reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.15 - Five percent of gross family income annual limit on cost-sharing (out-of-pocket) expenditures

Current through Register Vol. 56, No. 14, July 15, 2024
(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), and that exceed five percent of the
				individual's or family's gross annual income, they may submit proof of such
				expenditures to the PSP for review and possible reimbursement, in accordance
				with the provisions of this section. If the beneficiary chooses an
				employer-sponsored plan which costs more than the basic plan approved by the
				Premium Support Program for that employee and/or any other eligible family
				members, the difference between the approved premium and the actual premium:
1. Will not be reimbursed by the Premium
				Support Program; and
2. Will not be
				included in the five percent cost sharing calculation (see
				10:49-9.3 ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.16 - Covered services

Current through Register Vol. 56, No. 14, July 15, 2024
(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 coverage.
(b) Any services not covered by the employer
				plan, but covered under the enrollees' NJ FamilyCare category of eligibility,
				will be available to PSP participants as a "wraparound" service. Any such
				wraparound service (for example, optical appliances or hearing aids) shall be
				provided by a New Jersey Medicaid/NJ FamilyCare participating approved
				provider. The failure of a beneficiary to use a New Jersey Medicaid/FamilyCare
				provider for "wraparound services" will result in a denial of payment by the NJ
				FamilyCare Program. The services received would then be the full responsibility
				and liability of the beneficiary.
(c) To access any "wraparound" service, a
				Premium Support Program beneficiary/employee or eligible family member will be
				issued a NJ FamilyCare monthly identification card and shall present such proof
				of eligibility to the provider prior to receipt of services. Failure to present
				proof will not obligate the PSP to pay for such services or require the
				provider to bill NJ FamilyCare for such services. In case of failure to present
				proof of eligibility, the beneficiary/employee or eligible family member shall
				be liable for all incurred expenses. Any wraparound services shall be received
				from a NJ Medicaid/FamilyCare participating provider. Reimbursement will be
				made to the provider on a fee-for-service basis according to the Division's
				rules for those services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.17 - Certain Medicaid provisions applicable to the Premium Support Program

Current through Register Vol. 56, No. 14, July 15, 2024
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
				  30:4D-1 et seq. and N.J.A.C. 10:49
				  shall be fully applicable to the Premium Support Program:
				  30:4D-6.c, 6.f, 7.h, 7.i, 7.k,
				  7.l, 7.1, 12, 17(e)(1), 17(f), 17(g), 17(i), 17.1 and 17.2, as well as
				  10:49-3.2, 4.1 through 4.5, 5.5,
				  6.1(a)3, 7.3, 7.4, 7.5, 8.2(a)1ii, 9.6 through 9.12, 11.1, 12.1 through 12.7,
				  13.1, 13.4, 14.2 through 14.6 and 16.5.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.18 - Applicability of rules of the Department of Banking and Insurance; small employer health plans

Current through Register Vol. 56, No. 14, July 15, 2024
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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.19 - Interpretations of rules

Current through Register Vol. 56, No. 14, July 15, 2024
Circumstances which are neither specifically nor generally
				  addressed in these rules shall be referred to the DMAHS/PSP unit for
				  resolution.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 10 - FRAUD AND ABUSE UNDER NJ FAMILYCARE › Section 10:78-10.1 - Termination of eligibility for good cause for fraud and abuse

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Subject to the
				limitations contained in
				42
				U.S.C. §
										1320a- 7b(a), "Criminal
				Penalties for Acts involving Federal Health Care Programs," any violation of
				(b) below shall result in the issuance of a Notice of Proposed Termination of
				the processing of the applicant's application, or of the beneficiary's
				eligibility for NJ FamilyCare. An individual receiving a Notice of Proposed
				Termination may request a grievance review.
(b) Subject to the limitations contained in
				42
				U.S.C. §
										1320a- 7b(a), cause for
				termination exists when a NJ FamilyCare applicant or beneficiary:
1. Knowingly or intentionally makes or causes
				to be made false statements or misrepresentations of material fact in any
				application or reapplication for benefits under NJ FamilyCare;
2. Knowingly or intentionally makes or causes
				to be made false statements, misrepresentations of material fact, or
				alterations on any NJ FamilyCare claim, eligibility card, or other document
				issued by or on behalf of the Division;
3. Intentionally misuses or abuses NJ
				FamilyCare benefits;
4. Knowingly
				or intentionally converts all or part of NJ FamilyCare benefits to a use other
				than the individual's own legitimate use and benefit;
5. Gives, loans, or sells an eligibility card
				to anyone for use by an individual or individuals other than the eligible
				person or persons for whom the card was issued;
6. Engages in forgery or attempted forgery
				involving eligible services and/or claims for such services;
7. Engages in a course of conduct or performs
				an act deemed improper or abusive of the NJ FamilyCare program following
				notification that this conduct should cease; or
8. Fails to cooperate in a NJ FamilyCare
				investigation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 10 - FRAUD AND ABUSE UNDER NJ FAMILYCARE › Section 10:78-10.2 - Applications for readmission subsequent to termination of eligibility, or denial of applications for determination of eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The terminated
				individual, or anyone with authority to act on his or her behalf, may apply to
				the Director for readmission to the NJ FamilyCare program no earlier than one
				year from the date of the final agency decision terminating the applicant's
				application process or the beneficiary's eligibility.
(b) The Director shall approve or deny such
				an application in accordance with the provisions of this chapter.
(c) An individual whose application for
				readmission has been denied may request a grievance review on the denial,
				and/or may submit another application to the Director no earlier than two years
				from the date of the final agency decision denying readmission.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 10 - FRAUD AND ABUSE UNDER NJ FAMILYCARE › Section 10:78-10.3 - Applicability

Current through Register Vol. 56, No. 14, July 15, 2024
10:78-10.1(a) 
				  and 10.2 shall apply only to NJ FamilyCare applicants and beneficiaries whose
				  eligibility has been terminated for the reasons set forth in
				  10:78-10.1(b) 
				  and shall not apply to termination due to ineligibility initiated under
				  N.J.A.C. 10:78-2 through 4.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 11 - PROVISIONS GOVERNING FORMER NEW JERSEY HEALTH ACCESS ENROLLEES › Section 10:78-11.1 - Purpose, scope and definitions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of
				this subchapter is to set forth the general provisions of the New Jersey
				FamilyCare program as it applies to those who were enrolled in the New Jersey
				Health Access program on October 31, 2001.
(b) This subchapter applies to all
				individuals who:
1. Were enrolled in the New
				Jersey Health Access program on October 31, 2001; and
2. Are enrolled in the NJ FamilyCare
				program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 11 - PROVISIONS GOVERNING FORMER NEW JERSEY HEALTH ACCESS ENROLLEES › Section 10:78-11.2 - Eligibility and redetermination of eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Individuals who
				were enrolled in the New Jersey Health Access program on October 31, 2001, and
				who returned a plan selection form by November 13, 2001, shall be eligible to
				enroll in the NJ FamilyCare program.
1. An
				enrollee who is denied the opportunity to enroll in the New Jersey FamilyCare
				program because he or she did not return a plan selection form by November 13,
				2001 shall have the right to file a grievance with the Health Access New Jersey
				Grievance Board in accordance with (a)2 below, if the grievance is filed with
				the Access program within 10 days of receipt of notice of discontinuation of
				the Access program mailed November 14, 2001. If the enrollee has not filed a
				grievance within 10 days of receipt of the notice mailed on November 14, 2001,
				no further opportunity to file a grievance shall be available.
2. If an enrollee has a grievance pertaining
				to the subsidy level calculated or involuntary disenrollment in the Access
				Program, the enrollee shall submit a description of the grievance to the Access
				Program in writing within 10 days of the adverse notification. The Access
				Program shall notify the enrollee of its decision on the matter in writing,
				specifying the reasons for the decision, within 30 days of receipt of the
				complete documentation of the grievance. The Access Program shall retain all
				correspondence and documentation relating to the grievance in the enrollee's
				file. The Access Program's decision shall be considered the final agency
				determination.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 11 - PROVISIONS GOVERNING FORMER NEW JERSEY HEALTH ACCESS ENROLLEES › Section 10:78-11.3 - Subsidy, contribution and copayments

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The total
				subsidy the State shall submit on behalf of a former New Jersey Health Access
				program enrollee shall be based upon the contract in force between the State
				and the managed care organization in which the individual is enrolled. The
				subsidy shall be recalculated in accordance with the contract between the
				Division and the managed care organization.
(b) The contribution that a former New Jersey
				Health Access Program enrollee shall be required to pay to the State shall be
				as provided for in
				10:78-7.1(e).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 11 - PROVISIONS GOVERNING FORMER NEW JERSEY HEALTH ACCESS ENROLLEES › Section 10:78-11.4 - Disenrollment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any individual
				who does not submit timely payment for his or her share of the premium, as
				determined by the State, in accordance with
				10:78-7.1, shall be
				disenrolled.
(b) The Division may
				disenroll any former Access program enrollee from the NJ FamilyCare program for
				good cause, which shall include: failure to meet the eligibility requirements
				set forth in this subchapter; loss of eligibility; nonpayment of premium
				contribution; and fraud or abuse. The Division shall provide the enrollee with
				advance written notice of its intent to disenroll the enrollee specifying the
				reasons for the disenrollment action. Such notice shall specify an effective
				date of the notice, and shall describe procedures for disenrollemnt, including
				the enrollee's right to appeal the disenrollment decision pursuant to N.J.A.C.
				10:78-8.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 11 - PROVISIONS GOVERNING FORMER NEW JERSEY HEALTH ACCESS ENROLLEES › Section 10:78-11.5 - Applicability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as
				otherwise specified in this subchapter, all provisions of N.J.A.C. 10:78, NJ
				FamilyCare, shall apply to the administration of the NJ FamilyCare program
				services provided to former New Jersey Health Access program
				enrollees.
(b) Notwithstanding the
				provisions of this subchapter, in the case of a conflict between these rules
				and the rules of the Department of Banking and Insurance, the rules of the
				Department of Banking and Insurance shall apply.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 1 - INTRODUCTION › Section 10:79-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(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 to:
1. Set forth eligibility
				criteria for the NJ FamilyCare-Children's Program;
2. Specify the rights and responsibilities of
				program applicants and eligible persons; and
3. Describe the administration of the
				program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:79-2.1 - Application

Current through Register Vol. 56, No. 14, July 15, 2024
(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
. Applications
				for Plan A benefits can be forwarded to the CWA in the county in which the
				applicant resides or to any other eligibility determination agencies designated
				by the Division of Medical Assistance and Health Services. Applications for
				Plan B, C and D shall be forwarded to PO Box 9802, Trenton, N.J. 08650-9802.
				Applications for NJ FamilyCare-Children's Program can be mailed to the CWA or
				to the eligibility determination agency. The application, as well as any
				addenda to that form as prescribed by the Division of Medical Assistance and
				Health Services should be completed by the authorized agent of the child; or by
				the child if the child is an emancipated individual.
(b) The eligibility determination agency,
				under policies and procedures established by the Division of Medical Assistance
				and Health Services, has the direct responsibility in the application process
				to:
1. Inform the authorized agent or
				applicants of the purpose of and the eligibility requirements for the NJ
				FamilyCare-Children's Program, including their rights and
				responsibilities;
2. Receive
				applications and review them for completeness, consistency, and
				reasonableness;
3. Assist the
				authorized agent or program applicant in exploring eligibility for program
				benefits;
4. Make known to the
				authorized agent or program applicant the appropriate resources and services
				both within the agency and in the community; and
5. Assure the prompt and accurate submission
				of eligibility data to the NJ FamilyCare-Children's Program Eligibility File
				for eligible children and prompt notification to the authorized agent or
				ineligible program applicant of the reason for their ineligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:79-2.2 - Interview

Current through Register Vol. 56, No. 14, July 15, 2024
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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:79-2.4 - Application processing for the unborn NJ FamilyCare-Children's Program-Plan C and Plan D

Current through Register Vol. 56, No. 14, July 15, 2024
(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 should be
				processed utilizing information that is projected to be effective at the time
				of the birth of the child. The eligibility determination agency and/or the CWA
				shall conduct a status review at the time of the birth of the child. The
				redetermination date for the family shall be moved to the date that the newborn
				was added to the case record.
(c)
				At the time of the application, the pregnant woman should select the unborn
				child's MCO coverage, and provide the appropriate premium.
(d) The pregnant woman shall notify both the
				eligibility determination agency and the selected MCO of the birth of the child
				within 10 calendar days of the birth. Failure to report the birth, select the
				MCO, if not already selected, and pay the premium, if not yet paid, within 10
				calendar days of the birth shall negate the original application, and the
				applicant for the newborn shall have to refile a new application with
				verification of eligibility reprocessed before eligibility can occur for the
				newborn. In the instance where a new application must be processed, the
				eligibility rules in this subchapter through N.J.A.C. 10:79-4 are
				effective.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:79-2.5 - Date of initial eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(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 eligibility date will be established as of the first day
				of the month the beneficiary meets all eligibility requirements.
(b) Eligibility under Plan B, C, or D is
				established with the first date of enrollment with an MCO and payment of
				applicable premiums (see
				N.J.A.C.
				10:79-6.7 ).
1. Exception: For newborns, as indicated in
				N.J.A.C.
				10:79-2.4, there is eligibility for
				fee-for-service Plan C and Plan D services from the date of birth until
				enrollment of the child into the MCO, if all the requirements of
				N.J.A.C.
				10:79-2.4 are met.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:79-2.6 - Retroactive eligibility-Plan A only

Current through Register Vol. 56, No. 14, July 15, 2024
(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
				medical bills from DMAHS-enrolled providers for services rendered during the
				retroactive eligibility period, the eligibility determination agency shall
				assist the applicant with applying for payment of unpaid medical
				bills.
(c) The Statewide
				eligibility determination agency and the CWA shall be responsible for the
				determination of retroactive eligibility for NJ Family Care-Children's
				Program-Plan A.
(d) There is no
				retroactive eligibility coverage for children eligible for NJ
				FamilyCare-Children's Program-Plan B, C or D.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:79-2.7 - Redetermination of eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(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 FamilyCare-Children's
				Program-Plan A must be redetermined no later than 12 months following the month
				of initial eligibility or the last redetermination.
2. Eligibility for NJ FamilyCare-Children's
				Program-Plan B, C or D must be redetermined every 12 months.
3. The State provides 12 months of coverage
				to enrolled children, regardless of whether the child experiences changes in
				family income and/or household size that would render the child ineligible
				during the 12-month period.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:79-2.8 - Case transfer between eligibility determination agencies

Current through Register Vol. 56, No. 14, July 15, 2024
(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 individual to program entitlement.
1. A temporary visit out-of-county shall not
				be considered to be a change of county residence until the visit has continued
				for longer than three calendar months.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:79-2.9 - Case transfer from one State-approved eligibility determination agency to another

Current through Register Vol. 56, No. 14, July 15, 2024
(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 who, because of an initial
				screening, it is determined that the eligibility determination agency must
				transfer the application to the appropriate agency, the agency of origin has
				the responsibility to:
i. Transfer, within
				five working days from the date of the initial screening, a copy of the
				application form including all verification; and
ii. Send the above materials, a cover letter
				specifying that the file is being transferred and requesting written or verbal
				acknowledgment of receipt;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:79-3.1 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(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
				application form, are evidence. The statements must be consistent and meet
				prudent tests of credibility. Incomplete or questionable statements shall be
				supplemented and substantiated by corroborative evidence from other pertinent
				sources.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:79-3.2 - Citizenship

Current through Register Vol. 56, No. 14, July 15, 2024
(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 Islands, Swain's Island,
				American Samoa, and the Northern Mariana Islands.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:79-3.3 - State residency

Current through Register Vol. 56, No. 14, July 15, 2024
(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, with no intention of presently removing therefrom.
1. If the caretaker adult leaves New Jersey
				with the child or the applicant with the intent to establish permanent
				residence elsewhere, or for an indefinite period for purposes other than a
				temporary visit, the child or applicant ceases to be eligible to receive NJ
				FamilyCare-Children's Program from this State.
2. When the authorized agent of a child or
				the applicant enters the State in order to receive medical care and applies for
				NJ FamilyCare-Children's Program to meet all or a portion of the costs of such
				care, the fact that the immediate purpose of the move was to secure medical
				care does not, in and of itself, have the effect of making the child/applicant
				ineligible for the NJ FamilyCare-Children's Program. It is the responsibility
				of the eligibility determination agency to evaluate all such cases and to make
				an eligibility determination, considering carefully all the following criteria:
i. Whether the move is a temporary one, being
				solely for the purpose of receiving medical care for a limited time;
ii. Whether there is clear expression of
				intent on the part of the authorized agent or applicant to remain permanently
				in this State;
iii. Whether there
				is objective evidence that the authorized agent or applicant child has, in
				fact, abandoned or not abandoned residence in the State from which he or she
				came; and
iv. Whether the state in
				which the authorized agent or applicant previously resided recognizes him or
				her as having continuing eligibility under the state's Medicaid or Title XXI
				children's health assistance program, or other program providing payment for
				medical care, of that jurisdiction.
3. If, after full consideration of the
				factors in this subsection, the eligibility determination agency is satisfied
				that the authorized agent or applicant child has become a resident of this
				State, NJ FamilyCare-Children's Program eligibility may be established as long
				as all other eligibility criteria are met.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:79-3.4 - Eligible children

Current through Register Vol. 56, No. 14, July 15, 2024
(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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:79-3.5 - Household unit for NJ FamilyCare-Children's Program-Plan A

Current through Register Vol. 56, No. 14, July 15, 2024
(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 be considered members of the household
				unit:
1. The child;
2. The child's natural or adoptive
				parents;
3. The child's
				blood-related siblings, including those of half-blood, and adoptive siblings
				under the age of 21; and
4. At the
				option of the authorized agent or the applicant, the child's stepparent,
				whether or not there is a common child. If the sponsored relative or applicant
				elects not to include the stepparent in the household unit, his or her income
				will not be included in the determination of eligibility except to the extent
				that he or she makes it available to the eligible members, and the child's
				spouse, if applicable.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:79-3.6 - Household unit for NJ FamilyCare-Children's Program-Plan B, C, and D

Current through Register Vol. 56, No. 14, July 15, 2024
(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 of the household unit:
1. The
				child;
2. The child's natural or
				adoptive parents;
3. The child's
				blood-related siblings, including those of half-blood, and adopted siblings
				under the age of 21;
4. The
				natural or adoptive father of any children in the household unit; and
5. The stepparent, if the stepparent is
				married to the natural parent and his or her children residing in the
				household.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:79-3.7 - Third-party liability

Current through Register Vol. 56, No. 14, July 15, 2024
(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 beneficiary.
(b) Any authorized agent or applicant who
				applies for NJ FamilyCare-Children's Program who is eligible pursuant to
				10:79-3.4(a)1, by
				virtue of the application for benefits, is deemed to have assigned to the
				Commissioner of the Department for Human Services any rights to support for the
				applicant for the purpose of medical care as determined by a court or
				administrative order and any rights to payment for care from any third party.
				Authorized agents, program applicants and beneficiaries are required to
				cooperate in the identification of and the obtainment of any such
				rights.
(c) The eligibility
				determination agency shall advise authorized agents, program applicants and
				beneficiaries of the terms of the assignment and the consequences
				thereto.
(d) The eligibility
				determination agency shall require the authorized agent to pursue any coverage
				for health care services available through a group health plan for which the
				child is eligible that is noncontributory or otherwise results in no premium
				contribution cost to the household unit.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:79-3.8 - Health insurance coverage eligibility rules

Current through Register Vol. 56, No. 14, July 15, 2024
(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, including coverage
				for accidental death and dismemberment only;
3. Disability income insurance;
4. Credit insurance;
5. Liability insurance, and coverage issued
				as a supplement to liability insurance, including automobile
				insurance;
6. Workers' compensation
				or similar insurance;
7. Personal
				injury protection coverage in automobile insurance;
8. Long-term care insurance;
9. Dental-only and vision-only
				coverage;
10. An insurance plan in
				which the child's lifetime total cap has been reached;
11. Hospital indemnity or other fixed dollar
				indemnity insurance if the benefits of such insurance are provided under a
				separate policy, contract or certificate, and, there is no coordination or
				integration of the benefits with a group health plan or other health insurance;
				and
12. Coverage under
				Medicare.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:79-3.9 - Persons sanctioned under TANF or AFDC rules

Current through Register Vol. 56, No. 14, July 15, 2024
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 Program,
				  such as noncooperation with work registration, shall have eligibility
				  determined under this chapter without regard to the sanction.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:79-3.10 - Application for other benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(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 entitled, unless they can show good cause for
				not doing so.
1. Annuities and disability
				benefits include, but are not limited to, veterans' compensation and pensions,
				Social Security benefits, and unemployment compensation. They do not include
				TANF, Supplemental Security Income (SSI), or General Assistance.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:79-3.11 - Inmates of public institutions

Current through Register Vol. 56, No. 14, July 15, 2024
(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 Justice Commission facility awaiting adjudication, is not eligible for
				the NJ FamilyCare-Children's Program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:79-4.2 - Prospective budgeting of income

Current through Register Vol. 56, No. 14, July 15, 2024
(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 reflect changes in income
				that either have occurred or which are reasonably anticipated to occur which
				would affect the household unit's income during a period of eligibility. To
				establish the best estimate, the one-month period immediately preceding the
				date of application or redetermination shall be used.
2. In the case of irregular payments, more
				than one month of income may be used.
3. All applicants should be screened against
				the State wage/disability/unemployment databases and any other appropriate
				database.
4. Documentation of
				income may be pursued if a crossmatch of any of these databases produces
				significant undisclosed income.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:79-4.3 - Countable income-Plan A

Current through Register Vol. 56, No. 14, July 15, 2024
(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
				10:79-3.5, and shall be determined
				in accordance with the rules applicable to income in the AFDC-C program (see
				N.J.A.C. 10:69).
1. The maximum income limits
				as provided for at
				10:69-10.3 do not apply.
2. Neither the $ 30.00 nor the one-third
				disregard of earned income at
				10:69-10.13(c) 
				apply.
3. The deeming of stepparent
				income at 10:69-10.33(d) 
				does not apply. (See
				10:79-3.5(a) 
				regarding the inclusion or exclusion of the stepparent in the household
				unit.)
4. The deeming of an alien
				sponsor's income at
				10:69-10.43 shall not
				apply.
5. Wages paid by the U.S.
				Census Bureau for temporary employment related to Census 2000 activities shall
				not be considered household income.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:79-4.4 - Countable income-Plans B, C and D

Current through Register Vol. 56, No. 14, July 15, 2024
(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
				10:79-3.6.
1. Income from a legally responsible relative
				who does not reside with the family shall be counted only to the extent that
				the income is actually made available to the household unit.
2. A minor child who is in receipt of
				Supplemental Security Income (SSI) shall not be included in the household
				income.
3. Earned income of a child
				who is a student as defined in
				10:69-10.8 shall be counted in the
				household income.
4. Wages paid by
				the U.S. Census Bureau for temporary employment related to Census 2000
				activities shall not be considered household income.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:79-4.5 - Resource eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
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 establish income
				  that may result from the household unit's resources.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 5 - ADMINISTRATION › Section 10:79-5.1 - Eligibility determination agencies-Plans B, C, and D

Current through Register Vol. 56, No. 14, July 15, 2024
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 the NJ FamilyCare-Children's Program-Plans B, C, and D is administered by
				  the Statewide eligibility determination agency under the supervision of the
				  Division of Medical Assistance and Health Services. If a change in the family's
				  financial eligibility level necessitates a transfer from NJ
				  FamilyCare-Children's Program-Plan A to Plan B, the responsibility for the
				  administration of the case may be retained by the CWA if the child is enrolled
				  in an MCO.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 5 - ADMINISTRATION › Section 10:79-5.2 - Administration principles-availability of program rules

Current through Register Vol. 56, No. 14, July 15, 2024
(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 ensure that each staff member is thoroughly
				familiar with its requirements in order to apply the policy and procedures
				consistently.
(b) The Division of
				Medical Assistance and Health Services will issue revisions to this chapter as
				they are promulgated in accordance with New Jersey Administrative Procedure
				Act, 52:14B-1 et seq.
1. At least one administrative copy of all
				obsolete pages of this chapter must be maintained by the eligibility
				determination agency.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 5 - ADMINISTRATION › Section 10:79-5.3 - Principles of administration-general

Current through Register Vol. 56, No. 14, July 15, 2024
(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-Children's Program
				without delay.
2. The authorized
				agent or the emancipated child is the primary source of information concerning
				program eligibility. The eligibility determination agency shall, when
				necessary, in the process of determining eligibility, use secondary sources of
				information with the knowledge and consent of the applicant or eligible
				person.
3. There shall be strict
				adherence to law and complete conformity with rules and administrative policy.
				Requirements other than those established by law or rule shall not be imposed
				as a condition of receiving assistance under the NJ FamilyCare-Children's
				Program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 5 - ADMINISTRATION › Section 10:79-5.4 - Confidentiality of information

Current through Register Vol. 56, No. 14, July 15, 2024
(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. Names and addresses;
ii. Medical services provided;
iii. Social and economic conditions and
				circumstances;
iv. Eligibility
				determination agency evaluation of personal information; and
v. Medical data, including diagnosis and past
				history of disease or disability.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 5 - ADMINISTRATION › Section 10:79-5.5 - Material distributed to NJ FamilyCare-Children's Program applicants or eligible persons

Current through Register Vol. 56, No. 14, July 15, 2024
(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 the NJ
				FamilyCare-Children's Program; and
4. Identify those individuals only in their
				capacity with the State or the eligibility determination agency.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 79 - NJ FAMILYCARE-CHILDREN'S PROGRAM › Subchapter 5 - ADMINISTRATION › Section 10:79-5.6 - Nondiscrimination

Current through Register Vol. 56, No. 14, July 15, 2024
(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, color, national origin, or handicap in the administration of
				any program for which Federal funds are received. Strict compliance with the
				provisions of these Acts and any regulations based thereon is required as a
				condition to receive Federal funds for the assistance programs administered by
				the eligibility determination agencies. These principles apply to the NJ
				FamilyCare-Children's Program in New Jersey.
1. The eligibility determination agency shall
				inform all staff members of their obligations in regard to the Civil Rights Act
				of 1964 ( Pub. L. 88-352 ), section 504 of the Rehabilitation Act of 1973 and
				the Americans with Disabilities Act (ADA),
				Pub. L.
				101-336, codified as
				42 U.S.C. §§
											12101 et seq.
2. All persons seeking medical assistance
				shall be informed of Title VI of the Civil Rights Act of 1964 ( Pub. L. 88-352
				), section 504 of the Rehabilitation Act of 1973 and the Americans with
				Disabilities Act (ADA), Pub. L. 101-336, codified as
				42 U.S.C. §§
											12101 et seq.
3. All persons seeking or receiving medical
				assistance shall be afforded an opportunity to file a complaint alleging
				discrimination on the ground of race, color, national origin, or handicap. Such
				complaints may be filed directly with the Regional Manager, U.S. Department of
				Health and Human Services, Office of Civil Rights, Federal Plaza, New York, New
				York 10007, or with the Director, Division of Medical Assistance and Health
				Services, PO Box 712, Trenton, New Jersey 08625-0712.
4. In any instance in which a complaint of
				alleged discrimination is filed with a State or county agency, the complaint
				shall be forwarded immediately to the Director, Division of Medical Assistance
				and Health Services. The Director, upon receipt of any such complaint, will
				take any such action he or she deems appropriate to the situation. This action
				may include, but is not limited to, the securing of reports from whatever
				sources have knowledge pertinent to the situation and referral to the Division
				of Civil Rights of the New Jersey Department of Law and Public Safety, for
				investigation, evaluation, and recommendation by that agency.
5. The eligibility determination agency shall
				afford full cooperation in the investigation of complaints of discrimination as
				may be requested by the Federal Department of Health and Human Services, the
				State Division of Medical Assistance and Health Services, or the State Division
				of Civil Rights.