New Jersey Administrative Code

(a) Application for NJ FamilyCare benefits shall be accomplished by completing and signing the application form as well as any addenda to that form as prescribed by the Division of Medical Assistance and Health Services. Applicants may obtain NJ FamilyCare applications from vario…

The eligibility determination agency may, at the request of the applicant or authorized agent, conduct a personal face-to-face interview with the program applicant or the authorized agents as part of the process of determining program eligibility. Notes N.J. Admin. Code § 10:78-2…

(a) The eligibility determination agency shall verify all factors related to eligibility for the NJ FamilyCare program. Factors subject to verification include: 1. Birth date: The birth date of any person for whom benefits are sought shall be provided; if there is a discrepancy b…

(a) When individuals move permanently to another county within the State, responsibility for the case shall be transferred in accordance with the provisions of this section. The case transfer shall be accomplished in a manner so as not to adversely affect the rights of any indivi…

(a) When an individual's eligibility transfers from one eligibility determination agency to another, responsibility for the case shall be transferred in a manner so as not to adversely affect the rights of any individual to program entitlement. 1. For individuals for whom, becaus…

(a) Eligibility for NJ FamilyCare under this chapter shall be redetermined no later than 12 months following the month of initial eligibility or the last redetermination, unless eligibility is being redetermined in accordance with N.J.A.C. 10:90. (See N.J.A.C. 10:78-4.5.) (b) The…

Upon a determination of eligibility for the NJ FamilyCare program, beneficiaries have the ongoing responsibility to report changes in family circumstances and for the provision of information as set forth at N.J.A.C. 10:78-2.1(c). At any time that the eligibility determination ag…

(a) Eligibility for the NJ FamilyCare program shall be established in relation to each requirement of the NJ FamilyCare program to provide a valid basis for the granting or denying of NJ FamilyCare benefits. (b) The applicant's statements regarding his or her eligibility, as set …

(a) In order to be eligible for the NJ FamilyCare program, an individual shall be a citizen of the United States, an alien lawfully admitted for permanent residence, or an alien who can be classified as an eligible alien in accordance with this chapter. 1. The term "citizen of th…

(a) In order to be eligible for the NJ FamilyCare program, an individual shall be a resident of the State of New Jersey. The term "resident" shall be interpreted to mean a person who is living in the State voluntarily and not for a temporary purpose, that is, with no intention of…

(a) Except as specified in (b) through (d) below, the following persons who meet all the eligibility criteria of this chapter and are not eligible to receive Medicaid or NJ FamilyCare Children's Program coverage under current provisions shall be eligible for NJ FamilyCare benefit…

(a) The term "household unit" means those persons whose income is counted in the determination of eligibility under the provisions of this chapter. The following persons, if they reside with the program applicant or beneficiary, shall be considered members of the household unit: …

(a) Program applicants and beneficiaries are required to identify to the eligibility determination agency any third party (individual, entity, or program) that is or may be liable to pay all or part of the medical cost of injury, disease, or disability of an applicant or benefici…

Persons who would be ineligible for AFDC-related Medicaid using the rules in existence as of July 16, 1996 or due to the imposition of a sanction of ineligibility for a TANF eligibility factor that does not apply to NJ FamilyCare (such as noncooperation with work registration) sh…

(a) As a condition of eligibility for the NJ FamilyCare program, applicants and beneficiaries are required to take all necessary steps to obtain any annuities, pensions, retirement and disability benefits to which they are entitled, unless they can show good cause for not doing s…

(a) Any person who is an inmate of a public institution is ineligible for the NJ FamilyCare program. (b) Any person who is incarcerated in a Federal, State, or local correction facility (such as a prison, jail, detention center, or reformatory) shall not be eligible for the NJ Fa…

(a) For parents, and caretakers, of dependent children under the age of 19 who applied as such for NJ FamilyCare benefits prior to June 15, 2002, and continuously have received those benefits, income limits shall be based on 200 percent of the poverty income guidelines as defined…

(a) The eligibility determination agency shall establish the best estimate of income that shall be available to the household unit. 1. The best estimate of income shall be based on the household unit's income for the month preceding the date of application or redetermination. Adj…

(a) Except as specified below, countable income shall include the income of all members of the household unit as determined at N.J.A.C. 10:78-3.5(a), except that: 1. Income from a legally responsible relative who does not reside with the family shall be counted only to the extent…

(a) Before applying the NJ FamilyCare eligibility test, the eligibility determination agency staff shall evaluate, or make referrals, as appropriate, to determine eligibility for other medical coverage, including, without limitation, programs for the aged, blind and disabled, and…

(a) Once enrollment is completed for single adults and couples without dependent children, those family units shall be subject to verification of continuing eligibility for NJ FamilyCare. The same test outlined at N.J.A.C. 10:78-4.1 shall be applied in determining whether the gro…

Individuals seeking NJ FamilyCare benefits under the provisions of this chapter are eligible without regard to the value of the household unit's resources. The eligibility determination agency shall inquire about the household unit's resources only in order to establish income th…

Children who would qualify for Medicaid or NJ FamilyCare Children's Program except for the Federal immigrant residency restriction shall receive presumptive eligibility services under the provisions of N.J.A.C. 10:79. Pregnant women and children under the age of one year, with in…

Notes N.J. Admin. Code § 10:78-5.10 Repealed by R.2006 d.347, effective 10/2/2006. See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a). Section was "Subchapter effective period".

Notes N.J. Admin. Code § 10:78-5.2 Repealed by R.2006 d.347, effective 10/2/2006. See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a). Section was "Requirements for presumptive eligibility determination entities".

Notes N.J. Admin. Code § 10:78-5.3 Repealed by R.2006 d.347, effective 10/2/2006. See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a). Section was "Presumptive eligibility processing performed by the presumptive eligibility determination entity".

Notes N.J. Admin. Code § 10:78-5.4 Repealed by R.2006 d.347, effective 10/2/2006. See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a). Section was "Presumptive eligibility process performed by the Division of Medical Assistance and Health Services".

Notes N.J. Admin. Code § 10:78-5.5 Recodified to N.J.A.C. 10:78-5.1 by R.2006 d.347, effective 10/2/2006. See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a). Section was "Presumptive eligibility processing performed by the eligibility determination agency".

Notes N.J. Admin. Code § 10:78-5.6 Repealed by R.2006 d.347, effective 10/2/2006. See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a). Section was "Responsibility of the applicant".

Notes N.J. Admin. Code § 10:78-5.7 Repealed by R.2006 d.347, effective 10/2/2006. See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a). Section was "Notification and grievance review rights".

Notes N.J. Admin. Code § 10:78-5.8 Repealed by R.2006 d.347, effective 10/2/2006. See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a). Section was "Limitation on number of presumptive eligibility periods".

Notes N.J. Admin. Code § 10:78-5.9 Repealed by R.2006 d.347, effective 10/2/2006. See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a). Section was "Hospital-specific payment caps for presumptive eligibility".

(a) The eligibility determination agency shall promptly notify any applicant for, or beneficiary of, the NJ FamilyCare program in writing of any agency decision affecting the applicant or beneficiary. When a decision relates to any adverse action which may entitle a beneficiary t…

(a) The purpose of the case record is to provide a complete documentary record of eligibility determination agency actions and the reasons therefor. (b) The case record shall include: 1. A record of all eligibility determination agency actions and decisions relating to the case, …

(a) The NJ FamilyCare "Plan A" service package shall contain those services described at N.J.A.C. 10:49-5.2. (b) The NJ FamilyCare "Plan D" benefit package shall contain those services described at N.J.A.C. 10:49-5.7. Those FamilyCare Plan D beneficiaries whose income is above 15…

(a) All NJ FamilyCare applicants and beneficiaries shall be afforded the opportunity for a grievance review.1. Those agency actions which adversely affect an applicant or beneficiary and may be grieved shall include, but shall not be limited to: i. Determination of household comp…

No applicant or beneficiary of the NJ FamilyCare program shall be entitled to a fair hearing as a result of adverse agency action; however, nothing in this chapter shall prevent an applicant or beneficiary from requesting a fair hearing to which they may otherwise be entitled und…

Once determined eligible for NJ FamilyCare, the applicant shall have the on-going responsibility for reporting to the eligibility determination agency any changes in family circumstances and for providing information as delineated at N.J.A.C. 10:78-2.7. The applicant shall provid…

(a) The purpose of the Premium Support Program (PSP) is to provide financial support to adults and children to help defray the cost of employer-sponsored health insurance. (b) The Premium Support Program is designed to cover individuals eligible for NJ FamilyCare who have access …

(a) Cost-effectiveness shall be determined by comparing the cost of the beneficiary/employee and all eligible family members' participation in the NJ FamilyCare program against the total cost to the State of reimbursing the beneficiary/employee for the employee share of the cost …

(a) If the beneficiary/employee is found eligible to participate in the Premium Support Program (PSP), a letter of notification will be sent to the employee. The notification letter will advise the employee of PSP approval and request that the beneficiary/employee and all eligibl…

(a) All Premium Support Program (PSP) payments will be made directly to the beneficiaries, for a portion of the amount payable to the employer by the beneficiary for the employer-sponsored health plan. (b) The periodic payments to the beneficiary will coincide with the schedule o…

(a) A monthly premium charge shall be assessed and collected for all participants in the NJ FamilyCare Premium Support Program (PSP), in accordance with N.J.A.C. 10:49-9.2 and (b) below. PSP participants shall be assessed $ 10.00 less per payment for children and $ 5.00 less per …

(a) The Premium Support Program (PSP) will reimburse the beneficiary for the difference between the NJFC/PSP co-payment amount and that of the employer-sponsored plan co-payment amount. For example, if the NJFC/PSP co-payment amount for a physician's office visit is $ 5.00 and th…

(a) If, during the course of a regular plan year (January 1 to December 31), the beneficiary and/or any other eligible family members incur cost sharing expenditures (copayments, co-insurance and deductibles) that are not directly reimbursable by the Premium Support Program (PSP)…

(a) Participants in the NJ FamilyCare/Premium Support Program shall be eligible for all covered services based on their NJ FamilyCare category of eligibility (Plan A, B, C or D). Premium Support Program (PSP) participants shall utilize their employer-sponsored plan as primary cov…

All of the relevant provisions pertaining to fraud and abuse, third party liability, and administrative and judicial remedies which are contained in the following sections of N.J.S.A. 30:4D-1 et seq. and N.J.A.C. 10:49 shall be fully applicable to the Premium Support Program: N.J…

Notwithstanding the provisions of this subchapter, in the case of a conflict between the rules in this subchapter and the rules of the Department of Banking and Insurance, the rules of the Department of Banking and Insurance regarding small employer health plans shall apply. Note…

Circumstances which are neither specifically nor generally addressed in these rules shall be referred to the DMAHS/PSP unit for resolution. Notes N.J. Admin. Code § 10:78-9.19

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Large employer" means any person, firm, corporation, partnership or political subdivision that is actively engaged in business that emp…