous coverage that only applied to facility-based assisted living. Providers must request Special Program Code 62 assignment through a monthly Excel submission process to receive reimbursement for eligible members pending MCO enrollment.
Medium impact
Newsletter Vol. 35, No.07
New Jersey Medicaid·Effective Jul 1, 2025
New Jersey NJ FamilyCare now provides enhanced reimbursement for pediatric primary care visits (well and sick visits) for children ages 0-3 at HealthySteps-certified sites. Billing teams must co-bill CPT code H0025 TL with eligible visit codes to receive the enhanced rate (minimum $15). HealthySteps sites must notify all MCOs within 30 days and only practices meeting HealthySteps model fidelity are eligible.
High impact
Senior Services News Vol. 28, No. 01
New Jersey Medicaid·Effective Oct 1, 2025
Effective October 1, 2025, Bausch Health and select AbbVie products are withdrawn from New Jersey's PAAD and Senior Gold prescription assistance programs due to terminated rebate agreements. PAAD and Senior Gold beneficiaries will no longer receive copay assistance for drugs under 47 Bausch Health labeler codes and 3 AbbVie labeler codes; patients will be responsible for full copay costs unless they pursue tier reduction or manufacturer patient assistance programs.
High impact
Newsletter Vol. 35, No.08
New Jersey Medicaid·Effective Jul 1, 2025
New Jersey Medicaid is increasing reimbursement rates for primary care services to 70% of Medicare rates, effective July 1, 2025. This applies to evaluation and management codes (99202-99499) and immunization administration codes, with managed care organizations required to use these as minimum payment rates.
Medium impact
Newsletter Vol. 35, No.09
New Jersey Medicaid·Effective Jun 1, 2024
NJ FamilyCare now allows Physician Assistants (PAs) to enroll as rendering providers on professional claims, effective June 1, 2024. PAs will receive individual 7-digit Medicaid IDs and must be listed as the rendering provider on claims for services they provide, while the physician/group/clinic remains the billing provider. PAs are now searchable in the NJ FamilyCare Provider Directory and MCO directories.
Medium impact
Newsletter Vol. 35, No.10
New Jersey Medicaid·Effective Sep 11, 2025
NJ FamilyCare/Medicaid will continue to cover COVID-19 vaccines for all eligible members per NJ Department of Health guidelines, without requiring a prescription or evidence of underlying conditions. Coverage is available through both fee-for-service and managed care delivery systems, and includes vaccines administered by pharmacists, pharmacy interns, externs, and technicians to individuals age 3 and older.
Medium impact
Medicaid Alert MA-2025-02
New Jersey Medicaid·Effective Nov 13, 2025
New Jersey Medicaid is updating password requirements for the NJMMIS.com Portal, increasing the minimum password length from 9 to 15 characters. Starting November 13, 2025, users will be required to update their passwords when they expire or when resetting passwords.
Medium impact
Medicaid Alert MA-2025-03
New Jersey Medicaid·Effective Oct 1, 2025
New Jersey Medicaid is expanding the list of ICD-10-CM diagnosis codes that qualify for medical exception approval for outpatient dental services provided in a hospital operating room for beneficiaries with developmental disabilities and/or chronic medical conditions. This policy adds specific neurodevelopmental disorder codes (QA series) and clarifies which conditions meet the medical exception requirement. Prior authorization procedures and hospital reimbursement remain unchanged.
Medium impact
Senior Services News Vol. 28, No. 02
New Jersey Medicaid·Effective Jan 1, 2026
New Jersey has updated income eligibility limits for pharmacy assistance programs (PAAD, Senior Gold, Lifeline, and HAAAD) effective January 1, 2026, with a 2.8% increase based on Social Security COLA. PAAD limits are now less than $54,943 for singles and less than $62,390 for married couples; Senior Gold ranges from $54,943-$64,943 for singles and $62,390-$72,390 for married couples. Billing teams must update patient eligibility verification and ensure accurate program enrollment documentation.
Medium impact
Medicaid Alert MA-2025-04
New Jersey Medicaid·Effective Jan 1, 2026
New Jersey Medicaid is implementing the CMS Cell and Gene Therapy (CGT) Access Model for Sickle Cell Disease gene therapies (Casgevy and Lyfgenia). Effective January 1, 2026, providers must submit drug costs on separate professional CMS 1500 claims with actual acquisition costs and purchase invoices, exclude drugs from facility/DRG bundling, and comply with registry and study participation requirements.
Low impact
Newsletter Vol. 35, No.11
New Jersey Medicaid·Effective Jul 1, 2025
New Jersey Medicaid will reimburse Opioid Treatment Programs (OTPs) for preparing and transporting methadone/buprenorphine to residential facilities using two new bundled HCPCS codes based on distance. The weekly bundles cover medication costs, preparation, and travel for up to 7 doses and cannot be billed concurrently with other OTP services.

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Archive by year

2023 2024 2025 2026

Newsletter Vol. 34, No.11

Senior Services News Vol. 27, No. 02

Newsletter Vol. 34, No.12

Medicaid Alert MA-2024-02

Newsletter Vol. 34, No.13

Senior Services News Vol. 27, No. 03

Medicaid Alert MA-2024-03

Newsletter Vol. 34, No.14

Newsletter Vol. 35, No.01

Newsletter Vol. 35, No.02

Newsletter Vol. 35, No.03

Newsletter Vol. 35, No.04

Newsletter Vol. 35, No.05

Medicaid Alert MA-2025-01

Newsletter Vol. 35, No.06

Newsletter Vol. 35, No.07

Senior Services News Vol. 28, No. 01

Newsletter Vol. 35, No.08

Newsletter Vol. 35, No.09

Newsletter Vol. 35, No.10

Medicaid Alert MA-2025-02

Medicaid Alert MA-2025-03

Senior Services News Vol. 28, No. 02

Medicaid Alert MA-2025-04

Newsletter Vol. 35, No.11