MedicaidCoverageHigh impact
Newsletter Vol. 28, No.08
New Jersey Medicaid·NJ · Psychiatry, Emergency Medicine, Internal Medicine·Provider Notice
Effective date
Oct 1, 2018
We identified it
Jun 20, 2026
Summary
Effective October 1, 2018, New Jersey Medicaid managed care organizations (MCOs) under NJFC must now cover all acute care hospital admissions for enrolled beneficiaries, including psychiatric hospitalizations, regardless of diagnosis or age. Additionally, behavioral health and substance use disorder services become MCO-covered benefits for MLTSS, FIDE SNP, and DDD populations. Certain targeted case management and community support services remain Fee-For-Service covered.
Action Required
By September 30, 2018: (1) Billing team must update claim routing logic to direct all acute care hospital admissions (including psychiatric) for NJFC MCO-enrolled beneficiaries to the appropriate MCO rather than Fee-For-Service, effective 10/1/18. (2) Update internal billing system to classify behavioral health and substance use disorder services as MCO-covered (not FFS) for MLTSS, FIDE SNP, and DDD populations. (3) Create a reference sheet identifying which behavioral health services remain FFS-covered (TCM via JIS/CSOC/ICMS/PATH, PACT, BHH, CSS) and train billing staff to route these claims to FFS. (4) For any psychiatric hospital admissions already in progress before 10/1/18, ensure claims through discharge route to FFS; all admissions on or after 10/1/18 route to MCO. (5) Coordinate with providers and hospital discharge planners to clarify responsibility for post-discharge community mental health follow-up care, even when outpatient services are FFS-covered. Failure to route claims correctly will result in claim denials and payment delays.