New Jersey Administrative Code

(a) Single individuals, childless couples and families, as defined in N.J.A.C. 10:69, who have been determined eligible for NJ FamilyCare in accordance with this chapter shall be eligible to apply for participation in the Premium Support Program (PSP). (b) An applicant shall have…

(a) All applicants to the Premium Support Program shall first be found eligible for the NJ FamilyCare program. Applicants to the Premium Support Program shall provide information concerning employment and employer-sponsored health insurance benefits. If an otherwise eligible appl…

(a) The NJ FamilyCare Program eligibility vendor or County Board of Social Services will refer all applications to the Premium Support Program. The referral will consist of a copy of the original application for NJ FamilyCare and shall include copies of any pertinent documentatio…

(a) The Premium Support Program applicant shall provide employer health benefit plan information regarding all family members for whom coverage is sought. (b) The applicant shall assist the Division as needed in obtaining employer health benefits plan information. (c) If the empl…

(a) Upon receipt of a completed application, the Premium Support Program (PSP) will: 1. Issue a notification letter to the applicant(s) stating that the application has been referred to the Premium Support Program for determination of eligibility for PSP participation; and 2. Sen…

(a) The employer should complete the Request for Information Form and return the form to the Premium Support Program (PSP) with a copy of the employer's Statement of Insurance Coverage. (b) An application to participate in the Premium Support Program shall be supported by the ind…

(a) Upon return of the employer's completed "Request for Information Form" and "Statement of Insurance Coverage," the Premium Support Program will initiate a two step review of the employer plan to determine if the plan meets the Division's plan participation requirements, as fol…

(a) NJ FamilyCare-Children's Program is a program administered by the Division of Medical Assistance and Health Services, Department of Human Services to provide plan-defined health care benefits to certain children. (b) The purpose of the rules contained within this chapter is t…

Words and terms used in this chapter shall have the meanings specified below, unless specifically defined otherwise in this chapter, or the context clearly indicates otherwise. "Authorized agent" means a parent, guardian, caretaker or any other individual 18 or older who has suff…

(a) Applications for NJ FamilyCare-Children's Program benefits can be obtained from various locations by calling 1-800-701-0710 or downloaded and printed, free of charge from www.njfamilycare.org. The application can also be completed and filed online at www.njfamilycare.org. App…

The eligibility determination agency may, at the request of the authorized agent or applicant, conduct a personal face-to-face interview with the applicant, or the authorized agents as part of the process of determining program eligibility. Notes N.J. Admin. Code § 10:79-2.2 Amen…

(a) The Statewide eligibility determination agency or CWA shall screen all mail-in and walk-in applications against the existing Medicaid eligibility file. Applications that involve family members who are already enrolled in the Medicaid program shall be forwarded to the applicab…

(a) The eligibility determination agency may accept and process an application for an unborn child in the last trimester of the pregnant woman's term, but whose income is greater than 200 percent, but not greater than 350 percent of the Federal poverty level. (b) Eligibility shou…

(a) Eligibility under NJ FamilyCare-Children's Program-Plan A is effective back to the first day of the month of application provided that all eligibility requirements are met in that month. If eligibility requirements are not met during the month of application, a future eligibi…

(a) Retroactive eligibility is available to cover unpaid medical bills for up to three months prior to the date of application if the requirements are met in all or any of the three months. (b) If the applicant for NJ FamilyCare-Children's Program-Plan A benefits has unpaid medic…

(a) Eligibility for NJ FamilyCare-Children's Program under this chapter shall be redetermined, with the completion of a redetermination form, as indicated in (a)1 and 2 below. The redetermination form may be mailed. A face-to-face interview is not required. 1. Eligibility for NJ …

(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 State-approved 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 …

(a) Eligibility for the NJ FamilyCare-Children's Program must be established in relation to each requirement of the NJ FamilyCare-Children's Program. (b) The applicant's or the authorized agent's statements regarding the child or children's eligibility, as set forth in the applic…

(a) As a condition of eligibility for the NJ FamilyCare-Children's Program, authorized agents on behalf of applicants, applicants and beneficiaries are required to take all necessary steps to obtain any health insurance, annuities, and disability benefits to which the child is en…

(a) Any child who is an inmate of a public institution is ineligible for the NJ FamilyCare-Children's Program. (b) Any child who is incarcerated in a Federal, State or local correction facility (prison, jail, detention center, reformatory, etc.), including any child in a Juvenile…

(a) In order to be eligible for the NJ FamilyCare-Children's Program, an individual must be a citizen of the United States, or an eligible alien in accordance with this chapter. 1. The term "citizen of the United States" includes persons born in Puerto Rico, Guam, the Virgin Isla…

(a) In order to be eligible for the NJ FamilyCare-Children's Program, the applicant/child must be a resident of the State of New Jersey. The term "resident" shall be interpreted to mean an applicant who is living in the State voluntarily and not for a temporary purpose, that is, …

(a) A child who meets all eligibility criteria of this chapter shall be eligible for NJ FamilyCare-Children's Program benefits, as follows: 1. A child who has not attained the age of 19. (b) Any child receiving NJ FamilyCare-Children's Program benefits under the provisions of thi…

(a) For NJ FamilyCare-Children's Program-Plan 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 …

(a) For Plan B, C, or D, 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 as members o…

(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 beneficiar…

(a) For the purposes of this chapter, the term "health insurance" does not include: 1. Student coverage which is defined as a limited coverage policy which covers injuries sustained while the student is engaged in school or school-sponsored activities; 2. Accident-only coverage, …

Persons who are ineligible for TANF or would have been ineligible for AFDC-related Medicaid using the rules in effect as of July 16, 1996, due to the imposition of a sanction of ineligibility for a factor of AFDC or TANF eligibility that does not apply in NJ FamilyCare-Children's…

(a) Income limits for children through 18 years covered under the provisions of this chapter for NJ FamilyCare-Children's Program-Plan A shall be based on 133 percent of the poverty income guideline as defined by the U.S. Department of Health and Human Services in accordance with…

(a) The eligibility determination agency shall establish the best estimate of income that will be available to the household unit. 1. The best estimate of income shall be based on an average of the household unit's income. Adjustments shall be made to the estimated income to refl…

(a) For purposes of Plan A eligibility, except as specified below, countable income for children under the provisions of this chapter shall include the income of all members of the household unit as determined at N.J.A.C. 10:79-3.5, and shall be determined in accordance with the …

(a) For purposes of Plan B, C or D eligibility, gross income for the applicant shall include the gross income of members of the household unit as defined in N.J.A.C. 10:79-3.6. 1. Income from a legally responsible relative who does not reside with the family shall be counted only…

Children seeking NJ FamilyCare-Children's Program 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 est…

Financial eligibility for the NJ FamilyCare-Children's Program-Plan A is administered by either the Statewide eligibility determination agency or the county welfare agencies under the supervision of the Division of Medical Assistance and Health Services. Financial eligibility for…

(a) The director of the eligibility determination agency shall assign copies of this chapter to administrative staff, all staff responsible for the determination of NJ FamilyCare-Children's Program eligibility for children, and to social service staff as appropriate and shall ens…

(a) The following principles of administration apply in the NJ FamilyCare-Children's Program. 1. Any authorized agent or emancipated child who believes the applicant may be eligible shall be afforded an opportunity to make application (or reapplication) for the NJ FamilyCare-Chil…

(a) No member, officer, or employee of the eligibility determination agency shall produce or disclose any confidential information to any person except as authorized below in this section. 1. Information considered confidential includes, but is not limited to, the following: i. N…

(a) All materials distributed to program applicants or eligible persons must: 1. Directly relate to the administration of the NJ FamilyCare-Children's Program; 2. Have no political implications; 3. Contain names only of individuals directly connected with the administration of th…

(a) Title VI of the Federal Civil Rights Act of 1964 ( Pub. L. 88-352), section 504 of the Rehabilitation Act of 1973 ( 29 U.S.C. § 70b) and the Americans with Disabilities Act, Pub. L. 101-336, codified as 42 U.S.C. §§ 12101 et seq. prohibits discrimination on the ground of race…

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

(a) The eligibility determination agency shall promptly notify any applicant for, or beneficiary of, the NJ FamilyCare-Children's Program-Plan A in writing of any agency decision affecting the applicant or beneficiary. When a decision relates to any adverse action which may entit…

Notes N.J. Admin. Code § 10:79-6.10 Recodified to N.J.A.C. 10:79-6.9 by R.2009 d.232, effective 7/20/2009. See: 41 N.J.R. 945(a), 41 N.J.R. 2793(a). Section was "Copayments--Plans C and D".

(a) It is the right of every applicant for or beneficiary of the NJ FamilyCare-Children's Program-Plan A program to be afforded the opportunity for a fair hearing in the manner set forth in N.J.A.C. 10:49-10, including, when applicable, continuation NJ FamilyCare-Children's Progr…

(a) The Statewide eligibility determination agency shall promptly notify any applicant for, or beneficiary of, the NJ FamilyCare-Children's Program-Plan B, C and D program in writing of any agency decision affecting the applicant or beneficiary. When a decision relates to any adv…

Upon a determination of eligibility for the NJ FamilyCare-Children's Program, the authorized agent or applicant has the on-going responsibility for the reporting of changes in family circumstances and for the provision of information as delineated at N.J.A.C. 10:79-2.1(c). Furthe…

(a) It is the right of every applicant for, or beneficiary of, NJ FamilyCare-Children's Program-Plan B, C, or D, to be afforded the opportunity for a grievance review in the manner established in the policies and procedures set forth below. The notification of the right to a grie…

(a) Those agency actions which adversely affect an applicant or beneficiary and may be grieved include, but are not limited to: determination of household composition, earned and unearned income calculations, and interpretation of residency, citizenship and age requirements. (b) …

(a) Effective July 1, 2015, families with income above 150 percent and at or below 200 percent of the Federal poverty level eligible for NJ FamilyCare-Children's Program-Plan C do not have to pay a monthly premium. (b) Effective July 1, 2015, for children in families with gross i…

(a) There shall be a family limit on the level of cost-sharing equal to five percent of gross household income for Plan C and D beneficiaries. Cost-sharing shall include the premium payments and the personal contribution to care. (b) The cost-sharing limit shall be calculated ann…