Behavioral Health Benefits Grid
Horizon NJ Health covers a number of behavioral health benefits. Behavioral health includes both mental health services and Substance Use Disorder treatment services. Some services are covered by Horizon NJ Health, while others are paid for directly by Medicaid Fee-for-Service (FFS). You will find details in the chart below.
Certain services require authorizations and are noted below. To request authorizations, please use the Utilization Management Request Tool securely online through Navinet®.
Mental Health
| Service/Benefit | Members in DDD, MLTSS, or FIDE SNP | NJ FamilyCare Plan A/ABP | NJ FamilyCare Plan B | NJ FamilyCare Plan C | NJ FamilyCare Plan D |
Adult Mental Health Rehabilitation (Supervised Group Homes and Apartments) |
Covered. Authorization required. |
Covered by FFS. |
Not covered. |
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Inpatient Psychiatric |
Covered. Coverage includes services in a general hospital, psychiatric unit of an acute care hospital, Short Term Care Facility (STCF) or critical access hospital. Authorization required. |
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Independent Practitioner Network or IPN (Psychiatrist, Psychologist or APN) |
Covered. Only the services outlined below require authorization:
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Covered by FFS. |
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Outpatient Mental Health |
Covered. Only the services outlined below require authorization:
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Covered by FFS. Coverage includes services received in a General Hospital Outpatient setting, Mental Health Outpatient Clinic/Hospital services, and outpatient services received in a Private Psychiatric Hospital. Services in these settings are covered for members of all ages. |
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Autism Services |
Covered by Horizon NJ Health and FFS. Only covered for members under 21 years of age with Autism Spectrum Disorder. Covered services include Applied Behavioral Analysis (ABA) treatment, augmentative and alternative communication services and devices, Sensory Integration (SI) services, allied health services (physical therapy, occupational therapy and speech therapy), and Developmental Relationship based services including but not limited to DIR, DIR Floortime and the Greenspan approach therapy. Authorization required. |
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Partial Care (Mental Health) |
Covered. Authorization required. |
Covered by FFS. Limited to 25 hours per week (5 hours per day, 5 days per week). Prior authorization required. |
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Acute Partial Hospitalization Mental Health/Psychiatric Partial Hospitalization |
Covered. Authorization required. |
Covered by FFS. Admission is only through a psychiatric emergency screening center or post psychiatric inpatient discharge. Prior authorization required for Acute Partial Hospitalization. |
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Psychiatric Emergency Services (PES)/Affiliated Emergency Services (AES) |
Covered by FFS. |
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Substance Use Disorder Treatment
The American Society of Addiction Medicine (ASAM) provides guidelines that are used to help determine what kind of substance use disorder (SUD) treatment is appropriate for a person who needs SUD services. Some of the services in this chart show the ASAM level associated with them (which includes “ASAM” followed by a number).
| Service/Benefit | Members in DDD, MLTSS, or FIDE SNP | NJ FamilyCare Plan A/ABP | NJ FamilyCare Plan B | NJ FamilyCare Plan C | NJ FamilyCare Plan D |
Ambulatory Withdrawal Management with Extended On-Site Monitoring/ Ambulatory Detoxification ASAM 2 – WM |
Covered. Authorization not required. |
Covered by FFS. |
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Care Management Services |
Covered Authorization not required |
Covered by FFS. |
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Inpatient Medical Detox/Medically Managed Inpatient Withdrawal Management (Hospital-based) ASAM 4 - WM |
Covered. Authorization required. |
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Long Term Residential (LTR) ASAM 3.1 |
Covered. Authorization required. |
Covered by FFS. |
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Non-Medical Detoxification/ Non-Hospital-Based Withdrawal Management ASAM 3.7 – WM |
Covered. Authorization required. |
Please call 1-800-682-9094 for additional information. |
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Office-Based Addiction Treatment (OBAT) |
Covered. Covers coordination of patient services on an as-needed basis to create and maintain a comprehensive and individualized SUD plan of care and to make referrals to community support programs as needed. Authorization not required. |
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Opioid Treatment Services |
Covered. Authorization not required. |
Covered by FFS. Includes coverage for Methadone Medication Assisted Treatment (MAT) and Non-Methadone Medication Assisted Treatment. Coverage for Non-Methadone Medication Assisted Treatment includes (but is not limited to) FDA-approved opioid agonist and antagonist treatment medications and the dispensing and administration of such medications; substance use disorder counseling; individual and group therapy; and toxicology testing. |
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Peer Recovery Support Services |
Covered. Authorization not required. |
Covered by FFS. Includes coverage for Methadone Medication Assisted Treatment (MAT) and Non-Methadone Medication Assisted Treatment. Coverage for Non-Methadone Medication Assisted Treatment includes (but is not limited to) FDA-approved opioid agonist and antagonist treatment medications and the dispensing and administration of such medications; substance use disorder counseling; individual and group therapy; and toxicology testing. |
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Substance Use Disorder Intensive Outpatient (IOP) ASAM 2.1 |
Covered. Authorization required. |
Covered by FFS. | |||
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Substance Use Disorder Outpatient (OP) ASAM 1 |
Covered. Authorization not required. |
Covered by FFS. |
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Substance Use Disorder Partial Care (PC) ASAM 2.5 |
Covered. Authorization required. |
Covered by FFS |
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Substance Use Disorder Short Term Residential (STR) ASAM 3.7 |
Covered Authorization required |
Covered by FFS |
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