NJ FamilyCare and Medicaid: How Coverage Connects to Services

NJ FamilyCare is New Jersey's publicly funded health coverage program, and it includes the state's Medicaid program. Coverage rules, plan networks and prior-authorization requirements are set by the program and by your child's plan, so the reliable way to learn what applies to your child is to apply, then ask your plan and provider directly in writing.

Many New Jersey families hear the words Medicaid, NJ FamilyCare and managed care used as if they mean three different things. In New Jersey, NJ FamilyCare is the name used for the state's publicly funded health coverage, and Medicaid is part of it. Once a child is enrolled, most services are delivered through a managed care plan that has its own provider network and its own approval process.

That structure matters for special-needs families because a service can be covered by the program in general and still require a referral, a prescription, an evaluation or prior authorization before your child can start.

• Therapies such as speech, occupational, physical and feeding therapy are usually medical services that need a prescription or referral and an evaluation.
• Behavioral health and intellectual/developmental disability services for children are organized through New Jersey's Children's System of Care, with PerformCare as the central point of access.
• Some children are eligible for coverage based on disability rather than family income. Whether that applies to your child is a determination the state makes, not something a website can confirm.
• Coverage does not create provider availability. Families often find that a service is covered but the nearby provider has a waitlist.

1. 1Apply or confirm current coverage

   Apply through the official NJ FamilyCare site, or check the coverage your child already has, including which managed care plan your child is enrolled in.

2. 2Write down the plan details

   Keep the plan name, member ID location (do not store the number in email), member services phone number and your child's primary care provider in one place.

3. 3Ask for the coverage rule in writing

   When you ask about a therapy or service, ask member services to send the requirement in writing: what is needed, who submits it and how long a decision takes.

4. 4Get the referral or prescription first

   Many therapy providers cannot schedule an evaluation until they have the referral or prescription that the plan requires.

5. 5Track every request and denial

   Keep dates, names and reference numbers. If something is denied, ask for the written notice and the appeal instructions that come with it.

• Your child's insurance card and plan name
• Referrals, prescriptions and prior-authorization letters
• Evaluation reports from each provider
• Written denials and appeal deadlines
• A contact log with dates, names and what you were told

• Which NJ FamilyCare plan is my child enrolled in right now?
• Is this service covered for my child, and what does the plan require before it can start?
• Do you need a prescription, a referral, an evaluation or prior authorization?
• Is this provider in my child's plan network?
• If the request is denied, how do I appeal and what is the deadline?
• Who at the plan can help me coordinate several services at once?

• Being covered is not the same as being approved for a specific service.
• Being approved is not the same as having an available appointment.
• A recommendation in an evaluation report is not an authorization.
• Plan networks and covered services can change; verify before scheduling.
• Never send member ID numbers, Social Security numbers or medical records through a website form, including ours.

• Confirm which plan your child is enrolled in, then call member services and ask what is required for the one service you need first.
• If the need is behavioral or developmental, contact PerformCare to learn what the Children's System of Care can offer.

• Understanding PerformCare and NJ Children's System of Care
• Developmental Disability Services in New Jersey: DD vs. DDD and How to Apply
• Find ResourcesStatewide programs and county organizations.
• Find providersNew Jersey agencies and family resources.

• NJ FamilyCare (official State of New Jersey site) Program information, applications and member resources.
• NJ Division of Medical Assistance and Health Services The state division that administers Medicaid and NJ FamilyCare.
• PerformCare New Jersey Contracted system administrator for the New Jersey Children's System of Care. Available 24 hours a day at 1-877-652-7624.