NJ FamilyCare Autism Benefit for Children on Medicaid: Getting Started

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.

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.

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.

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.

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.