MedicaidCoverageHigh impact
Newsletter Vol. 12, No. 39
New Jersey Medicaid·NJ·Eligibility
Effective date
May 1, 2002
We identified it
Jun 20, 2026
Summary
New Jersey implemented the New Jersey Care 2000+ managed care program requiring most Medicaid and NJ FamilyCare beneficiaries to enroll in Medicaid-contracted HMOs. Providers must verify HMO network participation for their patients and ensure they are credentialed with applicable plans. Coverage changes include expanded drug coverage for protease inhibitors and anti-retroviral agents, with specific exclusions for certain NJ FamilyCare populations.
Action Required
IMMEDIATELY: Billing team and providers must (1) Contact all five Medicaid-contracted HMOs (AmeriChoice, AMERIGROUP, Horizon Mercy, Health Net, University Health Plans) to verify current network participation status and initiate credentialing applications if not yet enrolled; (2) Update patient eligibility verification processes to confirm HMO enrollment status before scheduling and billing—use REVS Hotline (1-800-676-6562) for real-time verification; (3) Communicate HMO network participation details to front desk staff and patients at check-in so patients can select HMOs based on provider availability; (4) For pharmacy claims: Update billing software to identify beneficiaries in NJ FamilyCare Plan A (adults without dependent children under 19) and Plan D (parents/caretakers and adults under 23) and route protease inhibitors (W5C) and anti-retroviral agents (W5B) through fee-for-service Medicaid and AIDS Drug Distribution Program instead of HMO claims; (5) Flag all other beneficiary categories for HMO claims submission. Verify eligibility and plan type before claim submission to prevent denials. Refer patients needing HMO enrollment assistance to Health Benefits Coordinator at 1-800-701-0710. Failure to verify HMO network participation will result in claim denials and loss of reimbursement.