Cost and Coverage of Medicaid in New Jersey

How much is Medicaid in New Jersey? And, what services are covered by New Jersey Medicaid? The costs and coverage and the types of Medicaid insurance in New Jersey vary when compared to the medical assistance programs of other U.S. states. New Jersey Medicaid coverage, also known as NJ FamilyCare, provides health care to qualified individuals such as children, pregnant women, the aged, the blind, the disabled, childless couples, single adults and parents/caretaker relatives.

NJ Medicaid services are offered under a comprehensive health program initiative. In this section, we will examine the follow topics:

  • How much does Medicaid cost in New Jersey?

  • What services are covered by Medicaid in New Jersey?

  • What does Medicaid not cover in New Jersey?

  • Types of Medicaid insurance in New Jersey

How much does Medicaid cost in New Jersey?

How much is Medicaid? You can estimate Medicaid costs in New Jersey based on the beneficiary. Some medical services are fully covered, while others are offered at a low cost. Some members with Medicaid coverage are exempt from making any payments. Examples of these members are children under 19 years of age and pregnant women.

When your Medicaid services application is approved, you will be contacted through mail with information about your NJ Medicaid coverage premium. The Medicaid cost estimates for your premium will depend on various factors, such as your family income size, the number of people that will be covered under Medicaid and so on.

Patients should send their first payments as soon as they know their monthly premiums. For new members, the NJ Medicaid benefits come into effect only when a full payment has been received. After enrolling in Medicaid coverage, members are billed monthly. If you are a patient who qualifies for full Medicaid benefits, even though you may not get a monthly bill, you may receive statements from time to time depending on the services and supplies you use.

What services are covered by Medicaid in New Jersey?

Now that you are aware of the Medicaid cost estimates, you must understand what is covered by Medicaid. NJ Medicaid coverage caters to the following services for eligible members:

  • Transportation to obtain medical services or items covered by Medicaid

  • Durable medical equipment and supplies, X-rays and laboratory services

  • Clinic services such as physical, occupational and speech therapies

  • Inpatient and outpatient hospital care, hospice care and rehabilitation services such as audiology

  • Orthopedic shoes, braces, artificial limbs, hearing aids and eyeglasses

  • Services from optometrists, psychologists, podiatrists, dentists and chiropractors

  • Personal care assistant, medical day care, nursing home care and home health care services

  • Prescription drugs from a pharmacy (including some over-the-counter medicines)

  • All medical services provided by a physician in a clinic, an office or another medical facility

  • Mental health services provided in a hospital outpatient department, approved mental health clinic or a doctor’s office

What does Medicaid not cover in New Jersey?

Although there are many Medicaid services covered by Medicaid, others are restricted. What is not covered by Medicaid? For some services, prior authorization is required in order to handle on your behalf. For other services, you will need to pay out-of-pocket. Generally, New Jersey Medicaid coverage does not apply to services that fall under the following guidelines:

  • The provider has not received a program payment from either your NJ Medicaid Health Plan or Medicaid FFS

  • The additional protections under New Jersey state and federal law do not apply

  • The service offered is not classified as a trauma or emergency as defined by NJ state law

  • The medical provider you are getting the service from does not generally participate in New Jersey Medicaid Health Plans, or does not when it comes to that specific service

  • The service has been determined to be medically unnecessary

  • The service is provided out-of-state without prior authorization

When it comes to what is not covered by Medicaid, the above guidelines will help you. For NJ Medicaid services not covered, the provider has to inform you in writing about this decision. Moreover, you have to voluntarily agree in writing that you will pay all or part of the provider’s charges for the services before they are rendered.

Your eligibility for Medicaid coverage as it applies to medical services will depend on the benefits package to which you have been allocated. New Jersey Medicaid services are offered under five benefits packages: Medicaid and NJ FamilyCare A, DDD Clients, NJ FamilyCare B and C, NJ FamilyCare D and NJ FamilyCare ABP.

While most Medicaid services are fully covered, a few are offered on a fee-for-service basis. For example, abortion and related services are not covered under any of the benefits. An exception to the rule applies if the abortion has to be done to save the life of the mother.

Other NJ Medicaid services may be fully covered or come with restrictions across some benefits packages. For example, all packages cover acupuncture services except NJ FamilyCare D. The benefit only covers acupuncture when it is performed as anesthesia for surgery.

Confirm what is not covered by Medicaid with your health plan provider prior to receiving a treatment or a procedure. Any services that are not covered may have to be fully paid for from your pocket or by a third-party insurance company.

Keep in mind, many medical providers and doctor offices are open to payment plans. If you plan on receiving a service that is not covered by your Medicaid policy, be sure to inquire about payments broken down over a period that is mutually agreed upon. That way, you can get the treatment or procedure you need without having to worry about immediate payment.

Types of Medicaid Insurance in New Jersey

The types of New Jersey Medicaid insurance plans may not necessarily be the same as those in other states. When applying for Medicaid coverage in New Jersey, you will need to choose a health plan to get the medical services covered. Each county in NJ has at least three health plans that you can choose from. The health plans available include: Aetna Better Health of New Jersey, AMERIGROUP New Jersey, Inc., Horizon NJ Health, UnitedHealthcare Community Plan and WellCare.

There are different Medicaid types of insurance in New Jersey that cater to various patients of different age groups with or without certain medical conditions. The insurances have different guidelines and coverage limits. In most cases, when your health insurance pays for a service covered by Medicaid, the service will also be covered by Medicaid as long as it does not exceed your allocated reimbursement rate for it.

All types of Medicaid insurance have to be renewed every 12 months. During renewal, both the financial and the the family situations of the applicant will be evaluated to see if anything has changed. Failure to renew the insurance may result in coverage interruptions or loss.



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