NJ FamilyCare Autism Benefit for Children on Medicaid: Getting Started

April 21, 2020

Essential Information for Families

As of April 1, 2020, NJ FamilyCare covers ABA services for children birth to 21 years, a much anticipated benefit for children on Medicaid.  This article provides information about how families can access this benefit for their child.

Are you a provider?  Learn more about how professionals can enroll to provide this benefit>>

Who’s Who

To understand how to access this benefit, it’s helpful to know who’s who.

Your Healthcare Professional

Qualified Healthcare Professional (QHP) is an insurance term.  Most often, there are two types of Qualified Healthcare Professionals (QHP) involved.  These are often two different people.

  • A diagnosing QHP — This is a physician or psychologist who makes a diagnosis of autism and recommends ABA services.
  • A treating QHP — This is the Board Certified Behavior Analyst who develops, oversees, and sometimes implements a treatment plan.

Finding qualified professionals:

  • Provider Network – Each MCO maintains its own provider network. See the chart below and contact your MCO for next steps.

Managed Care Organization

All families receiving NJ FamilyCare are enrolled* in a Medicaid Managed Care Organization (MCO).  The MCO is responsible for providing all medically necessary ABA treatment through their provider network.

MCOs currently operating in New Jersey are:
Aetna | Amerigroup | Horizon | United Healthcare | WellCare

Every MCO has different guidelines.  To begin the process, find your MCO’s contact information in the chart below and contact them for their specific autism coverage guidance.


*Note:  There may be a temporary period of Medicaid fee-for-service (FFS) coverage until the MCO enrollment occurs.  For families in this group, the State is responsible for FFS coverage of all medically necessary ABA services. To begin the process, contact Shanique McGowan at 609-433-0264 or shanique.mcgowan@dhs.state.nj.us.

Step by Step

Here is a simple breakdown of what to expect in the process.

Diagnosis

Note:  If your child already has a diagnosis, skip to the “Assessment” tab.

Authorization for diagnosis:
MCO authorizes a diagnosing QHP to conduct an evaluation (For FFS, no prior authorization is required until an MCO is assigned.)

For more information:
Read about what the diagnosis entails and download Autism New Jersey’s Start Here guide, available in English and Spanish.

Assessment

Authorization for assessment:
MCO authorizes a treating QHP to conduct an assessment (For FFS, no prior authorization is required until an MCO is assigned.)

Assessment:
Treating QHP conducts the assessment and submits a treatment plan to the MCO.

Treatment

Authorization for treatment:  MCO approves the treatment plan

Treatment:

  • Delivered by – A treating QHP or someone who is supervised by a QHP.  These treating professionals have credentials such as BCBA-D, BCBA, BCaBA, RBT, or another technician.
  • Targets – Treatment can include specific skill acquisition and behavior reduction goals with the overall goal of improving communication, social, and adaptive skills.
  • Ratio – Treatment can be delivered 1:1 or in small groups.
  • Family participation – Parent education is encouraged.
  • Location – Treatment may be provided in a therapist’s office, a community setting, or the child’s home.

For more information:
Visit our website for articles about treatment and ABA.

MCO Contact Information

MCO Contact Information
Joanna Jelleyman
Health Services Supervisor
609.282.8178
jelleymanj@aetna.com
Member Services
800.600.4441 
Member Services
800.682.9090
Member Services
800.941.4647
Customer Service
888.453.2534

Need help? Call Autism New Jersey’s Helpline 800.4.AUTISM or Medicaid’s Office of Customer Service 609.631.4641.

Receive updates by joining our email list: