MedicaidCoverageMedium impact
Newsletter Vol. 24, No.14
New Jersey Medicaid·NJ · Geriatrics, Palliative Care·Eligibility
Effective date
Jul 1, 2014
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid (NJ FamilyCare) now allows Assisted Living Programs to bill fee-for-service (FFS) for residents who are clinically and financially eligible for MLTSS but have pending MCO enrollment (gap period up to 60 days). Providers must notify DMAHS, wait 10 business days, then submit FFS claims using specific HCPCS codes with per diem rates until MCO enrollment becomes effective, after which claims route to the MCO.
Action Required
By service dates on or after July 1, 2014: Billing team must (1) identify NJ FamilyCare (NJFC) residents at Assisted Living facilities who are clinically and financially eligible but pending MCO enrollment; (2) notify DMAHS Office of Provider Relations (mahs.provider-inquiries@dhs.state.nj.us) with resident name, DOB, Medicaid ID, clinical eligibility date, and facility name; (3) wait 10 business days before submitting claims; (4) submit FFS claims to Molina Medicaid Solutions using the correct HCPCS code and modifier (T2031 for ALR at $72.50/diem, T2031-U1 for CPCH at $62.50/diem, T2031-U2 for ALP at $52.50/diem, or S5140 for AFC at $50.00/diem) for each day of service until MCO enrollment is active; (5) route subsequent claims to the assigned MCO once enrollment becomes effective. Claims submitted outside this window or using incorrect codes will be denied. Ensure billing system is configured to track clinical and financial eligibility dates separately and to identify the MCO enrollment effective date to route claims appropriately.