New Jersey

Updated on October 12, 2023

This data is meant to be used for educational purposes to inform providers, patients, insurers, and state Medicaid agencies what genetic services may or may not be written into each state’s Medicaid policy. The database is not meant to indicate or imply whether a certain program will cover a specific service, since many decisions are made on a case by case basis. If you have specific questions about whether a service is covered, you should reach out to your plan administrator. Please see this disclaimer below for more information.

Medicaid Coverage Information Published

Yes

State Contact Information

Jennifer Langer Jacobs
Assistant Commissioner
Division of Medical Assistance and Health Services
New Jersey Department of Human Services
PO Box 712
Trenton, NJ 08625-0712
Phone: (609) 588-2600

https://medicaiddirectors.org/wp-content/uploads/2023/06/Public_DirectorsList_June2023-1.pdf

General Genetic Testing Criteria

Genetic Testing Not Covered

State Specific Definition

Genetic Services for Children

Genetic Counseling Requirement

New Jersey Code 45:9-37.117 Licensure required for genetic counselors; exceptions.

Except as provided in this section, a person shall not engage in the practice of genetic counseling as a genetic counselor, or hold himself out as a genetic counselor unless the person is licensed in accordance with this act.

Metabolic Formula Coverage Legislation

New Jersey Statute Section 17:48E-35.16

Metabolic Formula Coverage & Criteria

No group or individual health service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the contract provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person’s physician.

For the purposes of this section, “inherited metabolic disease” means a disease caused by an inherited abnormality of body chemistry for which testing is mandated pursuant to P.L. 1977, c.321 (C.26:2-110 et seq.); “low protein modified food product” means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and “medical food” means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician.

The benefits shall be provided to the same extent as for any other medical condition under the contract.

The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium.

Prior Authorization Requirements

All orders for clinical laboratory services shall be in the form of an explicit order personall signed by the physician or other licensed practitioner requesting the services, or be in analternative form of order specifically authorized in (b)1 through 3 below. The written order shall contain the specific clinical laboratory test(s) requested, shall be on file with the billing laboratory and shall be available for review by Medicaid/NJ FamilyCare representatives upon request.
If a signed order is not utilized, then clinical laboratory services shall be ordered in one of the following ways:
1. In the absence of a written order, the patient’s chart or medical record may be used as the test requisition or authorization, but must be physically present at the laboratory at the time of testing and available to Federal or State representatives upon request;
2. A test request also may be submitted to the laboratory electronically, if the system used to generate and transmit the electronic order has adequate security and system safeguards to prevent and detect fraud and abuse and to protect patient confidentiality. The system shall be designed to prevent and detect unauthorized access and modification or manipulation of records, and shall include, at a minimum, electronic encryption; or
3. Telephoned or other oral laboratory orders are also permissible, but shall be followed up with a written or electronic request within 30 days of the telephone or other oral request, which shall be maintained on file with the clinical laboratory. If the laboratory is unable to obtain the written or electronic request, it must maintain documentation of its efforts to obtain them.