NJ FamilyCare, New Jersey's combined Medicaid and CHIP program, is administered by the Division of Medical Assistance and Health Services (DMAHS) within the Department of Human Services. Mandatory managed care runs through five health plans, and Managed Long Term Services and Supports (MLTSS), effective July 1, 2014, folds most long-term care into those same plans rather than running it as a separate fee-for-service system. Behavioral health is in the middle of a multi-year, phased integration into managed care that is still actively unfolding.
Five plans currently hold NJ FamilyCare managed care contracts: Aetna Better Health of New Jersey, Fidelis Care, Horizon NJ Health, UnitedHealthcare Community Plan, and Wellpoint. DMAHS also contracts separately for a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) product line serving members eligible for both Medicare and Medicaid, under its own model MIPPA contract distinct from the mainstream managed care contract.
Long-term services and supports are integrated into managed care through MLTSS, which took effect July 1, 2014. MLTSS coordinates nursing facility care, assisted living, community residential services, home and vehicle modifications, home-delivered meals, respite, and personal emergency response systems through the same five NJ FamilyCare managed care plans that handle acute and primary care, rather than through a separate LTSS-specific vendor. One legacy carve-out remains: nursing facility residents who were already receiving custodial Medicaid coverage before July 1, 2014 stay in fee-for-service for the duration of that stay. MLTSS eligibility itself is determined by New Jersey's Division of Aging Services rather than by the health plans. A related, older layer of the program (a set of standalone 1915(c) home- and community-based services waivers, including the Global Options for Long Term Care, Community Care, Community Resources for People with Disabilities, AIDS Community Care Alternatives, and Traumatic Brain Injury waivers) wound down between 2014 and 2021 as their populations moved into MLTSS, consistent with the program's own stated design.
Integrated into managed care
Behavioral health has moved from a largely carved-out system toward integration into managed care in stages, and that process is not yet complete. Coverage for behavioral health services for MLTSS, FIDE SNP, and Division of Developmental Disabilities beneficiaries was aligned with the managed care plans effective July 1, 2018, with FIDE SNP enrollees more broadly following in October 2018. A far larger integration, described by the state as the most significant behavioral health change since managed care itself began, started with Phase 1 on January 1, 2025, moving outpatient behavioral health services (outpatient counseling and psychotherapy, partial hospitalization, substance use disorder outpatient counseling, intensive outpatient and partial care services, and related peer support and case management programs) onto MCO coverage and billing for the broader NJ FamilyCare population, not just the MLTSS/FIDE SNP/DDD populations already integrated. A subsequent Phase 2, covering residential and opioid treatment programs, was expected to begin sometime after January 2026, with its exact scope and timing left to be determined based on how Phase 1 went; some behavioral health services, particularly residential and opioid treatment, may still be carved out depending on where that rollout currently stands.
Carved in
Dental care is listed among the services covered by NJ FamilyCare's managed care plans. No single statewide dental administrator vendor was identified; dental appears to be handled as an in-plan benefit by each of the five managed care organizations rather than carved out to one dedicated vendor.
Pharmacy benefits are carved into each managed care plan rather than run through one statewide pharmacy benefit manager. Wellpoint's NJ FamilyCare pharmacy benefit, for example, is administered through CarelonRx. A 2021 industry-commissioned analysis evaluated carving pharmacy out of the managed care benefit package and estimated it would cost the state tens of millions of dollars annually; New Jersey has not adopted a carve-out, and pharmacy remains a plan-administered benefit.
Non-emergency medical transportation is covered as part of NJ FamilyCare and is administered through Modivcare, a national NEMT broker. CMS's own most recent managed care enrollment data reports Modivcare's NEMT figure at well over 1.5 million, a number that is almost certainly a count of trips or encounters rather than enrolled members, since New Jersey's total Medicaid population is nowhere near that size; it should not be read as a member count.
Gainwell Technologies serves as NJ FamilyCare's fiscal agent, operating the NJMMIS provider portal (njmmis.com) that handles provider enrollment, claims processing, remittance advice, and the state's rate and fee schedule publications.
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See them with ProAdvocates urged New Jersey Department of Human Services officials at a Monday budget listening session to increase state funding for mental health, substance abuse, housing, elder care, childcare, and disability services. The session is a preliminary step as the department prepares its next budget, which this year topped $37 billion with 56% from federal dollars, amid expected federal funding cuts that the department says could strip Medicaid benefits from up to 300,000 people and food aid from another 50,000. Mental health providers said they would need added state funding to meet demand from people losing Medicaid coverage, while elder, disability, childcare, and child welfare advocates each called for protecting or expanding existing funding. Gov. Mikie Sherrill will compile a statewide budget proposal for introduction in February, and lawmakers must finalize a plan she can sign by July 1.
New Jersey's Department of Human Services has sharply increased scrutiny of Medicaid billing by "vendor" organizations that run add-on programs, such as art, fitness, and social skills classes, for disabled adults, according to the New Jersey Monitor. Starting last summer, the state began denying payment requests for some programs that had been reimbursed for years, with operators told their rates were too high or their programs not inclusive enough of the general public. Paid claims for these goods-and-services programs rose from $10.4 million in 2020 to more than $54.2 million last year, prompting the closer review, state officials said. The department says there is no policy change, only stricter enforcement of existing rules to protect Medicaid compliance and federal funding amid increased federal scrutiny of Medicaid spending; families and program operators say the denials have already cut off services for some disabled adults.
Sources describe a New Jersey senior home care company facing scrutiny over roughly $950 million in Medicaid billing, with allegations that it hired unqualified aides, some described by sources as recruited off the street, to provide in-home personal care services. Families and workers quoted in the report raise concerns about inadequate vetting and training of caregivers billed to Medicaid. The report does not specify charges filed, an enforcement agency, or a timeline for resolution. If substantiated, the allegations point to potential fraud and quality-of-care failures in a Medicaid-funded home care program affecting vulnerable elderly beneficiaries.
The New Jersey Harm Reduction Coalition, joined by 50 treatment and advocacy organizations and 100 individuals, asked the state Department of Human Services on Tuesday to hold a public hearing on oversight of opioid settlement funds. The request follows reports that some local governments spent settlement money on community events, concerts, and police equipment rather than treatment or prevention services, and after state lawmakers diverted $45 million from the fund to hospital aid. New Jersey is set to collect $1.1 billion through 2038 from opioid lawsuit settlements, with half controlled by the state and the rest distributed to towns and counties; the state has spent more than $100 million on treatment, housing, and harm reduction services including naloxone distribution. The Department of Human Services did not comment on the request.
New Jersey Gov. Mikie Sherrill said Democrats must prioritize affordability and reversing President Trump's cuts to Medicaid, food assistance, and other public welfare programs, speaking to reporters in Princeton the day after Democrats won control of Congress in the midterms. Sherrill noted that federal Medicaid eligibility rules narrowed a month earlier, eliminating coverage for hundreds of thousands of people, and that other changes are expected to cost Medicare billions a year, both stemming from legislation Trump signed that is projected to total over $1 trillion in federal cuts over the next decade. She said Democratic leaders should also hold hearings to scrutinize the Trump administration's conduct. Sherrill's PAC, Mission to Deliver, backed Democratic candidates in the midterms, including Cape May Mayor Zack Mullock's upset win over Rep. Jeff Van Drew.
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