horizonNJhealth.com
As a Horizon NJ Health member, you get the benets and services you are entitled
to through the NJ FamilyCare program.
You pay little or nothing for the medical care and services you get through
Horizon NJ Health. Make sure you know how Horizon NJ Health works, especially
when it comes to emergency care, seeing your doctor and when you need an
authorization. If you get services that are not covered by Horizon NJ Health or
authorized by your PCP, you may be billed. Before care is given, your doctor should
tell you if a service is not covered and if you will be billed.
If you are not sure whether a service is covered, call Member Services at
1-800-682-9090 (TTY 711).
Your Benets and Services
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Service Benet NJ FamilyCare A/ABP NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D
Abortions Covered by FFS.*
Abortions and related services, including (but not limited to) surgical procedure; anesthesia; history and physical
exam; and lab tests
Acupuncture Covered
Autism Services Covered by Horizon NJ Health and FFS. Only covered for members under 21 years of age with Autism
Spectrum Disorder.
Covered services include Applied Behavioral Analysis (ABA) treatment, augmentative and alternative
communication services and devices, Sensory Integration (SI) services, allied health services (physical therapy,
occupational therapy and speech therapy), and Developmental Relationship based services including but not
limited to DIR, DIR Floortime and the Greenspan approach therapy.
Blood & Blood
Products
Covered
Whole blood and derivatives, as well as necessary processing and administration costs, are covered.
Coverage is unlimited (no limit on volume or number of blood products).
Coverage begins with the rst pint of blood.
Bone Mass
Measurement
Covered
Covers one measurement every 24 months (more often if medically necessary), as well as physician’s
interpretation of results.
Cardiovascular
Screenings
Covered
For all persons 20 years of age and older, annual cardiovascular screenings are covered. More frequent testing
is covered when determined to be medically necessary.
Chiropractic
Services
Covered
Covers manipulation of the spine.
Colorectal
Screening
Covered
Covers any expenses incurred in conducting colorectal cancer screening at regular intervals for beneciaries
45 years of age or older, and for those of any age deemed to be at high risk of colorectal cancer.
• Barium Enema — Covered
When used instead of a exible sigmoidoscopy or colonoscopy, covered once every 48 months.
• Colonoscopy — Covered
Covered once every 120 months, or 48 months after a screening exible sigmoidoscopy.
• Fecal Occult Blood Test — Covered
Covered once every 12 months.
• Flexible Sigmoidoscopy — Covered
Covered once every 48 months.
*Fee-for-Service
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Service Benet NJ FamilyCare A/ABP NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D
Dental Services Covered
Covers diagnostic, preventive, restorative, endodontic,
periodontal, prosthetic, oral and maxillofacial surgical
services, as well as other adjunctive general services.
Some procedures may require prior authorization with
documentation of medical necessity. Orthodontic
services are allowed for children and are age restricted
and only approved with adequate documentation of a
handicapping malocclusion or medical necessity.
Examples of covered services include (but are not
limited to): oral evaluations (examinations); X-rays
and other diagnostic imaging; dental cleaning
(prophylaxis); topical uoride treatments; llings;
crowns; root canal therapy; scaling and root planing;
complete and partial dentures; oral surgical procedures
(to include extractions); intravenous anesthesia/
sedation (where medically necessary for oral surgical
procedures).
Dental examinations, cleanings, uoride treatment and
any necessary X-rays are covered twice per
rolling year. Additional diagnostic, preventive and
designated periodontal procedures can be considered
for members with special health care needs.
Dental treatment in an operating room or ambulatory
surgical center is covered with prior authorization and
documentation of medical necessity.
Children should have their rst dental exam when
they are a year old, or when they get their rst tooth,
whichever comes rst. The NJ Smiles program allows
non-dental providers to perform oral screenings, caries
risk assessments, anticipatory guidance and uoride
varnish applications for children through the age of ve
(5) years old. If additional care is needed, members
can nd a complete list of dentists who treat children
6 years of age or younger in The NJFC Directory of
Dentists Treating Children Under the Age of 6. This
separate list of dentists is located at
horizonNJhealth.com/kidsdentists.
Covered
Covers diagnostic, preventive, restorative,
endodontic, periodontal, prosthetic, oral and
maxillofacial surgical services, as well as other
adjunctive general services.
Some procedures may require prior authorization
with documentation of medical necessity.
Orthodontic services are allowed for children and
are age restricted and only approved with adequate
documentation of a handicapping malocclusion or
medical necessity.
Examples of covered services include (but are not
limited to): oral evaluations (examinations); X-rays
and other diagnostic imaging; dental cleaning
(prophylaxis); topical uoride treatments; llings;
crowns; root canal therapy; scaling and root planing;
complete and partial dentures; oral surgical
procedures (to include extractions); intravenous
anesthesia/sedation (where medically necessary for
oral surgical procedures).
Dental examinations, cleanings, uoride treatment
and any necessary X-rays are covered twice per
rolling year. Additional diagnostic, preventive
and designated periodontal procedures can be
considered for members with special health care
needs.
Dental treatment in an operating room or ambulatory
surgical center is covered with prior authorization and
documentation of medical necessity.
Children should have their rst dental exam when
they are a year old, or when they get their rst tooth,
whichever comes rst. The NJ Smiles program allows
non-dental providers to perform oral screenings,
caries risk assessments, anticipatory guidance and
uoride varnish applications for children through the
age of ve (5) years old. If additional care is needed,
members can nd a complete list of dentists who
treat children 6 years of age or younger in The NJFC
Directory of Dentists Treating Children Under the Age
of 6. This separate list of dentists is located at
horizonNJhealth.com/kidsdentists.
NJ FamilyCare C and D members have a $5
copay per dental visit (except for diagnostic and
preventive services).
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Service Benet NJ FamilyCare A/ABP NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D
Diabetes
Screenings
Screening is covered (including fasting glucose tests) if you have any of the following risk factors: high blood
pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history
of high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight
and having a family history of diabetes.
Based on the results of these tests, you may be eligible for up to two diabetes screenings every 12 months.
Diabetes
Supplies
Covered
Covers blood glucose monitors, test strips, insulin, injection aids, syringes, insulin pumps, insulin infusion
devices, and oral agents for blood sugar control. Covers therapeutic shoes or inserts for those with diabetic foot
disease. The shoes or inserts must be prescribed by a podiatrist (or other qualied doctor) and provided by a
podiatrist, orthotist, prosthetist, or pedorthist.
Diabetes Testing
and Monitoring
Covered
Covers yearly eye exams for diabetic retinopathy, as well as foot exams every six months for members with
diabetic peripheral neuropathy and loss of protective sensations.
Diagnostic and
Therapeutic
Radiology and
Laboratory
Services
Covered
Covered, including (but not limited to) CT scans, MRIs, EKGs, and X-rays.
Durable Medical
Equipment
(DME)
Covered
Emergency Care Covered
Covers emergency department and physician services.
Covered
Covers emergency
department and
physician services.
NJ FamilyCare C
members have a $10
copay.
Covered
Covers emergency
department and
physician services.
NJ FamilyCare D
members have a $35
copay.
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Service Benet NJ FamilyCare A/ABP NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D
EPSDT (Early
and Periodic
Screening,
Diagnosis and
Treatment)
Covered
Coverage includes (but
is not limited to) well
child care, preventive
screenings, medical
examinations, dental,
vision, and hearing
screenings and services
(as well as any treatment
identied as necessary as
a result of examinations
or screenings),
immunizations (including
the full childhood
immunization schedule),
lead screening and
private duty nursing
services. Private duty
nursing is covered
for eligible EPSDT
beneciaries under 21
years of age who live
in the community and
whose medical condition
and treatment plan
justify the need.
Covered
Coverage includes early and periodic screening and diagnostic medical
examinations, dental, vision, hearing, and lead screening services.
Family Planning
Services and
Supplies
Covered
Horizon NJ Health shall reimburse family planning services provided by non-participating network providers
based on the Medicaid fee schedule.
The family planning benet provides coverage for services and supplies to prevent or delay pregnancy and may
include: education and counseling in the method of contraception desired or currently in use by the individual, or
a medical visit to change the method of contraception. Also includes, but is not limited to: sterilizations, dened
as any medical procedures, treatments, or operations for the purpose of rendering an individual permanently
incapable of reproducing.
Covered services include medical history and physical examination (including pelvis and breast), diagnostic and
laboratory tests, drugs and biologicals, medical supplies and devices (including pregnancy test kits, condoms,
diaphragms, Depo-Provera injections and other contraceptive supplies and devices), counseling, continuing
medical supervision, continuity of care and genetic counseling.
Exceptions: Services primarily related to the diagnosis and treatment of infertility are not covered
(whether furnished by in-network or out-of-network providers).
Federally
Qualied Health
Centers (FQHC)
Covered
Includes outpatient and primary care services from community-based organizations.
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Service Benet NJ FamilyCare A/ABP NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D
Hearing
Services/
Audiology
Covered
Covers routine hearing exams, diagnostic hearing exams and balance exams, otologic and hearing aid
examinations prior to prescribing hearing aids, exams for the purpose of tting hearing aids, follow-up exams and
adjustments, and repairs after warranty expiration.
Hearing aids, as well as associated accessories and supplies, are covered.
Home Health
Agency Services
Covered
Covers nursing services and therapy services by a registered nurse, licensed practical nurse or home health aide.
Hospice Care
Services
Covered
Covers drugs for pain relief and symptoms management; medical, nursing, and social services; and certain
durable medical equipment and other services, including spiritual and grief counseling.
• Covered in the community as well as in institutional settings.
• Room and board included only when services are delivered in institutional (non-residence) settings. Hospice
care for members under 21 years of age shall cover both palliative and curative care.
NOTE: Any care unrelated to the member’s terminal condition is covered in the same manner as it would
be under other circumstances.
Immunizations Covered
Inuenza, Hepatitis B, pneumococcal vaccinations, and other vaccinations recommended for adults are covered.
The full childhood immunization schedule is covered as a component of EPSDT.
Inpatient
Hospital Care
Covered
Covers stays in critical access hospitals; inpatient rehabilitation facilities; inpatient mental health care; semi-
private room accommodations; physicians’ and surgeons’ services; anesthesia; lab, X-ray, and other diagnostic
services; drugs and medication; therapeutic services; general nursing; and other services and supplies that are
usually provided by the hospital.
• Acute Care — Covered
Includes room and board; nursing and other related services; use of hospital/Critical Access Hospital facilities;
drugs and biologicals; supplies, appliances, and equipment; certain diagnostic and therapeutic services,
medical or surgical services provided by certain interns or residents-in-training; and transportation services
(including transportation by ambulance).
• Psychiatric — For coverage details, please refer to the Behavioral Health chart.
Mammograms Covered
Covers a baseline mammogram for women age 35 to 39, and a mammogram every year for those 40 and over,
and for those with a family history of breast cancer or other risk factors. Additional screenings are available if
medically necessary.
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Service Benet NJ FamilyCare A/ABP NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D
Maternal and
Child Health
Services
Covered
Covers medical services for perinatal care, and related newborn care and hearing screenings, including midwifery
care, Centering Pregnancy, immediate postpartum LARC (Long-Acting Reversible Contraception) and all dental
services (to include but not limited to additional dental preventive care and medically necessary dental treatment
services).
Also covers childbirth education, doula care, lactation support.
Breastfeeding equipment, including breast pumps and accessories, are covered as a DME benet.
Medical Day
Care (Adult Day
Health Services)
Covered
A program that provides
preventive, diagnostic,
therapeutic and
rehabilitative services
under medical and
nursing supervision in an
ambulatory (outpatient)
care setting to meet the
needs of individuals with
physical and/or cognitive
impairments in order to
support their community
living.
Not covered
Nurse Midwife
Services
Covered Covered
$5 copay for each visit
(except for prenatal care visits)
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Service Benet NJ FamilyCare A/ABP NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D
Nursing Facility
Services
Covered
Members may have
patient pay liability.
• Long Term (Custodial
Care) —Covered.
Covered for those
who need Custodial
Level of Care (MLTSS).
Members may have
patient pay liability.
• Nursing Facility
(Hospice) — Covered.
Hospice care can be
covered in a Nursing
Facility setting.
*See Hospice Care
Services.
• Nursing Facility
(Skilled) —Covered.
Includes coverage
for Rehabilitative
Services that take place
in a Nursing Facility
setting.
• Nursing Facility
(Special Care) —
Covered. Care in a
Special Care Nursing
Facility (SCNF) or a
separate and distinct
SCNF unit within a
Medicaid-certied
conventional nursing
facility is covered for
members who have
been determined
to require intensive
nursing facility services
beyond the scope of a
conventional nursing
facility.
Not covered
Organ
Transplants
Covered
Covers medically necessary organ transplants including (but not limited to): liver, lung, heart, heart-lung,
pancreas, kidney, liver, cornea, intestine, and bone marrow transplants (including autologous bone marrow
transplants). Includes donor and recipient costs.
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Service Benet NJ FamilyCare A/ABP NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D
Outpatient
Surgery
Covered
Outpatient
Hospital/ Clinic
Visits
Covered Covered
$5 copay per visit (no copay if the visit is for
preventive services).
Outpatient
Rehabilitation
(Occupational
Therapy, Physical
Therapy, Speech
Language
Pathology)
Covered
Covers physical therapy,
occupational therapy,
speech pathology and
cognitive rehabilitation
therapy.
Covered
Covers physical, occupational, and speech/language therapy.
Pap Smears and
Pelvic Exams
Covered
Pap tests and pelvic exams are covered every 12 months for all women, regardless of determined level of risk for
cervical or vaginal cancers.
Clinical breast exams for all women are covered once every 12 months.
All laboratory costs associated with the listed tests are covered.
Tests are covered on a more frequent basis in cases where they are deemed necessary for medical diagnostic purposes.
Personal Care
Assistance
Covered
Covers health-related
tasks performed by a
qualied individual in
a beneciary’s home,
under the supervision of
a registered professional
nurse, as certied by a
physician in accordance
with a beneciary’s
written plan of care.
Covered through EPSDT
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Service Benet NJ FamilyCare A/ABP NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D
Podiatry Covered
Covers routine exams and medically necessary podiatric
services, as well as therapeutic shoes or inserts for
those with severe diabetic foot disease, and exams to t
those shoes or inserts.
Exceptions: Routine hygienic care of the feet, such
as the treatment of corns and calluses, trimming
of nails, and care such as cleaning or soaking feet,
are only covered in the treatment of an associated
pathological condition.
Covered
Covers routine exams and medically necessary
podiatric services, as well as therapeutic shoes or
inserts for those with severe diabetic foot disease,
and exams to t those shoes or inserts.
$5 copay per visit
Exceptions: Routine hygienic care of the feet, such
as the treatment of corns and calluses, trimming
of nails, and care such as cleaning or soaking feet,
are only covered in the treatment of an associated
pathological condition.
Prescription
Drugs
Covered
Includes prescription drugs (legend and non-legend,
including physician administered drugs); prescription
vitamins and mineral products including, but not
limited to, therapeutic vitamins, such as high potency
A, D, E, Iron, Zinc, and minerals, including potassium,
and niacin. All blood clotting factors are covered.
Covered
Includes prescription drugs (legend and non-legend,
including physician administered drugs); prescription
vitamins and mineral products including, but not
limited to, therapeutic vitamins, such as high potency
A, D, E, Iron, Zinc, and minerals, including potassium,
and niacin. All blood clotting factors are covered.
There is a $1 copay for generic drugs, and a $5
copay for brand name drugs.
Physician
Services —
Primary and
Specialty Care
Covered.
Covers medically necessary services and certain
preventive services in outpatient settings.
Covered
Covers medically necessary services and certain
preventive services in outpatient settings.
$5 copay for each visit (except for well-child
visits in accordance with the recommended
schedule of the American Academy of Pediatrics;
lead screening and treatment, age-appropriate
immunizations; prenatal care and pap smears,
when appropriate).
Private Duty
Nursing
Covered
Private duty nursing is covered for members who live in the community and whose medical condition and
treatment plan justify the need.
Private Duty Nursing is only available to EPSDT beneciaries under 21 years of age, and to members with
MLTSS (of any age).
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Service Benet NJ FamilyCare A/ABP NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D
Prostate Cancer
Screening
Covered
Covers annual diagnostic examination including digital rectal exam and Prostate Specic Antigen (PSA) test for
men 50 and over who are asymptomatic, and for men 40 and over with a family history of prostate cancer or other
prostate cancer risk factors.
Prosthetics
and Orthotics
Covered
Coverage includes (but is not limited to) arm, leg, back and neck braces; articial eyes; articial limbs and
replacements; certain breast prostheses following mastectomy; and prosthetic devices for replacing internal body
parts or functions. Also covers certied shoe repair, hearing aids and dentures.
Renal Dialysis Covered Covered
No copays
Routine Annual
Physical Exams
Covered Covered
No copays
Smoking/Vaping
Cessation
Covered
Coverage includes counseling to help you quit smoking or vaping, medicines such as Bupropion, Varenicline,
nicotine oral inhalers and nicotine nasal sprays, as well as over-the-counter products including nicotine
transdermal patches, nicotine gum, and nicotine lozenges.
The following resources is available to support you in quitting smoking/vaping:
• NJ Quitline: Design a program that ts your needs and get support from counselors. Call toll free
1-866-NJ-STOPS (1-866-657-8677) (TTY 711), weekdays, from 8 a.m. to 9 p.m. (except holidays), Saturday,
from 8 a.m. to 7 p.m., and Sunday, from 9 a.m. to 5 p.m., ET. The program supports 26 different languages.
Learn more at njquitline.org.
Transportation
(Emergency)
(Ambulance,
Mobile Intensive
Care Unit)
Covered
Coverage for emergency care, including (but not limited to) ambulance and Mobile Intensive Care Unit.
Transportation
(Non-Emergent)
(Non-Emergency
Ambulance,
Medical
Assistance
Vehicles/MAV,
Livery, Clinic)
Covered by FFS.
Medicaid Fee-for-Service covers all non-emergency transportation, such as mobile assistance vehicles (MAVs),
and non-emergency basic life support (BLS) ambulance (stretcher). Livery transportation services, such as bus
and train fare or passes, car service and reimbursement for mileage, are also covered.
May require medical orders or other coordination by Horizon NJ Health, PCP, or providers.
For COVID-related services, livery/car transportation services, ambulatory, ambulatory with assistance,
wheelchair, stretcher, mass transit/bus passes, and mileage reimbursement are covered.
Modivcare transportation services are covered for NJ FamilyCare A, ABP, B, C or D members. All
transportation including livery is available for all members including B, C and D.
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Service Benet NJ FamilyCare A/ABP NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D
Urgent
Medical Care
Covered
Covers care to treat a sudden illness or injury that isn’t
a medical emergency, but is potentially harmful to
your health (for example, if your doctor determines
it’s medically necessary for you to receive medical
treatment within 24 hours to prevent your condition
from getting worse).
Covered
Covers care to treat a sudden illness or injury
that isn’t a medical emergency, but is potentially
harmful to your health (for example, if your doctor
determines it’s medically necessary for you to
receive medical treatment within 24 hours to
prevent your condition from getting worse).
NOTE: There may be a $5 copay for urgent
medical care provided by a physician,
optometrist, dentist or nurse practitioner.
Vision Care
Services
• Corrective
Lenses —
Covered
Covers medically necessary eye care services for
detection and treatment of disease or injury to the eye,
including a comprehensive eye exam once per year.
Covers optometrist services and optical appliances,
including articial eyes, low vision devices, vision
training devices and intraocular lenses.
Yearly exams for diabetic retinopathy are covered for
member with diabetes.
A glaucoma eye test is covered every ve years for those
35 or older, and every 12 months for those at high risk
for glaucoma.
Certain additional diagnostic tests are covered for
members with age-related macular degeneration.
Covered
Covers medically necessary eye care services for
detection and treatment of disease or injury to the
eye, including a comprehensive eye exam once
per year. Covers optometrist services and optical
appliances, including articial eyes, low vision devices,
vision training devices, and intraocular lenses.
Yearly exams for diabetic retinopathy are covered for
member with diabetes.
A glaucoma eye test is covered every ve years for
those 35 or older, and every 12 months for those at
high risk for glaucoma.
Certain additional diagnostic tests are covered for
members with age-related macular degeneration.
$5 copay per visit for Optometrist services.
Covered
Covers 1 pair of lenses/frames or contact lenses every 24 months for members age 19 through 59, and once per
year for those 18 years of age or younger and those 60 years of age or older.
Covers one pair of eyeglasses or contact lenses after each cataract surgery with an intraocular lens.
Behavioral health benets
Horizon NJ Health covers a number of behavioral health benets for you. Behavioral health includes both
mental health services and Substance Use Disorder (SUD) treatment services. Some services are covered
for you by Horizon NJ Health, while some are paid for directly by Medicaid Fee-for-Service (FFS). You will
nd details in the chart on the next page. When requesting Prior Authorization or making arrangements to
receive a behavioral health service, members and providers should call ReachNJ - the Interim Managing
Entity (IME), for services covered by FFS. The phone number for ReachNJ is 1-844-276-2777 (TTY 711),
24 hours a day, seven days a week. For services covered by Horizon NJ Health, call Member Services at
1-800-682-9090 (TTY 711), 24 hours a day, seven days a week.
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Benet
Members in DDD,
MLTSS, or FIDE SNP
NJ FamilyCare
Plan A/ABP
NJ FamilyCare
Plan B
NJ FamilyCare
Plan C
NJ FamilyCare
Plan D
Mental Health
Adult Mental Health
Rehabilitation
(Supervised Group
Homes and Apartments)
Covered Covered by FFS. Not covered
Inpatient
Psychiatric
Covered
Coverage includes services in a general hospital, psychiatric unit of an acute care hospital, Short Term
Care Facility (STCF) or critical access hospital.
Independent
Practitioner Network
or IPN (Psychiatrist,
Psychologist or APN)
Covered Covered by FFS.
Outpatient
Mental Health
Covered Covered by FFS.
Coverage includes services received in a General Hospital Outpatient setting,
Mental Health Outpatient Clinic/Hospital services, and outpatient services
received in a Private Psychiatric Hospital.
Services in these settings are covered for members of all ages.
Partial Care
(Mental Health)
Covered Covered by FFS.
Limited to 25 hours per week (5 hours per day, 5 days per week).
Prior authorization required.
Acute Partial
Hospitalization
Mental Health/
Psychiatric Partial
Hospitalization
Covered Covered by FFS.
Admission is only through a psychiatric emergency screening center or post
psychiatric inpatient discharge.
Prior authorization required for Acute Partial Hospitalization.
Psychiatric
Emergency Services
(PES)/Afliated
Emergency Services
(AES)
Covered by FFS.
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Benet
Members in DDD,
MLTSS, or FIDE SNP
NJ FamilyCare
Plan A/ABP
NJ FamilyCare
Plan B
NJ FamilyCare
Plan C
NJ FamilyCare
Plan D
Substance Use Disorder
Substance Use
Disorder
Treatment
The American Society of Addiction Medicine (ASAM) provides guidelines that are used to help determine
what kind of Substance Use Disorder (SUD) treatment is appropriate for a person who needs SUD services.
Some of the services in this chart show the ASAM level associated with them (which includes “ASAM”
followed by a number).
Ambulatory
Withdrawal
Management with
Extended On-Site
Monitoring/
Ambulatory
Detoxication
ASAM 2 – WM
Covered Covered by FFS.
Care Management
Services
Covered Covered by FFS.
Inpatient Medical
Detox/Medically
Managed Inpatient
Withdrawal
Management
(Hospital-based)
ASAM 4 - WM
Covered
Long Term
Residential (LTR)
ASAM 3.1
Covered Covered by FFS.
Non-Medical
Detoxication/
Non-Hospital
Based Withdrawal
Management
ASAM 3.7 – WM
Covered Covered by FFS.
Ofce-Based
Addiction Treatment
(OBAT)
Covered
Covers coordination of patient services on an as-needed basis to create and maintain a comprehensive and
individualized SUD plan of care and to make referrals to community support programs as needed.
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Your Benets and Services (continued)
Benet
Members in DDD,
MLTSS, or FIDE SNP
NJ FamilyCare
Plan A/ABP
NJ FamilyCare
Plan B
NJ FamilyCare
Plan C
NJ FamilyCare
Plan D
Substance Use Disorder
Opioid Treatment
Services
Covered Covered by FFS.
Includes coverage for Methadone Medication Assisted Treatment (MAT) and
Non-Methadone Medication Assisted Treatment.
Coverage for Non-Methadone Medication Assisted Treatment includes (but is
not limited to) FDA-approved opioid agonist and antagonist treatment medications
and the dispensing and administration of such medications; substance use disorder
counseling; individual and group therapy; and toxicology testing.
Peer Recovery
Support Services
Covered Covered by FFS.
Includes coverage for Methadone Medication Assisted Treatment (MAT) and
Non-Methadone Medication Assisted Treatment. Coverage for Non-Methadone
Medication Assisted Treatment includes (but is not limited to) FDA-approved
opioid agonist and antagonist treatment medications and the dispensing and
administration of such medications; substance use disorder counseling; individual
and group therapy; and toxicology testing.
Substance Use
Disorder Intensive
Outpatient (IOP)
ASAM 2.1
Covered Covered by FFS.
Substance Use
Disorder Outpatient
(OP)
ASAM 1
Covered Covered by FFS.
Substance Use
Disorder Partial Care
(PC)
ASAM 2.5
Covered Covered by FFS.
Substance Use
Disorder Short Term
Residential (STR)
ASAM 3.7
Covered Covered by FFS.
DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO D-SNP)
MLTSS=Managed Long Term Services & Supports
Member Services: 1-800-682-9090 horizonNJhealth.com
Services not covered by Horizon NJ Health
or the NJ FamilyCare Fee-for-Service program
include:
• All services not medically necessary,
provided, approved or arranged by a
Horizon NJ Health participating doctor
(within their scope of practice) except
emergency services.
• Any service or items for which a provider
does not normally charge.
• Cosmetic services or surgery except when
medically necessary and approved.
• Experimental procedures or experimental
organ transplants.
• Services provided by or in an institution
run by the federal government, such as the
Veterans Administration hospitals.
• Respite care (except MLTSS members).
• Rest cures, personal comfort, convenience
items and services and supplies not directly
related to the care of the patient. Examples
include guest meals and telephone charges.
Costs incurred by an accompanying
parent(s) for an out-of-state medical
intervention are covered under EPSDT.
• Services in which health care records do not
reect the requirements of the procedure
described or procedure code used by the
provider.
• Services provided by an immediate relative
or household member.
• Services involving the use of equipment
in facilities in which its purchase, rental or
construction has not been approved by the
State of New Jersey.
• Services resulting from any work-related
condition or accidental injury when
benets are available from any workers’
compensation law, temporary disability
benets law, occupational disease law or
similar law.
• Services provided or started while on active
military duty.
• Services or items reimbursed based on
submission of a cost study in which there is
no evidence to support the costs allegedly
incurred or beneciary income to make up
for those costs. If nancial records are not
available, a provider may verify costs or
available income using other evidence that
the NJ FamilyCare program accepts.
• Services provided outside the United States
and its territories.
• Infertility diagnoses and treatment services
(including sterilization reversals and related
medical and clinic ofce visits, drugs,
laboratory services, radiological and
diagnostic services and surgical procedures).
• Services provided without charge. Programs
offered free of charge through public or
voluntary agencies should be used to the
fullest extent possible.
• Any service covered under any other
insurance policy or other private or
governmental health benet system or
third-party liability.
Services not covered by NJ FamilyCare
Fee-for-Service or Horizon NJ Health
Member Services: 1-800-682-9090 horizonNJhealth.com
Products are provided by Horizon NJ Health. Communications are issued by Horizon Blue Cross
Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its
companies. Both are independent licensees of the Blue Cross Blue Shield Association.
The Blue Cross
®
and Blue Shield
®
names and symbols are registered marks of the Blue Cross
Blue Shield Association. The Horizon
®
name and symbols are registered marks of Horizon Blue Cross
Blue Shield of New Jersey. © 2023 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza
East, Newark, New Jersey 07105. (0823) 086-23-73 ECN009735A
Getting Help in Your Language
If you need help understanding this information, you have the right to get help in your language
at no cost to you.
Nondiscrimination Policy
Read about Horizon NJ Health’s nondiscrimination policy.
