New Jersey

New Jersey FlagNew Updates (3/30/23)

Managed Long-Term Services and Supports On March 30, CMS approved New Jersey’s request to extend and amend its Medicaid 1115 demonstration entitled “New Jersey FamilyCare Comprehensive Demonstration.” The 1115 demonstration includes initiatives related to continuous eligibility, coverage expansion, and health-related social needs. The initiative also includes, among other elements, the extension of managed care to include LTSS and certain behavioral services, giving the state the flexibility to carve-in additional behavioral health services to managed care over time, which the state has indicated will take place gradually over the demonstration renewal period (April 1, 2023 – June 30, 2028).

Source: CMS Approval Letter; 3-30-2023)

Past Updates

Managed LTSS Program & State Initiative to Integrate Care for Dual Eligible Individuals

The New Jersey §1115 Comprehensive Medicaid Waiver seeks to provide State Plan benefits, as well as LTSS, to Medicaid and CHIP beneficiaries. The waiver combines authority for several existing Medicaid and CHIP waiver and demonstration programs, including:  two §1915(b) managed care waiver programs; a Title XIX Medicaid and a Title XXI CHIP §1115 demonstration waiver; and four §1915(c) HCBS waiver programs.  Phase 1 will include the non-dual population of aged, blind and disabled Medicaid beneficiaries; Community Care Waiver clients; clients already covered by a commercial or Medicare HMO; and breast or cervical cancer clients.  Phase 2 will include dual eligibles; an increased range of waiver clients; TBI clients; and persons participating in the AIDS Community Care Alternatives Program and Community Resources for People with Disabilities. (Source: Waiver Application)
Comprehensive Medicaid Waiver Website
Waiver Application (9/9/2011)
Approval Letter (10/2/2012)
Recommendations by workgroup

According to a state official, the state proposed to add nursing home and HCBS to Managed Care contracts for Medicaid-eligible individuals who meet a NF level of care. The state also worked with CMS on Special Terms and Conditions and Budget Neutrality. (Source: ADvancing States Membership Meeting, 9/9/2012)

In an October 2012 Press Release, the state announced CMS denied several of the state’s reform proposals within its §1115 Comprehensive Medicaid Waiver application, including:  the state’s request to no longer provide retroactive Medicaid eligibility for applicants; consolidation of all nine state waivers into one; and the state’s appeal for an estimated $107 million in Medicare Part B retro payment for Medicare services erroneously billed to Medicaid.  The federal government also determined that approval of future programmatic changes, as well as the Community Care Waiver, will remain outside the comprehensive waiver.  (Source: Press Release, New Jersey DHS, 10/4/2012)

On June 25, 2014, the state issued a public notice of its plan to request a State Plan Amendment from CMS to establish a Qualified Income Trust, known as a Miller Trust, for Medically Needy Individuals. This will allow individuals with monthly income above the state’s special income limit (SIL) to qualify for MLTSS, which includes nursing facility services. Income that exceeds the SIL would be transferred to the trust. The state must receive SPA approval from CMS before it can implement this feature of its §1115 Comprehensive Medicaid Waiver. The state is accepting comments in response to the public notice through July 30, 2014. (Source: State Public Legal Notice, 6/25/2014; HMA Weekly Roundup, 7/2/2014)

On July 1, 2014, the state implemented its §1115 Comprehensive Medicaid Waiver by launching its Medicaid MLTSS program. Effective July 1, 2014, MLTSS includes: personal care; respite; care management; home and vehicle modifications; home delivered meals; personal emergency response systems; mental health and addiction services; assisted living; community residential services; and nursing home care. Participants in the following Medicaid waiver programs will be automatically enrolled into MLTSS through their current MCO: Global Options for LTC; AIDS Community Care Alternatives Program; Community Resources for People with Disabilities; and TBI Waiver. (Source: State MLTSS website, 7/2/2014)

Any individuals with Medicaid entering a nursing home for the first time will have their acute and primary health care managed by the NJ FamilyCare MCOs with MLTSS or the PACE program. Individuals on MLTSS also will have their acute and primary health care services and nursing home care managed by a NJ FamilyCare MCO. Current custodial nursing home residents on Medicaid will remain in a fee-for-service environment. Medicaid beneficiaries living in SCNF as of July 1, 2014 will remain in the fee-for-service environment for two years. Any individual who is newly eligible for Medicaid and living in a nursing home after July 1, 2014 will have their care managed by a NJ FamilyCare MCO through the MLTSS program. Individuals who enter a SCNF after July 1, 2014 will have their acute and primary health care services and their nursing home care managed by a NJ FamilyCare MCO through the MLTSS program. (Source: State MLTSS website, 7/2/2014)

In July 2014, the state notified Medicaid waiver service providers that Medicaid Fee-for-Service will pay for MLTSS for any Medicaid-eligible individuals requiring waiver services during the transition to the effective date of their MCO membership.  (Source: HMA Weekly Roundup, 7/9/2014)  

On October 6, 2014, New Jersey DoAS provided an update to the Medical Assistance Advisory Council about the state’s transition to MLTSS since its July 1, 2014 launch.  As of October 6:  11,138 1915(c) waiver participants had been transferred from over one hundred community-based care management agencies to four MCOs.  (Source:  New Jersey DMAHS website
DMAHS Presentation (10/6/2014)

Also on October 6, 2014, New Jersey DMAHS provided the Medical Assistance Advisory Council with an update on the draft personal care assistant (PCA) assessment tool beta test.  DMAHS plans to release the final PCA assessment tool in February 2015 for use by its four MCOs as a common assessment tool.  (Source:  New Jersey DMAHS website; HMA Weekly Roundup, 10/8/2014)
DMAHS Presentation (10/6/2014)

New Jersey DMAHS has published a MLTSS Service Dictionary on its website.  The MLTSS Service Dictionary names every service available to individuals who meet the clinical, functional and financial eligibility requirements for nursing facility level of care, and therefore qualify for MLTSS.  The publication also lists the service limitations; provider specifications; billing codes; HIPAA compliant codes; units of service; licensing entities; accrediting entities; regulation cites; and taxonomy codes for each MLTSS service.  (Source:  HMA Weekly Roundup, 10/29/2014)
New Jersey MLTSS Service Dictionary

New Jersey DMAHS has provided a Qualified Income Trust (QIT) template on its website for people to use to establish income eligibility for MLTSS.  The state is currently seeking a State Plan Amendment from CMS for use of trust devices in home-based settings, nursing facilities, and assisted living facilities. (Source: DMAHS QIT website; HMA Weekly Roundup, 10/8/2014)
QIT Template

The New Jersey Department of Human Services, Division of Medical Assistance and Health Services (DMAHS) has uploaded a copy of the July 1, 2014 Medicaid Managed Care Contract to its website, which incorporates the contract provisions for the state’s MLTSS program.  (Source:  HMA Weekly Roundup, 11/5/2014) 
Managed Care Contract (7/1/2014)

On December 1, 2014, the state enacted a §1115 Comprehensive Medicaid Waiver amendment to establish Qualified Income Trusts for Medically Needy Individuals.  This change allows individuals with a monthly income above the state’s special income limit (SIL) to qualify for MLTSS by transferring any income that exceeds the SIL to a trust; this offers an alternative for individuals who can’t afford their medical costs but earn too much to qualify for full Medicaid assistance.  (Source: News, 11/30/2014; State Public Legal Notice, 6/25/2014)

On December 15, 2014, the New Jersey Division of Developmental Disabilities (DDD) presented a webinar overview of its Supports Program and proposed program amendments.  The Division is requesting stakeholder input through January 7, 2015; the Division is planning to submit the Supports Program amendments to CMS in January 2015 and implement the Supports Program in July 2015.  The Supports Program is a Medicaid program that will provide HCBS for New Jersey adults with intellectual and developmental disabilities who do not meet the Community Care Waiver Level of Care through MCOs.  (Source:  New Jersey DDD Supports Program website, 12/2014) 
Stakeholder Input into Supports Program Amendments:  Slide Presentation  

On May 5, 2015, New Jersey Acting DHS Commissioner, Elizabeth Connolly, testified before the Senate Budget and Appropriations Committee that an estimated 21,000 New Jersey residents will receive managed LTSS in 2016, a 64 percent increase from 2015 enrollment. (Source:, 5/5/2015)

On June 15, 2015, Deputy Commissioner Lowell Arye provided an update on New Jersey’s MLTSS program. As of spring 2015, roughly 39,000 New Jersey residents receive Medicaid long-term care: 14,460 are enrolled in MLTSS; and the remaining 25,449 remain under Medicaid fee-for-service.  From August 2014 to June 2015, the state’s MLTSS population has grown from 11,229 to 14,460. (Source:  New Jersey DHS website, 6/15/2015)
Behavioral Health Update Presentation (6/15/2015)

On July 10, 2015, the NJ Spotlight noted that the New Jersey legislature and Governor Christie agreed to supply $10 million in state and matching federal funds to the states managed long-term services and supports (MLTSS) program that will be directed toward nursing home facilities. This comes out to a reimbursement increase of approximately $1 per patient per day. The funds were allocated due to an increased focus on HCBS versus institutional services that has heavily impacted nursing facilities, pressure from labor groups, and support for nursing facilities in the state legislature. (NJ Spotlight, 7/10/2015)    

A new report from the Rutgers Center for State Health Policy, Initial Stakeholder Feedback on Implementation of the Managed Care Expansion in Long-Term Services and Supports, offers a first-look at the transition of New Jersey’s long-term services and supports program into managed care (MLTSS). The report brings together 13 broad themes, and also notes that home and community-based service (HCBS) use went up by 4 percent, and institutional-based care shrank by approximately 1,500 persons. (Source: HMA Roundup 10/7/2015; Report)

On October 19, 2015, the Director of New Jersey’s Division of Aging Services updated the Medical Assistance Advisory Council (MAAC) on the states’ MLTSS enrollment numbers. Currently, approximately 42,000 are receiving long-term services and supports in NJ, 43 percent of which are enrolled in managed care. Since implementation of MLTSS, the states’ nursing home population has fallen by 2,800, and individuals receiving HCBS has increased by over 2,700. (Source: HMA Roundup 10/28/2015)
The New Jersey Department of Human Services, Division of Medical Assistance and Health Services (DMAHS) released a notice to providers and MCOs of a new policy change that will provide LTSS to beneficiaries who are eligible for NJFamilyCare’s Alternative Benefit Plan (ABP). The affected population is the newly eligible individuals under the state’s Medicaid expansion, or those between the ages of 19 and 64 that are childless, and have incomes up to 133 percent of the Federal Poverty Level (FPL). The change is effective as of July 1, 2015. (SourceDMAHS, link no longer available 12/2015;  HMA Roundup 12/2/2015)

The New Jersey Hospital Association recently released a report on the impacts of nursing homes in the state. Highlights include expenditures of $5.4 billion, employing over 55,000 people, as well as $116 million in state taxes and payout out $2.1 billion in salaries. The report recognizes that the state is working to reduce institutional care through its Medicaid managed LTSS program, but asserts that nursing home capacity will remain important as the senior population continues to increse. (Source: NJHA Report 2/17/2016; HMA Weekly Roundup 2/24/2016)

On January 20, 2016, former Deputy Commissioner Lowell Arye provided the Medical Assistance Advisory Council an updated picture of the state's MLTSS program. Currently, NJ has over 43,000 long term care recipients, approximatey 48 percent of which are in managed care and 51 percent are in Medicaid FFS. (Source: HMA Weekly Roundup 1/20/2016)

At a recent meeting of the New Jersey Medical Assistance Advisory Council, Stuart Dubin from the Division of Medical Assistance and Health Services (DMAHS) informed attendees that as of February 2016, the percentage of MLTSS program beneficiaries receiving HCBS has reached 37.5 percent, an increase of over 7 percent from the program’s start in 2014. Over 46,000 Medicaid members are receiving LTSS according to February 2016 numbers, 52 percent of which are enrolled under MLTSS.  (Source: HMA Weekly Roundup 4/27/2016)  

On June 10, 2016, the New Jersey Division of Medical Assistance and Health Services (DMAHS) submitted a renewal application for the state’s comprehensive 1115 waiver demonstration, which is set to expire on June 30, 2017. The renewal application aims to build on the prior demonstrations’ emphasis on integration across the continuum of care, including LTSS; advancing Managed Long Term Services and Supports (MLTSS) as well as its emphasis on increased access to HCBS, and; delivery system reform through the state’s DSRIP.

Two central components of the waiver renewal include continued modernization of the state’s MLTSS program, as well as integrating cate for dual eligible individuals. New Jersey is one of a limited number of states that require all Dual-Eligible Special Needs Plans (D-SNPs) to achieve Fully Integrated Dual Eligible (FIDE) status in order to serve dually eligible beneficiaries. New Jersey is requesting the following changes in its renewal application:

  • The ability to mandate the states FIDE-SNP plans to automatically convert individuals into FIDE-SNP plans when they become eligible for Medicare and are already eligible for Medicaid.
  • The ability to auto-assign dual eligibles into a FIDE-SNP plan that is aligned with the beneficiary’s Medicare plan selection.

The public comment period on the renewal application was open from June 10 to July 10, 2016. (Source: NJ FamilyCare 1115 Waiver Application 6/10/2016)

According to the HMA Weekly Roundup, the most recent numbers indicate that New Jersey’s MLTSS program has 25,750 enrollees, 66 percent of whom are receiving HCBS services. (Source: HMA Weekly Roundup 6/22/2016) 

On November 18, 2016, the New Jersey Division of Medical Assistance and Health Services (DMAHS) submitted a letter to CMS to request an amendment to the Special Terms and Conditions (STCs) of the state’s section 1115 waiver, which is the operating authority for New Jersey’s MLTSS program. The amendment, which totals three pages, would allow the state to clarify enrollment and level of care (LOC) requirements for adults and children that may be eligible for MLTSS. The federal comment period for the amendment runs from December 1, 2016, through January 2, 2017. (Source: Waiver Application 11/18/2016)  
On July 27, 2017, CMS notified the New Jersey Department of Human Services that they have received approval for the renewal of the state’s section 1115(a) demonstration, NJ FamilyCare Comprehensive Demonstration, which includes MLTSS. NJ FamilyCare is extended through June 30, 2022. New Jersey aims to continue to enhance the current demonstration programs, including increasing access for HCBS LTSS; simplifying eligibility for LTSS; and overhauling the behavioral health system. New Jersey also has updated the state’s level of care requirements for children eligible for MLTSS. Finally, CMS approved a three-year renewal of New Jersey’s Delivery System Reform Incentive Payment (DSRIP) program. DSRIP will continue until June 30, 2020, at which point CMS will continue to work with the state to transition to a different payment structure. (Source: NJ Approval Letter 7/27/2017)
On October 19, 2017, the director of the Division of Aging Services provided an update on Medicaid LTSS in New Jersey. As of August 2017, New Jersey has 52,344 Medicaid beneficiaries receiving LTSS. Of these, 37,586 individuals are enrolled in MLTSS, and that population breaks down by setting as follows:
  • 20,328 individuals receiving HCBS;
  • 3,067 individuals in assisted living; and 
  • 13,928 individuals in nusring facilities (NF). 

New Jersey has experienced success with rebalancing the state’s LTSS away from institutions and towards more community-based care. In 2014, at the start of New Jersey’s MLTSS program, 27 percent of LTSS spending was on HCBS. In 2017, however, the state now spends 45 percent on HCBS. In a report published by ADvancing States in May 2017, rebalancing LTSS systems was cited as a key goal for states that choose to implement an MLTSS program. (Source: NJ Slidedeck 10/19/2017; HMA Weekly Roundup 10/25/2017) 

The New Jersey Department of Human Services has expanded the list of covered health benefits to certain individuals enrolled in Medicaid managed care in the state. The move aims to align behavioral health coverage for New Jersey Medicaid beneficiaries enrolled in MLTSS, Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs), and Division of Developmentally Disabled (DDD) MCO members. New Jersey is also expanding access to substance use disorder (SUD) services for individuals enrolled in MLTSS, FIDE SNPs, and DDD managed care. (Source: NJ DHS 11/2017)

The New Jersey Department of Human Services has posted the state’s newest version of its Medicaid MCO contract, which includes changes in the following broad buckets: provider networks; pharmacy; MLTSS; quality; finance; and other. A few of the changes to the MLTSS components of the contract include the addition of six new performance measures, and a new demonstration program that will provide incentives to high-performing MLTSS plans serving beneficiaries in the community. The contract is effective as of July 1, 2017, but the changes were recently approved by CMS. (Source: MCO Contract 7/2017; HMA Weekly Roundup 1/10/2018)

The New Jersey Division of Aging Services and Division of Medical Assistance & Health Services have announced an updated framework for the state’s quality improvement program for nursing facilities serving MLTSS members in the state’s NJ Family Care MLTSS program. Currently, all nursing facilities (NF) are included in all MCO networks under an ‘any willing provider’ requirement.  The state is proposing a modified any willing and qualified provider (AWQP) program that will identify NFs that are performing well on 5 state-set benchmark measures (pulled from Minimum Data Set data).  By January, 2019, NFs will be identified as an AWQP provider, which is intended to lead to quality-based contracting between the MCOs and the NFs.  NFs that are not designated as an AWQP provider may have residents relocate to another NF; cease getting new MLTSS long-term care admissions; or have contracts terminated by MCOs.  (Source: AWQP Site 3/5/2018;  Provider FAQs 2/2018) 

According to December 2017 figures, New Jersey currently has 40,500 beneficiaries enrolled in MLTSS. MLTSS enrollment by setting is: 

  • 21, 604 – HCBS; 
  • 3,094 – assisted living;
  • 15, 522 – nursing facility; 
  • 280 – specialty care nursing facility. 

(Source: HMA Weekly Roundup 2/14/2018)

The New Jersey Department of Human Services (DHS) released a proposed amendment to its Section 1115 Comprehensive Demonstration Waiver. The state intends to:

  • Pilot a new, expedited financial eligibility determination for individuals looking for LTSS that are under guardianship of the New Jersey State Office of the Public Guardian; and
  • Include a one-time allowance for pantry stocking and clothing to the state’s community transition benefit in its MLTSS program. (Source: Legal Notice)

Enrollment in New Jersey’s MLTSS program, as of February 2018, is 41,860. In terms of spending, nursing facilities are the costliest expenditure under MLTSS, equaling $1.7 billion in state fiscal year 2017. PCA/home-based supports was the second highest area of expenditure, at $222 million. (Source: HMA Weekly Roundup 4/18/2018)

In June 2018, the New Jersey legislature introduced Senate Bill 2761 to require home health and health care service providers to develop a plan of care for patients that includes coordinating services, collaborating with hospitals, and educating patients and families on care plans. This bill creates an incentive-based value payment (VBP) system that measures and rewards performance outcomes for Fully Integrated Dual Eligible Special Needs enrollees. Medicaid managed care organizations would administer the program by distributing incentive payments to providers. If the bill is passed, the governor will appoint eight new members, representing nursing, personal care assistants, hospice, home care administration, managed care organizations, and other organizations, to a Department of Human Services advisory board to develop regulations. (Sources: HMA Weekly Roundup, 6-27-2018; NJ Senate Bill 2761, 6-21-2018)

New Jersey’s Department of Human Services, released January 2018 amendments to its Medicaid MCO contract. The changes from the July 2017 version include: caregiver definitions, transportation services descriptions, clarification of mental health and substance abuse disorder benefits, HEDIS and MCO Drug Utilization Review reporting requirements, and MLTSS Capitation Rates updates. (Source: HMA Weekly Roundup, 6-27-2018; NJ Contract, July 2018)

The New Jersey Department of Human Services announced the launch of the Office of Medicaid Innovation. The office will focus on improving the quality, delivery, and cost of care for the state’s Medicaid program. One of the priorities for the new office is finding innovative approaches to the Medicare and Medicaid dual-eligible population.

The New Jersey Department of Human Services released the updated Medicaid managed care organization contract. HMA compared the new contract to the previous version and provides highlights from these amendments below.

  • Behavioral Health benefit alignment: Behavioral health benefits are now aligned across the populations who receive BH benefits from their MCO. This applies to members with developmental disabilities under the Division of Developmental Disabilities, members who qualify for MLTSS and members enrolled with a FIDE SNP
  • Any Willing Providers (AWP) Extends the AWP status of nursing facilities, special care nursing facilities, assisted living providers and community residential service providers by one more year (until June 30, 2019).
  • Care management compliance: Revises compliance measurement standards for MLTSS category measures
  • MLTSS Service Initiation: Revises the requirement for beginning MLTSS services from within 30 calendar days of enrollment to within 45 calendar days of enrollment

(Source: NJ Office of Medicaid Innovation, 2-6-2019); HMA Weekly Roundup, 2-27-2019)

New Jersey Medicaid released the 2018 results of their Consumer Assessment of Healthcare Providers and Systems (CAHPS) for the state’s managed care plans. Results for the Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) Program are broken down by participant’s satisfaction with the care they receive, the overall health plan, their personal doctor, and their specialists. United Health Care Dual Complete One scored highest in the health plan (90 percent satisfaction) and personal doctor (93 percent satisfaction) rankings. Amerivantage earned the highest satisfaction score for the health care category (86 percent). Amerivantage and Wellcare FIDE SNP both received 91 percent satisfaction scores from participants in the specialists category. (Source: NJ Family Care CAHPS Results, 3-27-2019)

Managed LTSS Program

The New Jersey Department of Human Services Division of Medical Assistance and Health Services (DMAHS) released the “Core Medicaid and MLTSS Quality Technical Report”. The report contains the results of quality review activities and assessments for MLTSS services and core Medicaid services provided by MCOs during January 2018 to December 2018 and an evaluation of MLTSS Performance Measures. The report includes an audit of the MLTSS HCBS Care Management program’s effectiveness, and in particular, Performance Measure #13, a care management record review that evaluated the delivery of MLTSS services compared with services listed in members’ plan of care (POC). The overall compliance rate across all MCOs was 32.4 percent, based off the average service delivery percentage for all weeks or months for each service.

(Source: Medicaid and MLTSS Quality Report 2018; 6-2019)

The New Jersey Division of Medical Assistance and Health Services (DMAHS) will transition coverage of long-term residential services for substance use disorder treatment from fee-for-service to managed care. Individuals who are eligible for managed long-term services and supports or are enrolled in FIDE-SNPs will have these services carved into managed care beginning October 1, 2019.

(Source: HMA Weekly Roundup; 9-4-2019)


Balancing Incentive Program

In March 2013, CMS approved New Jersey’s Balancing Incentive Program Application. The BIP program is funded through September 30, 2015. (Source: CMS website; New Jersey DHS website)
BIP Application, link no longer available (12/20/2012)
Structural Change Work Plan, link no longer available (1/16/2014)


Health Homes

CMS has approved the state’s Heath Home Planning Request. (Source: CMS State Health Home Proposal Status website, 6/2014)

On July 30, 2014, the state issued a public notice inviting public comment on a Medicaid state plan amendment to implement Health Homes in Mercer County for adults with SMI who are at risk for high utilization of medical and behavioral health care services; and to children, adolescents and young adults with SED and a chronic medical condition. (Source: State DHS website)
Public Notice (7/20/2014)

On March 9, 2015, the state issued a Request for Letters of Interest (RLI) to participate in a Behavioral Health Home Learning Community (BHH-LC).  The BHH-LC will be facilitated by the National Council for Behavioral Healthcare to build behavioral health home capacity in Monmouth, Cape May, and Atlantic Counties.  BHH-LC participants will develop BHH implementation plans; upon approval by the DHS Division of Mental Health and Addiction Services, participants will become eligible to provide BHH services and apply for state startup funds.  (Source:  State DHS website; HMA Weekly Roundup, 3/25/2015)
Request for Letters of Interest to Participate in BHH-LC (3/9/2015)

On March 12, 2015, CMS approved two Health Home State Plan Amendments (both effective July 1, 2014) for the state to implement Behavioral Health Homes in Bergen County for adults with one or more serious and persistent mental illness (SMI) conditions who are high utilizers or at risk of high utilization; and children (under the age of 21) with SED, co-occurring DD/MI, co-occurring MH/SA, or determined DD eligible.  (Source:
Approved State Plan Amendment (Effective 7/1/2014)
Approved State Plan Amendment (Effective 7/1/2014)

On April 8, 2016, the Cape May County Herald reported that New Jersey is set to expand its behavioral health home model, which treats physical and mental health, as well as substance use disorders, with integrated, coordinated care. There are currently four behavioral health homes statewide, with seven organizations pursuing certification. New Jersey’s behavioral health home model began in 2014 with the state’s Comprehensive Medicaid Waiver. The state intends to raise reimbursement rates and increase access for substance use and behavioral health, which will channel an additional $127 million to providers. (Source: Cape May County Herald 4/8/2016)