Community Care Consortium for Children
and Youth with Special Healthcare Needs
New Jersey Medicaid and
Children’s Health Insurance Program
Valerie Harr
Director
NJ Department of Human Services
Division of Medical Assistance and Health Services
April 10, 2012
Facts About NJ FamilyCare/Medicaid
2
•
Nearly 1.3 million clients enrolled
--750,000 children
--540,000 adults
•
Over 1 million clients enrolled in managed care
--98% of clients enrolled
•
Total Medicaid expenditures: Over $11 billion
State of New Jersey
Managed Care Activity
3
• Transitioned 160,000 clients to managed care
o
o
Remaining ABD duals and non-LTC
98% enrolled in 4 MCOs
• Service Carve-Ins
o
Pharmacy, Medical Day Care, PCA services, PDN services
• Annual Open Enrollment Period (October 1 - November 15)
• Quality Monitoring
o
HMO Performance Reports
• On the Horizon:
o
o
Global Health Plan Annual Assessment
Recalibrate Provider Network Access Standards
State of New Jersey
Comprehensive Medicaid Waiver
4
• Purpose
o
o
o
o
5-year roadmap
Medicaid and CHIP predictability
Administrative simplification
Delivery system reform
• Key Features
1. Manage LTSS (January 2013)
2. Manage & integrate behavioral health care (July 2013 )
3. Pilot programs for people with ID/DD
• Supports Waiver
• Dual Diagnoses
• Pervasive Developmental Disabilities
4. Administration simplification:
−
−
10-day Plan selection period
approvals of network capacity adjustments
• Next Steps
o
o
Program design, readiness assessments and testing
CASS, MMIS, Exchange, Medicaid Expansion 2014 (?)
State of New Jersey
Dental Benefits
5
Comprehensive dental benefits are available up to age 21 and include:
1. Exams & cleaning up to 4 times per year
2. Restorations
3. Root canals and Periodontal Services
4. Dentures
5. Oral Surgery & Orthodontics
o with adjunctive services: anesthesia, sedation nitrous oxide,
behavior management reimbursement, if needed
6. Dental services in the operating room or ambulatory surgical centers with
access to ancillary services
State of New Jersey
Orthodontic Services
6
In 2010 Orthodontia was not eliminated; revisions were made to:
1. Better define “medical necessity” through use of a new assessment tool
2. Enhance reporting by providers of treatment status & completion
2012 revisions have been developed based on recommendations from
the DMAHS Dental Advisory Council:
1. Additional guidance to providers and HMOs that “a case- by-case” evaluation must
be conducted to determine medical necessity, not a benchmark
2. Care/Case Management
3. Development of an HMO Annual Report Card based on performance
4. Clearly defined denial reasons and contact information must be issued to
beneficiaries to enhance the communication between the HMO consultant and
provider
State of New Jersey
For More Information About
New Jersey Medicaid/NJ FamilyCare
Visit us at:
http://www.state.nj.us/humanservices/dmahs/home/