reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 1 - INTRODUCTION › Section 10:78-1.8 - Assignment of medical support rights

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any person who
				applies for NJ FamilyCare, by virtue of the application for benefits, shall be
				deemed to have assigned to the Commissioner of the Department of Human Services
				any rights to support 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. Program applicants and beneficiaries shall cooperate in the
				identification of and the obtainment of any such rights. Failure to cooperate
				shall result in denial of eligibility for any adult. Children shall not be
				subject to this sanction.
1. The eligibility
				determination agency shall advise program applicants and beneficiaries of the
				terms of the assignment and the consequences thereto.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 1 - INTRODUCTION › Section 10:78-1.9 - Applicability to this chapter of Medicaid provisions relating to fraud and abuse, third party liability and administrative and judicial remedies

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 NJ FamilyCare:
				  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 2 - CASE PROCESSING › Section 10:78-2.1 - Application

Current through Register Vol. 56, No. 14, July 15, 2024
(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 various social service locations, by calling the
				Division or by calling the NJ FamilyCare program at 1-800-701-0710. Applicants
				may also apply for the NJ FamilyCare program by completing an online
				application form at
http://www.njfamilycare.org
or
http://www.NJHelps.org
. The
				eligibility determination agencies shall process all applications mailed,
				forwarded or presented to them.
(b)
				The eligibility determination agency shall:
1. Inform applicants of the purpose of and
				the eligibility requirements for the NJ FamilyCare program, including their
				rights to a grievance review;
2.
				Receive applications and review them for completeness, consistency, and
				reasonableness;
3. Assist program
				applicants in exploring their eligibility for program benefits;
4. Make known to program applicants 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 Eligibility File for
				beneficiaries and prompt notification to beneficiaries of the reason for their
				eligibility or ineligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 2 - CASE PROCESSING › Section 10:78-2.2 - Interview

Current through Register Vol. 56, No. 14, July 15, 2024
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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 2 - CASE PROCESSING › Section 10:78-2.3 - Verification requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(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
				between the age reported by the applicant and the age appearing on the program
				record and the discrepancy affects eligibility or categorical requirements then
				the applicant shall be required to submit proof of birth date;
2. Citizenship/Immigration status: The
				immigration status of any individual seeking benefits who is not a citizen of
				the United States shall be verified to establish entitlement for NJ FamilyCare
				benefits;
3. Household composition:
				The eligibility determination agency shall verify the household composition in
				order to ascertain which persons will be included in the determination of
				eligibility for NJ FamilyCare benefits;
4. Social Security number: The Social
				Security number of any person seeking NJ FamilyCare benefits shall be provided
				and verification shall be required when other information indicates a
				discrepancy regarding the Social Security number;
5. Eligibility for, or coverage under, other
				health insurance; and
6. All
				sources of income of any person whose income shall be counted in the
				determination of program eligibility.
i. To
				verify income, a new applicant shall submit one recent pay stub from each
				employer of each household member.
ii. If a household member cannot provide a
				recent pay stub, the household member may submit another form of income
				verification as the Division allows, such as a letter from his or her employer,
				on the employer's letterhead.
iii.
				If the applicant fails to submit income verification in a timely manner, before
				determining the applicant ineligible for the NJ FamilyCare program, the
				Division shall seek to verify the household's income by reviewing available
				records from the Department of Treasury or Department of Labor and Workforce
				Development concerning the household members, or such other records as the
				Division allows.
iv. Although
				resources are not a factor of eligibility, resources shall be identified and
				verified to determine if income is derived from the resources.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 2 - CASE PROCESSING › Section 10:78-2.4 - Case transfer from one county to another

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 78 - NJ FAMILYCARE › Subchapter 2 - CASE PROCESSING › Section 10:78-2.5 - Case transfer from one eligibility determination agency to another

Current through Register Vol. 56, No. 14, July 15, 2024
(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, because of an
				initial screening, it is determined that the eligibility determination agency
				shall 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 materials in (a)1i above, with a
				cover letter specifying that the application is being transferred and
				requesting written or verbal acknowledgment of receipt.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 2 - CASE PROCESSING › Section 10:78-2.6 - Redetermination of eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(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
				10:78-4.5.)
(b) The eligibility determination agency
				shall reassess program eligibility as follows:
1. When indicated based upon previous
				information obtained by the eligibility determination agency about anticipated
				change in the case situation or when additional information is needed to
				ascertain income eligibility for the program; and
2. Promptly after information is obtained by
				the eligibility determination agency which indicates changes in the case
				circumstances that may affect program eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 2 - CASE PROCESSING › Section 10:78-2.7 - Post-application beneficiary responsibilities

Current through Register Vol. 56, No. 14, July 15, 2024
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
				  10:78-2.1(c). At
				  any time that the eligibility determination agency lacks sufficient
				  information, including that information which is available from other programs
				  or data sources, to confirm continuing program eligibility because of the
				  unwillingness of an eligible person to provide necessary information, the
				  agency shall commence action to terminate the case.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 3 - NONFINANCIAL ELIGIBILITY › Section 10:78-3.1 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(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 forth in the application form, are evidence. The
				statements shall 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 78 - NJ FAMILYCARE › Subchapter 3 - NONFINANCIAL ELIGIBILITY › Section 10:78-3.2 - Citizenship

Current through Register Vol. 56, No. 14, July 15, 2024
(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 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 78 - NJ FAMILYCARE › Subchapter 3 - NONFINANCIAL ELIGIBILITY › Section 10:78-3.3 - State residency

Current through Register Vol. 56, No. 14, July 15, 2024
(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 presently removing therefrom.
1. If an individual leaves New Jersey with
				the intent to establish permanent residence elsewhere, or for an indefinite
				period for purposes other than a temporary visit, he or she ceases to be
				eligible to receive NJ FamilyCare from this State.
2. When an individual enters this State in
				order to receive medical care and applies for NJ FamilyCare 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 person ineligible for the NJ FamilyCare 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 individual to remain permanently
				in this State;
iii. Whether there
				is objective evidence that the individual 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 individual
				previously resided recognizes him or her as having continuing eligibility under
				the Medicaid program (or other program providing payment for medical care) of
				that jurisdiction.
3.
				If, after full consideration of the above factors, the eligibility
				determination agency is satisfied that the individual has become a resident of
				this State, NJ FamilyCare eligibility may be established.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 3 - NONFINANCIAL ELIGIBILITY › Section 10:78-3.5 - Household unit

Current through Register Vol. 56, No. 14, July 15, 2024
(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. In the case of a parent or caretaker:
i. The parent or caretaker;
ii. The spouse of the parent or
				caretaker;
iii. The parent or
				caretaker's natural or adoptive children under the age of 21;
iv. The blood-related siblings (including
				those of half-blood) of the parent or caretaker's children who are under the
				age of 21; and
v. The natural or
				adoptive father of any children in the household unit;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 3 - NONFINANCIAL ELIGIBILITY › Section 10:78-3.6 - Third party liability and other health insurance

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) For the purposes of this section, the
				terms "health insurance" or "group health plan" do not include:
1. Student coverage which is defined as a
				limited coverage policy covering injuries sustained during school or
				school-sponsored activities;
2.
				Accident-only coverage (including death and dismemberment);
3. Disability income insurance;
4. Credit insurance;
5. Liability insurance, and coverage issued
				as a supplement to liability insurance, including automobile
				insurance;
6. Worker's compensation
				or similar insurance;
7. Personal
				injury protection coverage in automobile insurance;
8. Long-term care insurance;
9. Dental-only and vision-only coverage;
				and
10. 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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 3 - NONFINANCIAL ELIGIBILITY › Section 10:78-3.7 - Persons sanctioned

Current through Register Vol. 56, No. 14, July 15, 2024
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) shall have
				  eligibility determined under this chapter without regard to the sanction.
				  Persons other than children and pregnant women sanctioned for non-cooperation
				  of medical support under provisions of
				  10:69-10.28 shall be subject to
				  the same sanction under NJ FamilyCare (for persons ineligible for AFDC-related
				  Medicaid due to a period of ineligibility imposed as a result of the receipt of
				  lump sum income, see
				  10:78-4.3(c)  ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 3 - NONFINANCIAL ELIGIBILITY › Section 10:78-3.8 - Application for other benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(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 so. Applicants and beneficiaries shall avail
				themselves of any health insurance coverage available to the household unit at
				no cost, such as coverage provided by an employer at no cost.
1. Annuities, pensions, retirement and
				disability benefits include, but are not limited to, veterans' compensation and
				pensions, Social Security benefits, and unemployment compensation. TANF,
				Supplemental Security Income (SSI), or Work First New Jersey/General Assistance
				are excluded.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 3 - NONFINANCIAL ELIGIBILITY › Section 10:78-3.9 - Inmates of public institutions

Current through Register Vol. 56, No. 14, July 15, 2024
(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 FamilyCare program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:78-4.2 - 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 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. 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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:78-4.3 - Countable income

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as
				specified below, countable income shall include the income of all members of
				the household unit as determined at
				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 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 full or part-time student as defined in
				10:69-10.15 shall be counted in
				the household income.
i. For those
				individuals who would qualify for AFDC-related Medicaid or NJ FamilyCare Plan A
				except for alien residency restriction, earned income of a child who is a full
				or part-time student as defined at
				10:69-10.15 shall not be counted;
				and
4. All wages paid by
				the Census Bureau for temporary employment related to Census 2000 activities
				shall be excluded from earned income.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:78-4.4 - Income eligibility for single adults and couples without dependent children who applied as such for NJ FamilyCare benefits prior to September 1, 2001, and who have received those benefits continuously

Current through Register Vol. 56, No. 14, July 15, 2024
(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 Medicaid Special.
(b) When a single adult or couple without
				dependent children is determined not to be eligible for WFNJ/GA, the
				eligibility determination agency shall continue to evaluate possible
				eligibility for NJ FamilyCare or refer the application to the appropriate
				agency. Eligibility shall exist when the single adult or couple without
				dependent children meets the following financial criteria:
1. The gross income of an eligible single
				adult or couple without dependent children shall be no greater than 100 percent
				of the poverty level for the applicable family unit size, one or two, at the
				time the individual applies or reapplies for coverage, or when the case is
				reopened.
i. If one member of a couple is
				currently enrolled in a Medicaid program other than the Medically Needy
				program, that person's gross income shall not be counted in determining the
				eligibility of the other member of the couple for NJ FamilyCare.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:78-4.5 - Redetermination of eligibility for single adults and couples without dependent children who applied as such for NJ FamilyCare benefits prior to September 1, 2001, and continuously have received those benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(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
				10:78-4.1 shall be applied in
				determining whether the gross income remains no greater than 100 percent of the
				poverty level.
(b) All wages paid
				by the Census Bureau for temporary employment related to Census 2000 activities
				shall be excluded from earned income.
(c) If, as a result of any eligibility
				redetermination, a single adult or couple without dependent children is found
				to be ineligible for NJ FamilyCare, the eligibility determination agency shall
				evaluate the case for possible eligibility for other programs and shall make
				direct arrangements or referrals, as appropriate, to enroll these individuals
				in other programs for which they may be eligible.
(d) An eligibility redetermination shall
				occur 12 months following the date of the previous determination or
				redetermination for each single adult or couple without dependent children
				initially determined to be eligible for NJ FamilyCare. This redetermination
				shall be conducted by the eligibility determination agency responsible for the
				case at the time the redetermination is required.
(e) For those individuals who are receiving
				benefits under Work First New Jersey/General Assistance, the redetermination
				cycle shall follow the schedule set forth in N.J.A.C. 10:90.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:78-4.6 - Resource eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
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 that may
				  result from the household unit's resources.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 5 - PRESUMPTIVE ELIGIBILITY › Section 10:78-5.1 - General presumption eligibility information

Current through Register Vol. 56, No. 14, July 15, 2024
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 income up to
				  185 percent of the FPL, receive presumptive eligibility services under the
				  provisions of N.J.A.C. 10:72. Pregnant women whose income is over 185 percent,
				  but does not exceed 200 percent, of the FPL receive presumptive eligibility
				  services in accordance with this chapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 6 - ELIGIBILITY DETERMINATION AGENCY ADMINISTRATIVE REQUIREMENTS › Section 10:78-6.1 - Notice of the eligibility determination agency decision

Current through Register Vol. 56, No. 14, July 15, 2024
(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 to a grievance review, the action shall not be
				implemented until at least 10 days after the mailing of the notice (see (e)
				below for exceptions to the 10-day notice requirement).
1. For notices of action adverse to a
				beneficiary, the date of mailing of the notice shall appear on the
				notice.
2. Notices of any
				eligibility determination agency action shall contain the name, address, and
				telephone number of the legal services agency serving that county.
3. In the case of an applicant or beneficiary
				who cannot be located, the notice shall be mailed to his or her last known
				address.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 6 - ELIGIBILITY DETERMINATION AGENCY ADMINISTRATIVE REQUIREMENTS › Section 10:78-6.2 - Case records

Current through Register Vol. 56, No. 14, July 15, 2024
(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, as well as documentary
				evidence relating to such actions and decisions, including application
				forms;
2. All forms relating to
				financial eligibility; and
3. All
				case-related correspondence, memorandum, and documents except those required by
				law or regulation to be maintained elsewhere.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 7 - SERVICES UNDER NJ FAMILYCARE › Section 10:78-7.1 - Scope of services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The NJ
				FamilyCare "Plan A" service package shall contain those services described at
				10:49-5.2.
(b) The NJ FamilyCare "Plan D" benefit
				package shall contain those services described at
				10:49-5.7. Those FamilyCare Plan D
				beneficiaries whose income is above 150 percent of the Federal poverty level
				shall be responsible for copayments for services received, in accordance with
				the provisions of this chapter.
1. No cost
				sharing shall be imposed on children who are American Indians or Alaska Natives
				as defined at
				42 CFR
				457.10. Proof of Federally recognized AI/AN
				tribal status shall be provided in the form of a tribal card or
				letter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 8 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:78-8.1 - Grievance reviews

Current through Register Vol. 56, No. 14, July 15, 2024
(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 composition;
ii. Earned and unearned income calculations;
				and
iii. Interpretation of
				residency, citizenship and age requirements.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 8 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:78-8.2 - Fair hearing

Current through Register Vol. 56, No. 14, July 15, 2024
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 under the
				  provisions of any other law, rule, or regulation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 8 - BENEFICIARY RIGHTS AND RESPONSIBILITIES › Section 10:78-8.3 - Post-application responsibilities

Current through Register Vol. 56, No. 14, July 15, 2024
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
				  10:78-2.7. The applicant shall
				  provide additional information as requested by the eligibility determination
				  agency. At any time that the eligibility determination agency lacks sufficient
				  information to confirm continuing program eligibility because of the
				  unwillingness of the applicant or beneficiary to provide necessary information,
				  the agency shall commence action to terminate the case and pursue recovery when
				  warranted.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(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 to employer-sponsored health plans. Assistance will be provided in the
				form of a direct subsidy payment to the beneficiary for a portion of the
				payroll deduction required for participation in the employer-sponsored health
				plan. Beneficiaries will be reimbursed on a regular schedule, to coincide with
				their employer's payroll deduction, so as to minimize any adverse financial
				impact on the beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
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
				  employed an average of more than 50 employees on business days during the
				  preceding calendar year.
"Small employer" means any person, firm, corporation,
				  partnership or political subdivision that is actively engaged in business that
				  employed an average of at least two, but no more than 50, employees on business
				  days during the preceding calendar year.
"Wraparound service" means any service that is not covered by
				  the enrollee's employer plan that is an eligible service covered by NJ
				  FamilyCare for the enrollee's category of eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.3 - Who is eligible to participate in NJ FamilyCare/Premium Support Program

Current through Register Vol. 56, No. 14, July 15, 2024
(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
				access to an employer-sponsored health plan prior to applying to participate in
				the PSP.
(c) In order to
				participate in the PSP, a PSP applicant employed by a large employer shall
				first have access to an employer-sponsored plan which provides coverage at
				least equal to the services provided in the NJ FamilyCare Plan D service
				package.
(d) If an applicant is
				employed by a small employer, the specific services available to the applicant
				shall be at least equal to the services in the NJ FamilyCare Plan D service
				package; however, the extent of coverage of the services need not be the same
				as the extent of coverage in the NJ FamilyCare Plan D service package. For a
				comprehensive listing of small employers health plans, refer to N.J.A.C. 11:21.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.4 - Premium Support Program enrollment process

Current through Register Vol. 56, No. 14, July 15, 2024
(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 applicant has access to employer-sponsored
				health benefits, the applicant shall enroll in the Premium Support Program, in
				accordance with the provisions of this subchapter.
(b) If the applicant meets the criteria in
				(a) above, the State Eligibility Vendor for the NJ FamilyCare program or the
				County Board of Social Services that made the determination of eligibility will
				refer the case record for review to:
DMAHS/PSP
PO Box 712
Mail Code 46
Trenton, NJ 08625-0712
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.5 - Application review

Current through Register Vol. 56, No. 14, July 15, 2024
(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 documentation, including, but not limited to,
				any information provided by the applicant regarding his or her employer's
				health benefit plan.
(b) The
				application will be reviewed for completeness and NJ FamilyCare eligibility
				will be verified by the Division.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.6 - Applicant's responsibilities during the application process

Current through Register Vol. 56, No. 14, July 15, 2024
(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 employee fails to provide the
				Division with the information needed to complete the application review, the
				application for premium support shall be denied.
1. If the application for premium support is
				denied due to lack of cooperation by the employer, the applicant (and family,
				if applicable) shall continue to participate in a State-contracted managed care
				plan through the NJ FamilyCare program.
2. If the application for premium support is
				denied due to lack of cooperation by the applicant, after three attempts by the
				Premium Support Program to contact the applicant by letter (in addition, a
				phone call will be made if a phone number is available), the NJ FamilyCare
				participation of the applicant and any other adult eligible members of the
				household shall be terminated immediately. The eligible children in the
				household will continue to remain eligible until the next annual
				redetermination, at which time the applicant's failure to cooperate and provide
				necessary information shall result in termination of NJ FamilyCare eligibility
				for all members of the household.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.7 - Premium Support Program data collection

Current through Register Vol. 56, No. 14, July 15, 2024
(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. Send a letter and a Request
				for Information Form to the applicant's employer, seeking information on the
				type of employer-sponsored health plan(s) available to the employee.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.8 - Employer participation criteria

Current through Register Vol. 56, No. 14, July 15, 2024
(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 indication by the applicant's employer that the employer contributes, at a
				minimum, 50 percent of the annual cost of the insurance premium for the
				employee (and family, as applicable). If the employer does not contribute 50
				percent of the premium cost, the PSP application shall be denied and the
				applicant shall continue to participate in a State-contracted managed care
				program through the NJ FamilyCare program.
(c) If the employer does attest to
				contributing, at a minimum, 50 percent of the annual cost of premium on behalf
				of the employee (and family, as applicable), the Division will evaluate the
				application for cost-effectiveness, in accordance with
				10:78-9.10.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.9 - Employer plan review

Current through Register Vol. 56, No. 14, July 15, 2024
(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 follows:
1.
				Step I: The employer-sponsored plan shall be compared, benefit-by-benefit, to
				the NJ FamilyCare Plan 'D' service package, to determine whether the
				employer-sponsored plan's services are the same services the employee would be
				eligible for under NJ FamilyCare.
i. If the
				employer is a large employer, both the specific services and the extent of
				coverage of the services shall be at least equal to the services in the NJ
				FamilyCare Plan D service package.
ii. If the employer is a small employer, the
				specific services shall be identical to the services in the NJ FamilyCare Plan
				D service package; however, the extent of coverage of the services need not be
				the same as the extent of coverage in the NJ FamilyCare Plan D service package.
				For small employer health plan information, refer to N.J.A.C. 11:21.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.10 - Cost-effectiveness test

Current through Register Vol. 56, No. 14, July 15, 2024
(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 of family coverage less
				a monthly premium contribution amount for the family purchasing the employer
				plan. The amounts used for the calculations in this section shall be derived
				from actuarial tables used by the NJ FamilyCare program and actual costs
				reported by the employee/employer during the processing of the Premium Support
				Program (PSP) application.
(b) For
				the State to provide benefits under NJ FamilyCare, an actuarially valid total
				cost per family per month will be determined, using current data from NJ
				FamilyCare (NJFC), Managed Care participant rates.
(c) The cost of the employer-sponsored plan
				shall be determined by totaling the costs to the State to participate in the
				employer-sponsored plan.
1. The monthly amount
				of the employee premium plus the actuarial value of all excess cost-sharing
				expenditures (co-payments, deductible and coinsurance), less the NJ
				FamilyCare/Premium Support Program monthly premium amount, plus the cost of
				"wraparound" services, if applicable, will constitute the total cost to the
				State to purchase the employer plan.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.11 - Plan approval notification and premium support payments

Current through Register Vol. 56, No. 14, July 15, 2024
(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 eligible family members be enrolled in the
				employer-sponsored plan at the earliest possible date.
(b) The letter of notification will provide a
				suggested future date of plan enrollment, and a date on which the first PSP
				payment should be made.
1. The first PSP
				payment will be made to the employee in advance of the first payroll deduction
				by the employer.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.12 - Payment of premium support to beneficiaries

Current through Register Vol. 56, No. 14, July 15, 2024
(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 of
				payroll deductions as established by the employer.
(c) The amount of the periodic payments to
				the employee shall be the amount of the employee's contribution to the
				employer's plan, less the monthly NJFC/PSP premium amounts for which the
				employee is responsible, in accordance with
				10:78-9.13.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.13 - NJ FamilyCare/Premium Support Program payment formula

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A monthly
				premium charge shall be assessed and collected for all participants in the NJ
				FamilyCare Premium Support Program (PSP), in accordance with
				10:49-9.2 and (b) below. PSP
				participants shall be assessed $ 10.00 less per payment for children and $ 5.00
				less per payment per adult than the standard NJ FamilyCare premium payments.
				The assessments shall be deducted from the premium support payments remitted to
				the beneficiary in accordance with
				10:78-9.12.
(b) Premiums shall be paid monthly for
				children and parents/caretakers enrolled in NJ FamilyCare Plans C, D and H who
				are PSP participants in accordance with Table 1 below. The single monthly
				premium for children shall include all children in the family. The monthly
				premium for parents/ caretakers shall include the first parents/caretaker and
				the second parents/caretaker premiums indicated in Table 1, as applicable.
TABLE 1
NJ FamilyCare Premium Payments for PSP
						  Participants
Effective July 1, 2006
Premiums for Children
Plan C
$ 8.00
Plan D (over 200 percent FPL up to and
$ 26.00
including 250 percent FPL)
Plan D (over 250 percent FPL up to and
$ 62.00
including 300 percent FPL)
Plan D (over 300 percent FPL up to and
$ 110.50
including 350 percent FPL
Premiums for parents/caretakers
Plan D (over 150 percent FPL up to and
including 200 percent FPL)
First parent/caretaker in the family
25.50
Second parent/caretaker in the family
$ 7.50
Plan H (over 150 percent FPL up to and
including 250 percent FPL)
First parent/caretaker in the family
$ 25.50
Second parent/caretaker in the family
$ 7.50
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 78 - NJ FAMILYCARE › Subchapter 9 - PREMIUM SUPPORT PROGRAM PSP › Section 10:78-9.14 - Payment of cost sharing expenditures

Current through Register Vol. 56, No. 14, July 15, 2024
(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 the employer-sponsored plan co-pay
				charge is $ 15.00 for the same service, the PSP will reimburse the beneficiary
				the difference in excess of the NJFC/PSP co-payment amount ($ 10.00).
(b) Copayment amounts for services available
				through the HMO shall be consistent with those of the NJ FamilyCare program
				(see N.J.A.C. 10:78).