The state of New Jersey administers its public health insurance program, known as Medicaid, under the official name NJ FamilyCare. This program provides comprehensive medical coverage to qualifying low-income individuals and families. Unlike traditional fee-for-service Medicaid, NJ FamilyCare operates through contracts with private health insurers, called Managed Care Organizations (MCOs). Choosing the “best” plan means selecting the MCO that most closely aligns with an individual’s specific health needs and geographic location. These MCOs receive a fixed payment per member to manage and coordinate all covered medical services.
Determining Eligibility for NJ FamilyCare
Before selecting a plan, prospective members must first establish eligibility for NJ FamilyCare. Eligibility is based on residency, citizenship status, and financial criteria, grouped into different coverage categories. Applicants must be New Jersey residents and either U.S. citizens or qualified immigrants, though children under age 19 can qualify regardless of immigration status.
For most adults, children, and pregnant women, financial eligibility uses the Modified Adjusted Gross Income (MAGI) method. This formula counts income and household size based on federal tax rules and compares the result to the Federal Poverty Level (FPL) guidelines. For instance, an adult aged 19–64 can qualify with income up to 138% of the FPL, while children have limits up to 355% of the FPL.
Different rules apply to the Aged, Blind, and Disabled (ABD) population and those requiring Managed Long Term Services and Supports (MLTSS). Eligibility for these groups does not use MAGI methodology; instead, it considers both income and resources (assets), which are not counted for MAGI-based eligibility. Applicants should refer to the official New Jersey Department of Human Services guidelines for the most current financial standards.
Managed Care Organizations Available in New Jersey
New Jersey currently contracts with five private companies to serve as Managed Care Organizations for the NJ FamilyCare program. These MCOs administer health benefits and coordinate all medical care for enrolled members. While the core benefits offered by all MCOs are mandated by the state, the specific provider network and any additional non-standard benefits can differ significantly.
The five major health plans are:
- Aetna Better Health of New Jersey
- Fidelis Care (formerly Wellcare)
- Horizon NJ Health
- UnitedHealthcare Community Plan
- Wellpoint (formerly Amerigroup)
The availability of certain MCOs or specific plan types, such as those for MLTSS, may vary depending on the member’s county of residence or eligibility track.
Key Factors for Comparing Plan Performance
The most important factor in selecting an MCO is the composition and accessibility of its Provider Network. This network includes primary care physicians, specialists, hospitals, and pharmacies. A plan is practical only if a member’s current or desired doctors are enrolled as in-network providers, which prevents unexpected costs and ensures continuity of care. Individuals should confirm participation using the MCO’s online provider directory or by calling the provider’s office directly.
Standardized Quality Ratings are used to assess MCO performance in delivering care and ensuring patient satisfaction. The state monitors MCOs using data compiled by organizations like the National Committee for Quality Assurance (NCQA).
Quality Indicators
Key quality indicators include Healthcare Effectiveness Data and Information Set (HEDIS) scores, which measure how often MCOs deliver preventive and appropriate care, such as immunizations or screenings. Patient satisfaction is gauged using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, which collect member feedback on their experience. These quality reports are often publicly available, allowing comparison beyond simple network size.
MCOs often provide Value-Added Benefits to attract and retain members. These supplementary services go beyond federally and state-mandated Medicaid benefits. Examples include transportation assistance to medical appointments, specific dental and vision services beyond the minimum, or health education programs. Evaluating these additional perks based on personal needs can differentiate one MCO from another. Users should review each MCO’s specific offerings, as these extras are not uniform across all plans.
Enrollment, Switching, and Renewal Process
The process of enrolling in an MCO begins once an individual is determined eligible for NJ FamilyCare. After approval, the member must select one of the contracted MCOs to coordinate their care. If a choice is not made within the specified timeframe, the state will automatically assign an available MCO.
Members have the right to change their MCO during certain periods. They can switch plans without providing a reason within the first 90 days following initial enrollment. After this period, members can switch MCOs during the annual open enrollment period.
Switching Plans
Swapping plans outside of open enrollment is possible under a “good cause” exception. Valid reasons include a necessary provider leaving the network, the MCO failing to provide contracted services, or a lack of access to a specific specialist. Members can contact a Health Benefits Coordinator through the NJ FamilyCare helpline for assistance or to request a switch.
Maintaining coverage requires actively participating in the Redetermination process, which verifies continued eligibility. NJ FamilyCare members must renew their coverage once a year. The state sends a renewal packet through the mail, and members must complete and return the forms by the deadline to avoid a gap in coverage.