Federal, exists in every state
Ask NJ FamilyCare to review care your child needs (EPSDT)
Children under 21 on Medicaid have a right to a broad review of medically necessary care, including services outside the usual list.
What it is
Children under 21 on Medicaid have a right to a broad review of medically necessary care, including services outside the usual list.
For a child under 21 on Medicaid, medically necessary care that fits a Medicaid benefit category must be covered, even when the plan’s usual list leaves it out. It is a coverage protection, not cash, and a doctor’s order is not automatic approval; the clinician explains the need and the plan reviews it.
Rules
- The service must fit a federal Medicaid benefit category and meet medical-necessity rules. NJ child Medically Needy coverage does not include EPSDT; the FamilyCare name alone does not establish the full treatment benefit.
- For NJ FamilyCare managed care, the current handbook allows 60 calendar days from the initial decision notice for a plan appeal, normally decided within 30 calendar days or within 72 hours if urgent. A permitted extension can add up to 14 calendar days, with the required justification and notice. Medicaid members entitled to a state fair hearing normally have 120 calendar days from the internal appeal decision notice; an optional independent review does not restart that hearing deadline. The family’s denial notice should identify the applicable route because CHIP categories do not all have Medicaid fair-hearing rights.
- For a reduction or ending of previously authorized care, continued services must be requested separately and quickly. The current NJ handbook gives the later of 10 calendar days after the initial notice or the last authorization day at the plan-appeal stage; other conditions for continued benefits still apply. At the hearing stage it describes the latest of 10 days after the internal decision, 10 days after an independent-review decision, or the last authorization day, without extending the separate 120-day hearing-filing limit. The social worker and plan can help check those dates against the notice. A final adverse hearing decision can leave the family liable for continued services, so continuation is not a guarantee that every disputed bill is erased.
- The appeal and travel examples use the 2026 Fidelis NJ handbook. Your own plan must confirm the applicable notice, category, dates and benefits.
What you get
- A route to coverage of nursing, equipment, therapies or other care the plan’s standard list omits.
- Expedited review when waiting could harm your child.
What it is not
- Not a promise of any service requested, and not a cash program.
If you decide to apply
- Ask the NJ FamilyCare care manager, in writing, to review the specific service under EPSDT.
- Have the clinician send records describing the service, frequency, expected benefit and the risk of going without.
- If care is denied, ask your social worker and care team to compare the appeal deadline, urgent review and any separate request to continue existing care.
Medicaid: EPSDT · Official page ↗
Records
- Keep the request date and the plan’s reference number.
Good to know
Ask for a named care manager at the plan as soon as your child is enrolled; that is who receives these requests. If a service might be cut, do not wait for the reduction to happen before asking about continued services.
Other details
- This applies inside Medicaid only; a work plan has its own appeal route (below).
Related New Jersey card: Nursing and care at home.
Official sources
“Does our child’s exact NJ FamilyCare category include full EPSDT treatment benefits? If care is refused, could you help us compare the appeal options and deadlines?”
Why I’m asking: We want to know the route before a refusal happens.
More background and detailed requirements
How this works
Children under 21 on Medicaid have a right to a broad review of medically necessary care, including services outside the usual list.
For a child under 21 on Medicaid, medically necessary care that fits a Medicaid benefit category must be covered, even when the plan’s usual list leaves it out. It is a coverage protection, not cash, and a doctor’s order is not automatic approval; the clinician explains the need and the plan reviews it.
- A route to coverage of nursing, equipment, therapies or other care the plan’s standard list omits.
- Expedited review when waiting could harm your child.
- Ask the NJ FamilyCare care manager, in writing, to review the specific service under EPSDT.
- Have the clinician send records describing the service, frequency, expected benefit and the risk of going without.
- If care is denied, ask your social worker and care team to compare the appeal deadline, urgent review and any separate request to continue existing care.
Rules
- The service must fit a federal Medicaid benefit category and meet medical-necessity rules. NJ child Medically Needy coverage does not include EPSDT; the FamilyCare name alone does not establish the full treatment benefit.
- For NJ FamilyCare managed care, the current handbook allows 60 calendar days from the initial decision notice for a plan appeal, normally decided within 30 calendar days or within 72 hours if urgent. A permitted extension can add up to 14 calendar days, with the required justification and notice. Medicaid members entitled to a state fair hearing normally have 120 calendar days from the internal appeal decision notice; an optional independent review does not restart that hearing deadline. The family’s denial notice should identify the applicable route because CHIP categories do not all have Medicaid fair-hearing rights.
- For a reduction or ending of previously authorized care, continued services must be requested separately and quickly. The current NJ handbook gives the later of 10 calendar days after the initial notice or the last authorization day at the plan-appeal stage; other conditions for continued benefits still apply. At the hearing stage it describes the latest of 10 days after the internal decision, 10 days after an independent-review decision, or the last authorization day, without extending the separate 120-day hearing-filing limit. The social worker and plan can help check those dates against the notice. A final adverse hearing decision can leave the family liable for continued services, so continuation is not a guarantee that every disputed bill is erased.
- The appeal and travel examples use the 2026 Fidelis NJ handbook. Your own plan must confirm the applicable notice, category, dates and benefits.
What it is not
- Not a promise of any service requested, and not a cash program.
Records
- Keep the request date and the plan’s reference number.
Other details
- This applies inside Medicaid only; a work plan has its own appeal route (below).
The plan’s care manager can explain the review route. A request to continue existing care has a separate, shorter deadline than the appeal itself.
The service must fit a federal Medicaid benefit category and meet medical-necessity rules. NJ child Medically Needy coverage does not include EPSDT; the FamilyCare name alone does not establish the full treatment benefit.
For NJ FamilyCare managed care, the current handbook allows 60 calendar days from the initial decision notice for a plan appeal, normally decided within 30 calendar days or within 72 hours if urgent. A permitted extension can add up to 14 calendar days, with the required justification and notice. Medicaid members entitled to a state fair hearing normally have 120 calendar days from the internal appeal decision notice; an optional independent review does not restart that hearing deadline. The family’s denial notice should identify the applicable route because CHIP categories do not all have Medicaid fair-hearing rights.
For a reduction or ending of previously authorized care, continued services must be requested separately and quickly. The current NJ handbook gives the later of 10 calendar days after the initial notice or the last authorization day at the plan-appeal stage; other conditions for continued benefits still apply. At the hearing stage it describes the latest of 10 days after the internal decision, 10 days after an independent-review decision, or the last authorization day, without extending the separate 120-day hearing-filing limit. The social worker and plan can help check those dates against the notice. A final adverse hearing decision can leave the family liable for continued services, so continuation is not a guarantee that every disputed bill is erased.
The appeal and travel examples use the 2026 Fidelis NJ handbook. Your own plan must confirm the applicable notice, category, dates and benefits.
Not a promise of any service requested, and not a cash program.
Keep the request date and the plan’s reference number.
This applies inside Medicaid only; a work plan has its own appeal route (below).
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
Ask the plan for a care manager, keep a two-week log of the daily tasks, and put every request in writing under Medicaid's rule that a child under 21 gets what is medically needed.
Your social worker
Gets the care manager assigned and sends the request to the right approval desk.
The care team
Writes the order and the letter of medical necessity naming the service, the frequency and the risk without it.
- Who decides
- The Medicaid plan or agency, on medical necessity
- Ask your social worker
- “Can you get us a care manager at the Medicaid plan? Will the team write the letter asking for home nursing, equipment and rides?”
How to apply
First step: Ask the Medicaid plan for a care manager. Put the request in writing and ask for review under EPSDT.
- Ask the Medicaid plan for a care manager.
- Put the request in writing under EPSDT.
- Ask the clinician to write what the service corrects, how often, and the risk without it.
Where it starts: Written request to the plan's care manager. Medicaid appeal if denied
What to gather
- The doctor's order and a letter of medical necessity
- A two-week log of the daily tasks at home
- Any denial letter, with the date
How long: An appeal of a “no” is decided within 30 days, or 72 hours when waiting is unsafe.
What a yes looks like
An approval with hours or units and a start date.
What a no looks like, and the next move
A written denial with appeal rights. Appeal within the notice's period and ask for benefits to continue.
Watch out
- “Not a covered benefit” is not the end of it for a child. Ask the plan to review the request under Medicaid's rule that a child under 21 gets what is medically needed, in writing.
- Medical necessity is still reviewed. The doctor's letter must say what the service corrects or prevents, how often, and what happens without it.
- Nursing and personal care fit. A parent's wages for care usually do not, unless the state runs a paid-caregiver option.
- Hospice does not mean stopping chemo for a Medicaid child. Since 2010 a child under 21 can have hospice and treatment at the same time. A CHIP-only plan can choose not to cover hospice; if it does, the same rule applies.
The numbers and the rules
The arcane layer, kept on purpose. Checked September 8, 2026.
What it is worth
Home nursing, personal care, equipment, therapies and transport paid by Medicaid on the doctor's word.
Covers: Private-duty nursing at home · Personal care · Feeding pumps, oxygen and other equipment · Therapies and behavioral health · Rides to treatment
Legal protection: Correct-or-ameliorate standard for any service in a Medicaid category · The state owes the benefit even when a managed-care plan says no · Hospice does not mean stopping treatment: since March 23, 2010 a Medicaid child under 21 can have hospice and curative care at the same time (a doctor still certifies a prognosis within six months for hospice)
What it costs the family: Part of Medicaid. No separate premium.
The eligibility facts, as published
- Age under
- 21
- Medicaid required
- yes
Decisions this site cannot make: Medical necessity · Medicaid service category (section 1905(a))
Expect friction on: Prior approval · Clinical documentation
The trap: Medicaid's rule that a child under 21 gets what is medically needed changes the standard, not the review: the doctor's letter still has to say what the service corrects, how often, and what happens without it.
What changes by state: Nothing in the rule. The plan's forms and the state's paid-caregiver option do.
Where I read this
- Early and Periodic Screening, Diagnostic, and Treatment — Centers for Medicare & Medicaid Services, read August 27, 2026
- State Medicaid Director letter 23-006: non-emergency medical transportation guide — Centers for Medicare & Medicaid Services, read September 7, 2026
- 42 CFR 438.408: Resolution and notification of managed-care appeals — Cornell LII (eCFR mirror), read September 7, 2026
- CMS State Medicaid Director letter 10-018: concurrent care for children (ACA §2302) — Centers for Medicare & Medicaid Services, read September 8, 2026