DIR® Services for Children Diagnosed with Autism Spectrum Disorder
DIR is now covered, in New Jersey, for people with Medicaid through NJFamilyCare Medicaid health insurance.
We are of course very excited about this! In an attempt to make these services accessible we would like to support you in the process. Below you will find answers to frequently asked questions with the intent to support families and practitioners through the process of providing and/or receiving these services.
What this Means for New Jersey Families Covered by Medicaid
The New Jersey Department of Health has recognized the value of developmental services for children with Autism Spectrum Disorder. Until now, coverage for developmental interventions, including the Developmental, Individual-Difference, Relationship-based Model (DIR), has only been accessible to a limited number of families. These services are now available through Medicaid and so is the possibility they could provide a life-improving change to families across the state of New Jersey.
DIR and other developmental interventions will now be covered by New Jersey’s Medicaid program, NJFamilyCare. This program is administered by five private Managed Care Organizations (MCOs).
- Aetna
- Amerigroup
- Horizon
- United Healthcare
- WellCare
Below are frequently asked questions from providers and families. Click on the + to the left of each question for the answers.
FAQs for Providers
Why should I consider becoming a DIR provider?
This is an opportunity to serve more children and families who may not have previously been able to access DIRFloortime® services.
Success in Medicaid will provide health insurers much-needed data to evaluate DIR, which, if successful, will pave the road for additional insurance coverage in New Jersey regardless of income level.
Success in New Jersey should lead other states to follow and expand access to DIR across the country.
Who can become a Qualified Healthcare Provider?
A Qualified Healthcare Provider (QHP) is a Profectum Certificate Level 2 (CL2) Course certificate holder and has a license in his or her field (e.g., education, mental health, occupational therapy, physical therapy, speech-language pathology, creative arts).
Profectum and ICDL certificate holders will be qualified to provide services through these MCOs. All licensed professionals with CL2 certificates will be qualified to provide direct intervention.
Profectum is currently in the process of developing an expedited process for non-certificate holders and CL1 certificate holders to achieve a CL2 in order to participate in NJFamilyCare Medicaid. We will share more details as they are finalized.
All Profectum Certificate Level 1 (CL1) providers are qualified to work independently with families and children in homes, clinics, and schools. They are qualified to coach parents and other professionals in person or through teletherapy. CL2 Providers are also qualified to provide introductory level training in the DIR-FCD Model to other providers and supervise paraprofessionals, (Developmental Floortime Players), CL1, and CL1Ed providers.
What if I do not hold an official DIR certification but am interested in becoming a provider?
Unfortunately, you cannot provide DIR services through the Medicaid program without a DIR certificate. However, if you are interested in becoming a provider Profectum has programs starting to support you in the certification process.
What are the opportunities beyond direct treatment?
Summary of Approved CPT Codes
- 96158EP-96159EP: Behavior treatment …administered by or under the direction of QHP
- 96164EP-96165EP: Group sessions 2-8 individual patients (parent workshops or training can be done simultaneously)
- 96167EP-96168EP: Parent(s) and child sessions
- 96170EP-96171EP: Parent(s) without child present
Settings
- Office
- Clinic
- Community
- Home
How do I contact the Managed Care Organizations (MCOs)?
NJ FamilyCare Autism Benefit Points of Contact for Providers
| I/DD and Special Needs (Non I/DD) Youth | |
| NJ FamilyCare/Medicaid | Shanique McGowan
609-433-0264 |
| Aetna | Sally O’Brien, Director of Behavioral Health
609-282-8232 o’briens@aetna.com |
| Amerigroup | Contracting
Lynda Grajeda 732 623-5801 Clinical Ann Basil 732-623-5835 For Authorization 800-454-3730 |
| Horizon | BHNetworkRelations@horizonblue.com
Contracting Denise Mizell (856) 638-3538, x735 Lauren Woods (973)-466-6690 For Utilization Management (escalations only) Sarah Disanto For Authorization 1-800-682-9094 Vincent Visioli, Behavioral Health Administrator |
| United Healthcare | Contracting – Catherine Wadsworth
Specialty Network Manager 888-362-3368 |
| WellCare | Contracting Provider Relations
Kate Mignone C: 201-259-5934 Utilization Management Danielle Sandy O: 813-206-7696 C: 808-341-6812 Care Management Kim Brown-Jones O: 973-274-2141 C: 862-229-4132 Noralisa Santiago Noralisa.Santiago@wellcare.com O: 973-274-2166 C: 862-240-2495 |
| PerformCare | 1-877-652-7624 |
What if I am already working with a family who meets the criteria to receive these services?
Once you have started this process you can treat families using a single case agreement that you can request from the families MCO.
FAQs for Families
Who qualifies for the NJ DIR Services?
Children under 21 with an ASD diagnosis eligible for Medicaid through NJ FamilyCare.
How can families get started?
For details on eligibility visit NJFamilyCare.org
If your family is already registered with NJFamilyCares you can get started with services by reaching out to a Medicaid DIR provider OR by contacting your Medicaid plan administrator found on your insurance card. Request access to ASD services available through your plan.
Families who believe they qualify for the NJ Medicaid program can find out more by contacting NJFamilyCare.
- apply online at NJFamilyCare.org OR
- call NJ FamilyCare at 1-800-701-0710
What if my child has autism but I don’t qualify for Medicaid?
The Medicaid coverage for DIR is the first step. Reach out to your insurance carriers, your doctors, and your service providers. Start the conversation and help educate your community that there is a need for parent choice when it comes to available quality and evidence-based services for children with an autism diagnosis. Conversations are happening with major national insurers. Let your voice be heard.