MedicaidReimbursementMedium impact
Newsletter Vol. 35, No.07
New Jersey Medicaid·NJ · Pediatrics, Family Medicine, General Practice·Medical Policy
Effective date
Jul 1, 2025
We identified it
Jun 20, 2026
Summary
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.
Action Required
By August 1, 2025 (30 days from policy release): HealthySteps site billing teams must contact all five MCO Provider Services departments (Aetna Better Health of NJ, Fidelis Care, Horizon NJ Health, UnitedHealthcare Community Plan, WellPoint) to notify them of HealthySteps status and request configuration for enhanced reimbursement. Billing teams must update billing system to co-bill CPT code H0025 TL (modifier TL) with one of the eligible well visit codes (99381, 99382, 99391, 99392) or sick visit codes (99211-99215, 99202-99205) for NJ FamilyCare managed care enrollees ages 0-3 only. Ensure H0025 TL is only billed at the designated HealthySteps office location if billing NPI covers multiple locations. Re-submit claims for dates of service on or after July 1, 2025 that were eligible but submitted before policy release, following MCO timely filing limits. Failure to co-bill H0025 TL will result in missing enhanced reimbursement ($15 minimum per visit). Document Zero to Three HealthySteps model fidelity confirmation for your practice and maintain in credentialing files. Schedule annual reporting of aggregated metrics on NJ FamilyCare children ages 0-3 when DMAHS contacts your practice.