Effective Date: April 1, 2009

Approval Date: ____________ 1

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN'S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children's Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Effective Date: April 1, 2009

Approval Date: ____________ 2

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN'S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: ___________________New Jersey________________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

__________________________/S/______________________________________________ Jennifer Velez [James M. Davy]

Date (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children's Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Jennifer Velez [James M. Davy]

Position/Title: Commissioner, Department of Human Services Name: John R. Guhl [Ann Clemency Kohler] Position/Title: Director, Division of Medical Assistance and Health Services Name: Carol Grant [Michelle Walsky] Position/Title: Chief of Operations, Division of Medical Assistance and Health Services Name: Michael P. Keevey [John R. Guhl]

Position/Title: Chief Financial Officer, Division of Medical Assistance and Health Services

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for

Effective Date: April 1, 2009

Approval Date: ____________ 3

improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2

Providing expanded benefits under the State's Medicaid plan (Title XIX); OR

1.1.3

A combination of both of the above.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

The State assures that it will not claim expenditures for child health assistance prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

The State assures that it complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

1.4

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Original Submission:

Effective Date: February 1, 1998

Implementation Date: February 1, 1998

Effective Date: April 1, 2009

Approval Date: ____________ 2

SPA# 1. Six-Month Rule

Effective Date: January 13, 1999

Implementation Date: January 13, 1999

SPA# 2. NJ KidCare Plan D

Effective Date: July 1, 1999

Implementation Date: July 1, 1999

SPA# 3. Crowd Out (Exceptions to 6-month period)

Effective Date: July 26, 1999

Implementation Date: July 26, 1999

SPA# 4. Presumptive Eligibility

Effective Date: January 1, 2000

Implementation Date: January 1, 2000

SPA# 5. No cost share for AI/AN children

Effective Date: August 24, 2001

Implementation Date: August 24, 2001

SPA# 6. Income disregard of cash rewards for reporting fraud/abuse

Effective Date: February 4, 2002

Implementation Date: February 4, 2002

SPA# 7. Premium Increases for NJ KidCare (NJ FamilyCare Children’s Program)

Effective Date: May 22, 2003

Implementation Date: May 22, 2003

SPA# 8. SCHIP Compliance SPA

Effective Date: August 24, 2001

SPA# 10. Prior Authorization for Personal Care Assistant Services Effective Date: (Withdrawn)

SPA# 11. Substitution of Insurance; Presumptive Eligibility; Continuous Eligibility

Effective Date: May 1, 2005

Implementation Date: May 1, 2005

SPA# 12. Pregnant Women 185% to 200% FPL, CHIP Reauthorization Act 2009

Effective Date: April 1, 2009

Implementation Date: April 1, 2009

Effective Date: April 1, 2009

Approval Date: ____________ 3

Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

The descriptions contained in this section are related to the State Child Health Insurance Program only. Section 2 does not contain information related to New Jersey's 1115 demonstration.

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public- private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

The chart below describes the extent to which children in New Jersey currently have creditable coverage. The data for the number of children with employer- related group coverage, with other/non-group coverage and Medicaid coverage, as well as the number of uninsured children, is based on the March 1996 Current Population Survey (CPS) data for 1995. While there are some known deficiencies with CPS data, it does provide for the most consistency at this time. The CPS data will be updated based on the March 2002 CPS.

Attributes of Population Children in Employer-related group Coverage Children with other/non-group coverage* Medicaid- enrolled children Uninsured children Income Level

< 100% 29,987 23,537 143,357 67,749 < 133% 48,876 3,804 22,974 37,989 < 185% 82,882 19,773 23,890 43,692 < 200% 22,885 7,228 0 8,562 > 200% 1,301,132 48,539 32,348 90,630 Age

0 - 1 80,606 5,433 7,311 19,160 1 - 5 451,865 13,808 53,041 88,418 6 - 12 555,381 31,905 77,599 72,982 13 - 18 397,910 51,736 84,618 68,062

Effective Date: April 1, 2009

Approval Date: ____________ 4

Race and Ethnicity

American Indian or Alaskan Native 6,390 0 0 0 Asian or Pacific Islander 117,218 2,491 13,239 5,706 Black, not of Hispanic origin 127,197 7,268 67,293 16,804 Hispanic 148,701 8,330 84,896 63,167 White, not of Hispanic origin 1,086,257 84,792 57,140 162,945

* Includes Champus/TriCare and Medicare

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

New Jersey has taken a wide variety of steps to identify and enroll all uncovered children who are eligible to participate in public health insurance programs such as Medicaid and NJ FamilyCare. Fundamental to this effort are the existing providers and social services network. Providers likely to come in contact with low-income uninsured individuals, such as hospitals and federally-qualified health centers, are aware of the Medicaid/NJ FamilyCare eligibility standards and refer children to the appropriate eligibility determination entity (county boards of social services and the state health benefits coordinator). Additionally, eligibility workers are outstationed in hospitals and Federally Qualified Health Centers (FQHCs) in order to take on-site applications for potentially eligible individuals, using the expedited presumptive eligibility process.

Public health agencies are another important source of outreach and information for potentially eligible children. Staff at programs run by WIC, HeadStart and local health departments are familiar with Medicaid/NJ FamilyCare eligibility requirements and screen their clients accordingly. Programs such as Healthy Mothers, Healthy Babies send outreach workers into the community in attempts to assist pregnant women and children in getting necessary health care services. Additional methods used follow.

Application Process: The eligibility and enrollment process is now simpler and

Effective Date: April 1, 2009

Approval Date: ____________ 5

faster. The application has been revised and simplified, so that information regarding all potentially eligible children will be easier for parents to include on the application. The new application design was field tested in 2003 and proved successful. Resource and asset tests are no longer components of expansion programs involving children.

The application process now allows self-declaration of income in eight school districts of the State, of which at least two each are in the northern, central and southern areas of the State, respectively, and at least four of which are in the so- called “Abbott” (i.e., lower income) school districts.

“NJ Helps” is a social service computer network used by several state agencies. Technology allows screening for several programs, including Medicaid/NJ FamilyCare, to take place which results in a determination of potential eligibility.

Back to School Fairs: NJ FamilyCare participates with the Covering Kids and Families grantees in annual back-to-school campaigns around the state, where NJ FamilyCare giveaways (pens, pencils, lanyards, rulers) and program materials are distributed. These items are also provided to local health departments around the state, where uninsured children go for their immunizations before they start school.

Health Assemblies: NJ FamilyCare provided health assemblies for grades K-6. The assemblies are targeted to schools in areas representing the potential Plan D population (200-350% FPL), whose percentage of enrollment is much less than that of lower income groups. The “Caring Coach” Robot, the official NJ FamilyCare mascot, represented NJ FamilyCare and did an exciting job of promoting healthy habits and utilization of health services. Following his 45- minute presentation, each child is given a colorful activity book to take home. Information about NJ FamilyCare is included in this booklet.

School Athletics Programs: The NJ FamilyCare Sports Brochure is mailed to Athletic Directors to help get uninsured children in school athletic programs covered so the children can participate on the school teams. The athletic directors were given lanyards (for their whistles) with the NJ FamilyCare name and phone number printed on them, so they have the number handy for referrals. The Commissioner of Education’s office encourages the Athletic Directors to help get the uninsured athletes enrolled in NJ FamilyCare. The state provides Athletic Directors with a Sports Brochure which they can send home to parents of athletes, along with letters encouraging applications to NJ FamilyCare.

School Newspaper Essay Contest for Teens: Despite the steady growth of enrollment in NJ FamilyCare, one pocket of our target audience that has been more difficult to reach is the teen population. Using information provided by Health Resources and Services Administration (HRSA) through Health Systems Research, Inc., which showed that many teens have very little understanding of

Effective Date: April 1, 2009

Approval Date: ____________ 6

the concept of health insurance, and often lack the knowledge to seek preventative health services, the state developed a NJ FamilyCare journalism contest. High school newspapers were invited to submit articles informing their fellow students about the problems related to having no health insurance and the availability of state-sponsored health insurance for those who qualify, as well as addressing the long-term benefits of preventative care and living a healthful life. Many instructive articles were submitted from school newspapers around the state, and three winners were chosen from among the participants. Each winner received a laptop computer, and the schools they represented received a desktop computer for the school paper.

School Nurses: A NJ FamilyCare “tool kit” was mailed to all school nurses to help them spread the word about the program. The tool kit includes letter templates for the nurses’ use in communicating with parents, program materials, premium items and other items.

Free and Reduced School Lunch Program: The Free and Reduced School Lunch application is used to inform families about NJ FamilyCare. Uninsured families are directed to the NJ FamilyCare website and toll-free number for information about the program. The Commissioner of Education annually supports the NJ FamilyCare efforts to reach uninsured children by writing a letter to superintendents and principals asking them to duplicate the NJ FamilyCare fact sheet and distribute it to all students, and to identify and help enroll the uninsured children in their school. The New Jersey Department of Education also has NJ FamilyCare information on their website. An Express Enrollment for Children’s Health Care Coverage pilot program was developed for the 2004-2005 school year. The application process now allows self-declaration of income in eight school districts of the State, of which at least two each are in the northern, central and southern areas of the State, respectively, and at least four of which are in the so-called “Abbott” (i.e., lower income) school districts.

Teachers Annual Education Association Convention: NJ FamilyCare staff attend the two-day NJ Education Association (NJEA) convention in Atlantic City, where they distribute promotional and educational materials about NJ FamilyCare and speak to thousands of teachers and school nurses, keeping them informed of the latest issues regarding the program.

American Indian/Alaska Native Outreach: Although New Jersey does not have any federally recognized tribes living in the state, the Office of NJ FamilyCare has contacted the education coordinator of the Powhatan-Lenape Nation, which provides services to other tribes in New Jersey. Information regarding NJ FamilyCare was sent and an offer was extended to speak at one of their meetings. Further contact will be made with the Indian Health Service to facilitate communication.

Multilingual Materials: Informational materials on NJ FamilyCare are now

Effective Date: April 1, 2009

Approval Date: ____________ 7

available in eight different languages, including English, Spanish, French, Portuguese, Korean, Polish, Chinese, and Arabic, making it possible for outreach efforts to touch every segment of the population. Informational materials reminding parents of well-child services, such as blood lead level testing, are also available and are mailed regularly to parents of enrollees. Applications are routinely available in English and Spanish, and are also made available in other languages, when requested. Letters and emails are received and responded to in any language used by the writer.

Primary Care Association: NJ FamilyCare meets with the Association bimonthly to coordinate outreach efforts and to provide program updates, such as training on updated application forms.

Give Kids A Smile: Letters and materials are sent to dentists annually to encourage them to refer children for enrollment, and to provide locations for enrollment during this national event.

Child Behavioral Health Services Outreach: Training sessions regarding enrollment are provided for care management organizations serving children with mental/behavioral health service needs.

New Jersey Motor Vehicle Commission: The NJMVC displays posters and informational materials in MVC offices throughout the state.

Conferences: Staff attend, and present information at various conferences regarding the targeted population groups, such as the NJIPN Immigrant Healthcare conference.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

Outreach efforts included a private/public sector school outreach program, corporate partnerships with organizations serving markets that attract low- and middle-income children and parents, a grant-funded collaborative effort to reach community-based organizations, development of outreach training sessions and printed material to encourage hospital and faith-based organizations to participate. A directory, listing 500 application assistance sites statewide, an education/awareness video for use in county welfare offices and in local businesses, and a number of exhibits, training sessions and presentations are used to encourage application to NJ FamilyCare.

NJ FamilyCare participated in the development of the education/awareness video with Health Research and Educational Trust of NJ (HRET), in an effort to inform people about NJ FamilyCare and the importance of health insurance in meeting a family’s healthcare needs. The video was produced in both English and Spanish,

Effective Date: April 1, 2009

Approval Date: ____________ 8

and was distributed to WIC offices, hospital emergency rooms, pre/post natal birthing classes and primary care offices. Other viewing sites include county welfare offices, unemployment offices, and local business sites, such as closed circuit TVs in convenience stores.

The NJ FamilyCare Outreach Worker Training Manual is designed to complement the state’s training programs for government and non-government organizations and serve as a reference tool for trained outreach workers, as well as a train-the- trainer or self-instructing manual for new employees or those who may not be able to attend the one-day training. The manual includes a summary of the NJ FamilyCare eligibility guidelines, information on application completion, outreach tips and important contact information. Also, sample outreach materials can be found in the pockets, along with an order form for requesting more copies. By assisting outreach workers, this resource guide makes the application process easier and more accessible for families, and eventually improves children’s access to health insurance coverage.

Scholastic Inc. Magazine: The state partners with Scholastic Marketing Partners to produce health-based curricula for the schools with the NJ FamilyCare logo prominently displayed. For the school year 2002-2003, three different sets of materials were provided for grades K-3, 4-6, and 6-8, stressing the importance of good nutrition, fitness, safety, and preventative care. In addition, for the older grades, there was a lesson on the comparison of annual NJ FamilyCare costs a non-insured versus an insured person. The content was age- appropriate and included: lesson plans that meet the state’s core curriculum standards, creative homework assignments requiring parent participation, and posters for the teachers to display. All of the take home materials contained NJ FamilyCare contact information.

Media: NJ FamilyCare has used a variety of media outlets to inform the targeted public. The Governor has promoted the availability of NJ FamilyCare through paid radio advertisements during the annual “Back to School” campaign.

In addition, NJ FamilyCare is in partnership with NJN (the New Jersey public television network). A 15-second spot promoting health insurance for children aired throughout the year around “PBS Kids” and “NJEA Classroom Close-up” programming. In addition, NJ FamilyCare ran a 60 second spot, with participation from our Governor, on 30 radio stations throughout the state, in both English and Spanish, with the message “Don’t think you make too much to qualify. Families qualify every day who never imagined they’d be eligible.”

Gannett Publishers, which includes seven newspapers across the state (Courier Post, Vineland Daily Journal, Asbury Park Press, Home News Tribune, Daily Record, and the Courier News), promotes “Kids Health” and spotlights the availability of NJ FamilyCare.

Effective Date: April 1, 2009

Approval Date: ____________ 9

The NJ FamilyCare website (www.njfamilycare.org) was updated to reflect not only program changes, but to include an extensive question and answer section. The most frequently asked questions and other possible issues or questions that a potential applicant might have are addressed on the web site.

WebMD, a nationwide web-based information resource for medical issues, includes information regarding NJ FamilyCare on its web site, including the application form, which facilitates completion of the application in such sites as hospitals, where intake and billing staff can assist parents in applying for NJ FamilyCare coverage for their children.

Community Partnerships:

The Insure Kids Now hotline, 1-800-KIDS-NOW, is available nationwide to connect interested families to NJ FamilyCare information. In our state, this number rings through to the Division of Medical Assistance and Health Services Solutions Unit for follow up.

In 2000, NJ FamilyCare was launched with a statewide multimedia advertising campaign.

The Robert Wood Johnson Foundation “Covering Kids” project continues to support enrollment of eligible, uninsured children.

Over 500 application assistance sites continue to conduct outreach and enrollment activities throughout the state. They consist of community-based organizations, faith-based organizations, healthcare providers, and other governmental agencies. State staff provides training for their workers and keeps them updated as to any changes to the program.

Posters: NJ FamilyCare sends posters to libraries, laundromats, enrollment sites, video stores, diners, and YMCAs. The posters focus on utilization of health services, such as immunizations and well-child check-ups, as well as providing NJ FamilyCare information.

Medical Assistance Advisory Council (MAAC): The NJ FamilyCare Advisory Committee is a part of the MAAC, which is comprised of interested community agencies, consumers and stakeholders such as Legal Services of New Jersey and the Association for the Betterment of Citizens with Disabilities. The MAAC meets quarterly and receives information regarding NJ FamilyCare and other Medicaid programs and provides comments and input regarding the information and the programs.

McDonald’s: The New Jersey Commissioner of Human Services helped NJ FamilyCare launch the Ronald McDonald CareMobile in Trenton. It is a mobile unit that covers areas in Central and South Jersey where many children do not

Effective Date: April 1, 2009

Approval Date: ____________ 10

have a medical home. Health screening and education are provided by the staff of the CareMobile. NJ FamilyCare materials are made available to encourage families to apply for health care coverage. McDonald’s also produced tray liners and hung informational posters at selected McDonald’s locations.

Marshall’s and TJ Maxx: Thirty-four Marshall’s stores and 20 TJ Maxx stores around New Jersey were given NJ FamilyCare fact sheets and income guideline charts. Part-time employees without health insurance or employees who only had coverage for themselves could use this information to apply for their children.

H&R Block: H&R Block participated in a nationwide effort to inform families about the Child Health Insurance Program by printing a message on their return form that included the 1(877) KIDS-NOW phone number. The state sent NJ FamilyCare fact sheets to New Jersey regional managers, to be distributed to their clients.

Giant Food Stores: Nine “Super G” markets in Trenton and Camden, where children likely to be eligible reside, were sent NJ FamilyCare fact sheets, to be distributed through their pharmacy departments.

Faith-Based Outreach: The state partnered with faith-based organizations, such as the United Methodist Church and others, and provides outreach training and enrollment materials to assist in reaching as many potential enrollees as possible. A faith-based toolkit was developed to encourage the participation of faith-based organizations and houses of worships in identifying uninsured families and referring them to an enrollment site for assistance. In addition to NJ FamilyCare materials, it includes tips on how to get the faith-based community involved, as well as sample sermons on child health and sample notices for the church bulletin board. This toolkit was mailed to over 1,500 faith-based organizations and houses of worship throughout the state.

Premium Assistance Program: The state’s Premium Assistance Program (see Attachment 8) includes partnerships with employers to inform employees of the availability of coverage and to evaluate the employer-provided coverage for comparability.

Housing Mortgage and Finance Administration (HMFA): NJ FamilyCare partnered with the HMFA to outreach and enroll uninsured families residing in housing developments throughout the state. Working directly with the administrators who oversee the Housing Managers for rent controlled properties, NJ FamilyCare gained access to these families. The Housing Managers not only agreed to have NJ FamilyCare information available for families, but were also invested in helping these families access insurance by assisting with the distribution of program materials, and helping families complete the NJ FamilyCare application.

Effective Date: April 1, 2009

Approval Date: ____________ 11

New Jersey Department of Labor Rapid Response Team: NJ FamilyCare partners with the Department of Labor’s Rapid Response Team, which assists when plants or businesses close or lay off numbers of workers. The Rapid Response Team has agreed to include an overview of the NJ Family Care program in presentations to businesses slotted for closing or layoffs. Our association with the Department of Labor helps to facilitate the enrollment of hundreds of eligible dislocated workers, who might not be able to afford COBRA coverage.

NJ Employer Council: The Office of NJ FamilyCare joined forces with the NJ State Department of Labor in collaboration with the New Jersey Employer Council. The NJ Employer Council provides a communication link between the employer community and the Department of Labor on employment and training issues. There is a state council and nine regional councils. Outreach Coordinators from the Office of NJ FamilyCare participated in many of the regional meetings, and gave a thorough presentation of the NJ FamilyCare program. In addition, the office of NJ FamilyCare participates in the New Jersey Employer Council Annual Statewide Conference by staffing a booth to provide valuable NJ FamilyCare information.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

Public health and Title V agencies: Public health agencies are an important source of outreach and information for potentially eligible children. Staff at programs run by Women, Infants and Children (WIC), Head Start and local health departments are familiar with Medicaid and NJ FamilyCare eligibility requirements and screen their clients accordingly. Programs such as Healthy Mothers, Healthy Babies send outreach workers into the community in attempts to assist pregnant women and children in getting necessary health care services, and utilize information regarding NJ FamilyCare when they contact their consumers, assisting in completion of applications. The NJ FamilyCare program partners with NJ Special Child Health Services, the Maternal Child Health Consortia, Women, Infants, and Children Program (WIC), the Child Health Regional Network (CHRN) and other Title V programs of the New Jersey Department of Health and Senior Services to assure NJ FamilyCare enrollment of all eligible children.

Presumptive eligibility, coupled with the enhanced services provided as part of the HealthStart program, such as nutrition counseling and social services, has helped assure continuity of care during pregnancy.

Effective Date: April 1, 2009

Approval Date: ____________ 12

Sources of health benefits coverage for children: NJ FamilyCare continues to work with the state Office of Child Support and Paternity to seek medical child support when such support is available to the child.

Effective Date: April 1, 2009

Approval Date: ____________ 13

Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 4.

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

Under NJ FamilyCare Plan A, the Medicaid program is expanded to include all Optional Targeted Low Income Children who meet the Title XXI requirements, are below the age of 19 years, and have family income at or below 133% of the federal poverty level. Therefore, for this group of children, the service delivery system is the Title XIX system of mandatory managed care using licensed HMOs, with certain services carved out of the managed care contracts and provided on a fee-for-service basis. The children in this group will receive the services described in Attachment 6 for Plan A.

For the Title XXI eligible children under 19 years of age with gross family income above 133% and at or below 200% of the federal poverty level (NJ FamilyCare Plans B and C) the State purchases a subset of the Medicaid package from the Title XIX program. The health benefit coverage provided under the Title XXI program consists of the managed care product offered under the Title XIX program with the addition of fee-for-service payment to existing Medicaid participating network providers for certain benefits not included in the managed care contracts, but essential to the care of this population. The children in this group will receive the services described in Attachment 6 for Plans B and C.

For the Title XXI eligible children under 19 years of age with gross family income above 200% and at or below 350% of the federal poverty level, whose net income falls at or below 200% of the federal poverty level after application of disregards (NJ FamilyCare Plan D), the State purchases a subset of the Medicaid package from the Title XIX program which consists of a version of the managed care product under the Title XIX program modified to mirror a commercial plan with the addition of fee-for-service payment to existing Medicaid participating network providers for certain benefits not included in the managed care contracts, but included in the commercial benchmark plan. The children in this group will receive the services described in Attachment 6 for Plan D.

Participation in the managed care contracts is limited to licensed HMOs and is a fully-capitated, risk-based contract. Given that the cost-sharing amounts act as an incentive payment to the direct service provider, the managed care contract

Effective Date: April 1, 2009

Approval Date: ____________ 14

and the capitation payment paid to the participating plans are not amended for the Title XXI population to account for the copayments for children in families with income above 150% of the federal poverty level. Premiums are collected by a vendor on behalf of the State and, therefore, have no impact on managed care rates, although the premiums help to offset the total cost of the program. The premiums are not used as any part of the state share.

The services paid for on a fee-for-service basis are part of the purchased Medicaid package and are not counted as a contract with providers for direct service in computing the 10% cap. Essential, non-HMO covered services provided under Title XXI, however, are not equivalent to those provided under the Medicaid program (see Section 6 regarding benefits).

There are three significant advantages to this approach. First, it allows the State and Federal government to take advantage of the purchasing power of the Medicaid program, while providing a service package that moves closer to or, in the case of NJ FamilyCare-Children's Program Plan D, equals that provided by commercial plans. Second, it recognizes the need to develop a unified, managed care approach to the carved-out behavioral health services under the State's publicly financed programs. Third, it allows the State to take advantage of the stringent consumer protections and utilization control standards included in the Medicaid managed care contracts.

HMOs are required to have toll free telephone numbers, 24 hours a day, 7 days a week, for after-hours and urgent care needs. In addition, HMOs have case management systems, staffed by appropriate medical professionals, to assure that HMO members receive needed services in a supportive, effective, efficient, and cost-effective manner. Case management must be client-centered, goal- oriented, and culturally competent to assure appropriate provider/service linkages are made.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

Because Title XXI is not an entitlement program, enrollment and expenditures are monitored closely against the allotment. Enrollment will be stopped when total expenditures are projected to equal the available funding level. At any time that point is reached, additional applicants will be placed on a waiting list, with preference determined based on date of application and income. Appropriate referrals to other sources of care will be made and enrollment will resume as quickly as feasible given that the children will be without coverage in the interim. New Jersey does not have a waiting list currently.

Effective Date: April 1, 2009

Approval Date: ____________ 15

Under NJ FamilyCare Plans B, C and D there are requirements concerning fraud and abuse that do not apply under the Medicaid/Plan A program. Specifically, family members may lose NJ FamilyCare eligibility if the family is found to have engaged in program fraud and abuse. For example, card loaning as a means to pay for services provided to a non-eligible child may result in disenrollment from the program.

For the portion of the care covered by the managed care contracts, the existing system of utilization controls used by the Medicaid managed care program will be in effect. HMOs must have a written Quality Management Program, which also includes a Utilization Review Plan approved by the Division of Medical Assistance and Health Services. An annual External Quality Review that meets the requirements of 42 CFR 438 Subpart E is performed by a qualified External Quality Review Organization each managed care organization.

The administrative infrastructure, quality operating systems, provider networks and the health care delivery system of all HMOs are reviewed and approved before contracting. All HMOs contracting with the State have referral systems for specialty care and prior authorization requirements for certain elective services to further monitor and control unnecessary utilization of services.

Clinical practice guidelines are utilized by the HMOs for their internal monitoring of the delivery of care by HMO providers.

The State, through its ongoing monitoring process conducts audits jointly with a contracted independent Peer Review Organization of each HMO's utilization control systems and contract compliance to ensure that all utilization control standards are met. The audits are comprehensive reviews of HMO operations that meet with the standards at 42 CFR 438 Subpart E, with additional modifications to meet New Jersey's needs. Further additions are made to the review process on an individual HMO basis to address HMO-specific issues and concerns identified through complaints, data from other types of quality reviews, and member satisfaction surveys.

The State also collects comprehensive member- and provider-specific encounter data from the HMOs. These data allow the State to develop utilization reports to compare services within a single HMO against an accepted norm, as well as to compare services across all contracted HMOs. Financial data reported by the plans as well as onsite reviews of financial records by State staff provide the State with information on the cost efficiencies of each HMO.

Effective Date: April 1, 2009

Approval Date: ____________ 16

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1

Geographic area served by the Plan: Statewide 4.1.2

Age: Under 19 years of age 4.1.3

Income:

The application process now allows self-declaration of income in eight school districts of the State, of which at least two each are in the northern, central and southern areas of the State, respectively, and at least four of which are in the so- called “Abbott” (i.e., lower income) school districts.

For children in families with income at or below 133% of the federal poverty level, coverage is available under the Medicaid program (NJ FamilyCare Plan A). Household income is defined as the gross income, earned and unearned, that is available to the eligible unit. The eligible unit is comprised of natural or adoptive parent(s) and all blood-related or adoptive brothers or sisters living in the household.

In determining family income, the following deductions and disregards apply:

• For self-employed, the cost of producing income;

• From gross earnings the first $90.00 per month of such earnings for each employed individual in the eligible family (including earnings of a child under the age of 21 who is not a full-time student) to cover work-related expenses including, but not limited to, transportation and mandatory payroll deductions;

• From the remaining earned income, an amount equal to the actual expenditures for child care or for care of an incapacitated individual living in the same home as the eligible child when specific circumstances are met. Maximum amounts for this type of disregard are:

• $175.00 per month per child age two or older, or incapacitated adult, for full-time employment;

• $200.00 per month per child under age two, for full-time

Effective Date: April 1, 2009

Approval Date: ____________ 17

employment;

• $135.00 per month per child age two or older, or incapacitated adult, for part-time employment

• $150.00 per month, per child under age two, for part-time employment

Methods for evaluating family income include verification through wage stubs or documentation from the employer. All earned and unearned income received within a four week period must be verified and documented. On-line access to wage, unemployment, and disability files is available through the Department of Labor.

For children in families with gross income at or below 200% of the federal poverty level (NJ FamilyCare Plans B and C), a modified benefit package is available, with cost sharing required for families with income above 150% of federal poverty level (NJ FamilyCare Plan C). Determining whether a family meets either the 200% or 150% limit is a simple calculation of gross income with no deductions or disregards. Household and family income is defined as the gross income of the family including the gross income of all legally responsible adults in the household, the gross income of the minor child(ren), and all other income or support in-kind actually received in the household, including child support.

Methods for evaluating family income include pay check stubs, W-2 forms, letters from employers on company letterhead, or statement of the gross benefit amount from any governmental agency providing benefits. In addition, access to the Department of Labor’s Wage and Unemployment Files is available.

For children in families with gross income at or below 350% of the federal poverty level before disregards (NJ FamilyCare Plan D), a commercial benefit package is available, with cost sharing required for all families based on income. Net household and family income is defined as the gross income of the family including the gross income of all legally responsible adults in the household, the gross income of the minor child(ren) and all of the other income or support in-kind actually received in the household, including child support, less the applicable income disregards described below. Determining income for purposes of setting the premium amount, is a simple calculation of gross income with no deductions or disregards. Children under 150% FPL do not pay premiums.

Effective Date: April 1, 2009

Approval Date: ____________ 18

INCOME DISREGARDS Gross Income as % of FPL Income Disregards (as a % of FPL) NJ FamilyCare Plan 133 Medicaid disregards apply A 150 0 B 200 0 C 250 50 D 300 100 D 350 150 D

In addition, all wages paid by the Census Bureau for temporary employment related to Census 2000 activities are excluded, as are monetary rewards paid by the Division of Medical Assistance and Health Services for information leading to the recovery of at least $100.00 from individuals or entities that have engaged in health care-related fraud or abuse.

4.1.4

Resources (including any standards relating to spend downs and disposition of resources): 4.1.5

Residency (so long as residency requirement is not based on length of time in state): Must be a current New Jersey resident 4.1.6

Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7

Access to or coverage under other health coverage:

Based on guidance provided by CMS, a child who meets the eligibility criteria for the expanded Medicaid program (NJ FamilyCare Plan A) is not eligible if the child is covered by other health coverage. This ineligibility for the expanded Medicaid coverage is a federal statutory exception to the entitlement requirements that would otherwise apply under Title XIX, where the other insurance would be treated as a third party resource with Medicaid remaining payer of last resort.

Unlike NJ FamilyCare Plans B, C or D, under the Medicaid expansion, (NJ FamilyCare Plan A) there is no requirement that the child be uninsured for a 3 month period. This is due to “crowd-out” being of less concern in the lower income population. In addition, it tends to diminish the disparity between the children covered under the Medicaid expansion and other Medicaid-eligible children.

For NJ FamilyCare Plans B and C, a child must be uninsured for a minimum of three months. Exceptions are made for children losing Medicaid eligibility and who have no other health care coverage at the time of termination. Exceptions are also made to the three-month requirement in certain limited circumstances (if, for example, prior coverage was lost because an employer went out of business or the employee was laid off or changed jobs and does not have access to

Effective Date: April 1, 2009

Approval Date: ____________ 19

affordable coverage in the new job) where crowd-out concerns are not an issue. Also, a child is not determined ineligible if the child was previously covered under an individual health benefits plan or COBRA plan preceding application for NJ FamilyCare and the child had not been voluntarily disenrolled from employer- sponsored group insurance coverage during the three-month period prior to applying for NJ FamilyCare.

A child with income greater than 200% of the federal poverty level who meets the criteria for NJ FamilyCare coverage under Plan D must be uninsured for a minimum of 3 months. Exceptions are made for children losing Medicaid eligibility and who have no other health care coverage at the time of termination. Exceptions are also made to the 3 month requirement in certain limited circumstances (if, for example, prior coverage was lost because an employer went out of business or the employee was laid off or changed jobs) where crowd- out concerns are not at issue).

There is no other requirement regarding access to other health coverage.

4.1.8

Duration of eligibility:

The State provides continuous coverage for the 12 months between redeterminations, and has done so since September 2000. Redeterminations will be conducted at 12-month intervals for children eligible under the Medicaid expansion (NJ FamilyCare Plan A) and at 12-month intervals for children eligible under NJ FamilyCare Plans B, C or D. Under both the Medicaid expansion (NJ FamilyCare Plan A) and NJ FamilyCare Plans B, C or D, eligibility will be terminated if income exceeds the allowable threshold, based on information provided/obtained during the redetermination process. Termination is effective the first day of the month following the month in which the income level is exceeded.

4.1.9

Other standards (identify and describe):

Title XXI is a federal means tested program and therefore subject to the same alien restrictions as the Title XIX program. Accordingly, benefits are available only to children who are qualified aliens and who are not subject to the five-year bar or who have a parent on active military duty or who is a veteran. Qualified aliens include aliens lawfully admitted for permanent residence, asylees, refugees, aliens paroled into the United States for a period of at least 1 year, aliens whose deportation is being withheld, conditional entrants, and Cuban/Haitians.

4.1-P. The following standards may be used to determine eligibility of targeted low-income pregnant women for health assistance under the plan. (Section 2112).

4.1.1-P. Geographic area served by the Plan: Statewide

Effective Date: April 1, 2009

Approval Date: ____________ 20

4.1.2-P. Age: Pregnant women with no age limitation

4.1.3-P. Income:

Pregnant women with gross income greater than 185% and not to exceed 200% FPL

4.1.4-P. Resources:

4.1.5-P. Residency:

Must be a current New Jersey resident (residency requirement is not based on length of time in state).

4.1.6-P. Disability:

4.1.7-P. Access to or coverage under other health coverage:

Applicants must be uninsured. New Jersey will utilize a three-month crowd- out provision for group health insurance coverage, with exceptions for situations such as expiration of Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage. In addition, an applicant may voluntarily terminate coverage under COBRA, or any other health insurance purchased through the individual market, in order to be considered for NJ FamilyCare eligibility. There is no asset test or cost sharing. Retroactive eligibility is available for this population.

4.1.8-P. Duration of eligibility:

Coverage is provided until 60 days following delivery.

4.1.9-P. Other standards (identify and describe):

Title XXI is a federal means tested program and therefore subject to the same alien restrictions as the Title XIX program. Accordingly, benefits are available only to children who are qualified aliens and who are not subject to the five-year bar or who have a parent on active military duty or who is a veteran. Qualified aliens include aliens lawfully admitted for permanent residence, asylees, refugees, aliens paroled into the United States for a period of at least 1 year, aliens whose deportation is being withheld, conditional entrants, and Cuban/Haitians.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan (Section 2102)(b)(1)(B)) (42CFR 457.320(b)).

Effective Date: April 1, 2009

Approval Date: ____________ 21

The State makes the same assurances as to pregnant women eligible pursuant to Section 4.1-P :

4.2.1

These standards do not discriminate on the basis of diagnosis. 4.2.1

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.1

These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

4.3.1 Describe the state's policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b)) Check here if this section does not apply to your state.

An application can be requested via a toll-free number operated under contract for the state or obtained through an outreach source, or obtained from the county board of social services. The application is the same for those applying for NJ FamilyCare Plan A (Medicaid expansion) or NJ FamilyCare Plans B, C and D. The form is designed to ensure all federal requirements are met, but the application process is simplified as much as possible.

In addition, a computer-assisted application may be filed with any agency that is on the One Ease-E Link network and which has indicated a desire to provide that service. One Ease-E Link is capable of screening individuals for eligibility under NJ FamilyCare Plans A, B, C and D and transmitting an electronic application including documentation to the state vendor for processing.

For children eligible under the Medicaid expansion (NJ FamilyCare Plan A), the application can be mailed in to a state vendor or the County Board of Social Services or the client may complete the application through the face-to-face process at the County Board of Social Services. If the application is mailed in, it is screened for completeness. If incomplete, any missing information will be requested. Potential beneficiaries who do not respond to the request within 60 days, will be outreached by mail. If there is no response within 30 days, they will be referred to an outreach worker for a telephone follow-up. The state makes a final determination regarding completed applications processed by the vendor.

Eligibility under the Medicaid expansion (NJ FamilyCare Plan A) is applied back to the date of the application. Eligibility is effective the first day of the first month in which the person is found eligible. Retroactive eligibility is available to cover unpaid medical bills for the three months prior to the date of application if the

Effective Date: April 1, 2009

Approval Date: ____________ 22

requirements for eligibility are met in each of the three months. (NOTE: Retroactive eligibility is not available for any period prior to the start of the program.) Monthly eligibility cards are issued in accordance with existing Medicaid practices, although this may change with the future application of new technology. During the period of time when the child is choosing and being enrolled in a specific HMO, all services are available on a fee-for-service basis. The family will be asked to select from participating HMOs covering the county in which the child resides. If no selection is made, the NJ Care 2000 default assignment rules will apply.

For children eligible only under Title XXI (NJ FamilyCare Plans B, C and D), the application can be mailed to a state vendor or the client can request assistance from one of the servicing sites in the community. Assistance is also available through state field offices (e.g. the Medical Assistance Customer Centers) and county offices (e.g. Offices on Aging for grandparent caretakers). If incomplete, the application will be returned by the vendor. Potential beneficiaries who have an application returned to them and do not resubmit within 60 days, will be outreached by mail. If there is no response within 30 days, they will be referred to an outreach worker for either an attempt at telephone or face-to-face follow-up.

A child who presents himself/herself at an acute care hospital, a federally qualified health center or local health department that agrees to be a presumptive eligibility determination agency, is deemed presumptively eligible for all covered NJ FamilyCare program services if a preliminary determination by the staff of the facility indicates that the child meets NJ FamilyCare program eligibility standards for NJ FamilyCare Plan A, B, C or D and the child is a member of a household with a gross income not exceeding 350% of the federal poverty level. An application for the program must be completed by the child (if appropriate), child’s parent, guardian or caretaker, no later than the end of the month following the month in which presumptive eligibility is determined. Presumptive eligibility applies to NJ FamilyCare Plan A, B, C and D children.

The state vendor is responsible for making the final determination of eligibility for Title XXI. State staff monitors the performance of the vendor on an ongoing basis to ensure the adequacy and accuracy of the eligibility process. State staff is also responsible for certain income verification activities.

Eligible beneficiaries under NJ FamilyCare Plans B, C and D are subject to a managed care approach that mirrors the commercial insurance environment. Under such mainstream plans, enrollment is not effective until the application process is complete and the individual is enrolled in the managed care plan. Therefore, retroactive eligibility does not apply.

There is an exception to this process, however, for newborns. To ensure that newborns are not denied needed services, including those associated with birth, for newborns who are deemed potentially eligible based on initial screening, services will be covered on a fee-for-service basis until the end of the month

Effective Date: April 1, 2009

Approval Date: ____________ 23

following the month of birth.

Families may choose among participating HMOs in their county of residence to provide coverage for all the children in the family. The effective date of eligibility is the date the child is enrolled in a participating HMO. Enrollment usually occurs between 15 and 45 days of the date that eligibility for the program is determined. Children are allowed to change plans once every 12 months, unless there is good cause for a change to occur earlier.

Separate and distinct NJ FamilyCare cards are issued monthly. For children required to participate in cost sharing in the form of copayments, any copayment amount is listed on the card.

For children eligible under the Medicaid expansion (NJ FamilyCare Plan A), the formal fair hearing mechanism is available for appeals involving the eligibility determination. For the children denied eligibility under Title XXI (NJ FamilyCare Plans B, C and D ) or who are terminated for non-payment of premium, there is a mediation mechanism used as the first step in the appeal process. This can be followed by a formal appeal to DMAHS, which must be submitted in writing within 10 days of the adverse notification, regardless of whether mediation is attempted. This appeal will be heard by a panel comprised of state staff, who will make recommendations to the Division Director. Within 45 days of receipt of the appeal, the DMAHS Director will issue a final agency decision, which is subject to judicial review in the Appellate Division.

Applications which involve family members already enrolled in the Medicaid program will be forwarded to the County Board of Social Services to be added to the existing case. In addition, the County Board of Social Services refers any child found not eligible for Medicaid or any child losing eligibility for Medicaid to the NJ FamilyCare program. The County Board of Social Services provides the necessary application and assistance in completing it.

Each agent is required to maintain records supporting their determinations (manual and/or electronic). A system for tracking the case disposition is available to respond to inquiries from the client or the state, as appropriate.

All members are required to report changes that affect eligibility to their respective intake agent. A unique code has been identified that allows agencies with access to the file to identify the responsible eligibility agent.

Effective Date: April 1, 2009

Approval Date: ____________ 24

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Section 2102)(b)(3)(A)) (42CFR 457.350(a)(1) and 457.80(c)(3))

As part of the eligibility process, the applicant must submit supporting information that adequately demonstrates income. For those applying under the Medicaid program (NJ FamilyCare Plan A), this will be checked by the state against outside sources, such as state Wage and Unemployment data and other sources provided through the Income Eligibility Verification System. Outreach is made to the employer to ensure that group or other employer-sponsored coverage is not being provided. For children living with a custodial parent or guardian, outreach is made to the Child Support agency to determine if the child support order includes medical support.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

All applications are screened by the state vendor for potential Medicaid eligibility. Those that involve children that are members of families already receiving Title XIX benefits through the County Boards of Social Service or who appear to meet the standard for cash assistance are sent to the County Board of Social Services for a determination. For the remaining children with income at or below 133% of poverty, a determination will be made whether they are eligible for Medicaid and whether they would have been eligible prior to the NJ FamilyCare expansion.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

Since the inception of New Jersey's SCHIP program, NJ FamilyCare has worked closely with the county boards of social services (CBOSSs), to promote the program. The NJ FamilyCare application requests all of the information necessary to determine Medicaid eligibility for a child. If the children are determined to be ineligible for Medicaid, the CBOSS mails the application to NJ FamilyCare for processing, without requiring the family to

Effective Date: April 1, 2009

Approval Date: ____________ 25

complete an additional form or application. Also see outreach efforts detailed in section 2.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution. Coverage provided to children in families at or below 200% FPL (Plans A, B and C): The NJ FamilyCare application (used for initial application and redetermination), has been redesigned to contain a separate section to be completed for each child applicant. The application section for each child asks for information regarding that child's current health insurance, and whether the insurance is from the school, COBRA, an employer, a custodial parent, a non- custodial parent, Medicare and/or Medicaid. The application also asks whether the child had health insurance within the last three months, and if so, whether it ended, and why it ended. The minimum period without coverage under a group health plan is three months. The NJ FamilyCare program will collect this data from all applications and redeterminations regarding the health coverage available to a family, and sends it to the premium support program. The premium support program staff contact the family, gather information and review the information regarding substitution, employer contribution and cost-effectiveness in order to determine whether participation in the premium support program is appropriate for a particular child.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. Coverage provided to children in families over 200% and up to 250% FPL (Plan D): The NJ FamilyCare application (used for initial application and redetermination), has been redesigned to contain a separate section to be completed for each child applicant. The application section for each child asks for information regarding that child's current health insurance, and whether the insurance is from the school, COBRA, an employer, a custodial parent, a non- custodial parent, Medicare and/or Medicaid. The application also asks whether the child had health insurance within the last three months, and if so, whether it ended, and why it ended. The minimum period without coverage under a group health plan is three months. The NJ FamilyCare program will collect this data

Effective Date: April 1, 2009

Approval Date: ____________ 26

from all applications and redeterminations regarding the health coverage available to a family, and sends it to the premium support program. The premium support program staff contact the family, gather information and review the information regarding substitution, employer contribution and cost-effectiveness in order to determine whether participation in the premium support program is appropriate for a particular child.

New Jersey monitors the actual incidence of substitution, assessing the extent to which substitution, or "crowd-out," is experienced. If the State finds that NJ FamilyCare is covering substantial numbers of children who were covered under employer-sponsored plans, the State will consider additional strategies to prevent substitution, or "crowd-out."

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution. Coverage provided to children in families above 250% FPL (Plan D): The NJ FamilyCare application (used for initial application and redetermination), has been redesigned to contain a separate section to be completed for each child applicant. The application section for each child asks for information regarding that child's current health insurance, and whether the insurance is from the school, COBRA, an employer, a custodial parent, a non-custodial parent, Medicare and/or Medicaid. The application also asks whether the child had health insurance within the last three months, and if so, whether it ended, and why it ended. The minimum period without coverage under a group health plan is three months. The NJ FamilyCare program collects this data from all applications and redeterminations regarding the health coverage available to a family, and sends it to the premium support program. The premium support program staff contact the family, gather information and review the information regarding substitution, employer contribution and cost-effectiveness in order to determine whether participation in the premium support program is appropriate for a particular child.

4.4.4.4. If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period. The state provides coverage under a premium assistance program in its State Plan and under its 1115 waiver program. The minimum

Effective Date: April 1, 2009

Approval Date: ____________ 27

period without coverage under a group health plan is three months. The requirements for the minimum period without coverage under a group health program are the same for NJ FamilyCare and the Premium Assistance program.

Exceptions based on access to health care coverage are made for:

A child who is eligible for coverage under a health insurance policy which is not readily accessible to the child;

A child who has coverage under a government-funded, non- employee based health insurance program which is targeted for low-income uninsured individuals;

A child recently terminated under COBRA, if the reason for the termination is expiration of the COBRA continuation rights. (If the coverage was voluntarily terminated by the family prior to the expiration of continuation rights, the child is precluded only from participation in the NJ FamilyCare- Children's Program-Plan D for three months from the date of COBRA termination.)

Exceptions based on income are also made for:

A child who is otherwise eligible as Medically Needy but for an unmet "spend-down" liability. (The child is not precluded from Plan B, C or D eligibility during the spend-down period.)

Exceptions based on health care coverage discontinued less than three months prior to application are made for:

A child who is otherwise eligible for NJ FamilyCare- Children's Program-Plans B, C and D coverage, as applicable, under a group health benefits plan, whether sponsored through a governing entity or private employer, when:

The employer has ceased operations in the State, and there is no succeeding employer for that business;

The employer has ceased operations in the State, and the succeeding employer has not retained the group health plan;

The employer has ceased operations in the State,

Effective Date: April 1, 2009

Approval Date: ____________ 28

and the succeeding employer has altered the terms of a noncontributory group health plan to require a premium contribution (for a class of employee to which the child's household member belongs); or

The employee-certificate holder becomes unemployed, through no fault of the employee.

The minimum employer contribution. The minimum employer contribution is 50 percent of the cost of coverage for the employee and family.

The cost-effectiveness determination. The cost-effectiveness determination performed by the State consists of a comparison of the services offered by the employer, benefit by benefit, with the services offered under NJ FamilyCare Plan D. If the employer is a large employer, both the specific services and the extent of coverage must be the same as NJ FamilyCare. If the employer is a small employer, the services must be the same, but the extent of coverage is not required to be the same as the NJ FamilyCare Plan.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

To support the assurance regarding child health assistance, the state has a mechanism in place for determining whether American Indian or Alaska native children (as defined in 42 CFR 457.10) are among targeted low income children in the state. The state collects this information on the NJ FamilyCare application initially and upon redetermination and notifies AI/AN applicants and beneficiaries of the exemption. In addition, the state will not impose premiums, deductibles, coinsurance, copayments or any other cost sharing charges on children who are American Indians or Alaska Natives.

Effective Date: April 1, 2009

Approval Date: ____________ 29

Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

In October 2000, New Jersey began a statewide ad campaign to promote the change in the name of the program from NJ KidCare to NJ FamilyCare. This campaign included television advertising, radio and print ads, as well as bus advertising. In addition, the Department of Human Services partnered with private and public organizations to offer free food and ticket incentives for new NJ FamilyCare applicants.

Other outreach efforts include a joint private/public sector school outreach program, Back-to-School campaigns, corporate partnerships with organizations serving markets that attract low- and middle-income children and parents, a grant-funded collaborative effort to reach community-based organizations, development of outreach training sessions and printed material to encourage hospital and faith-based organizations to participate, Production of a directory listing the more than five hundred application assistance sites statewide, production of an education/awareness video for use in county welfare offices and in local businesses, and a series of over 110 exhibits, training sessions and presentations during Federal Fiscal Year 2001.

The outreach campaign consists of a comprehensive effort to reach uninsured children. This plan uses a phased approach to outreach that includes 4 major components. The public awareness and media campaign supports the effort with various public information material including posters, brochures, public service announcements, press releases, letters and notices.

The targeted outreach uses known resources and databases as well as concentrating on specific locations such as day care centers and schools with a high percentage of children eligible for school meal programs. It involves a coordinated effort between the Department of Human Services, the Department of Health and Senior Services and the Department of Education and includes efforts such as Train the Trainer sessions. Direct outreach workers, including outreach workers for other maternal child health and public health programs, are trained to respond to questions concerning the program. Outstationed eligibility workers in certain hospitals and FQHCs serve as both outreach and referral sources. Bilingual staff and/or language lines are used as needed. In all cases, the use of culturally competent outreach resources is a paramount consideration.

Effective Date: April 1, 2009

Approval Date: ____________ 30

Efforts will be made to reach special populations. For example, presentations will be made to staff and materials will be shared with homeless shelters, domestic violence counselors and programs that interact with families dealing with HIV and AIDS.

A broad-based consumer support network helps educate and disseminate informational materials to families with children. This process includes health care providers, including FQHCs, community organizations, the perinatal consortium, businesses, government field offices, participants in electronic networks, political leaders and consumer advocates.

A comprehensive customer education plan that incorporates information on consumer choice and utilization of health care services is in use, and is updated as needed.

Additional assistance is available in completing the application process by contacting a State enrollment vendor at a toll-free number dedicated to the NJ FamilyCare program, or by visiting one of the designated application centers locater throughout the State, including Medical Assistance Customer Centers, WIC sites, Head Start centers, county Offices on Aging, etc. The vendor assists applicants in completing the process by telephone as well as following up on incomplete applications or missing documentation.

To ensure coordination of the administration of this program with other public health insurance programs, staff from Human Services and Health and Senior Services sit on a number of key committees or attend committee meetings that consider Title XXI-related issues, such as the Medical Assistance Advisory Committee and the Quality Management Council. Title XXI issues are discussed on an ongoing basis in regular meetings held between the two departments.

In addition, the NJ FamilyCare staff present program updates to the Medical Assistance Advisory Council, which meets quarterly. The staff also solicit comments from the Council regarding the program. See Section 2 for additional information regarding outreach.

Effective Date: April 1, 2009

Approval Date: ____________ 31

Section 6. Coverage Requirements for Children's Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) (Plans B & C) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.) (Plan D)

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3. Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania]. Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state- based coverage.

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1. Coverage the same as Medicaid State plan 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3.

Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population

Effective Date: April 1, 2009

Approval Date: ____________ 32

6.1.4.4. Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Other (Describe)

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

6.2.1.

Inpatient services (Section 2110(a)(1)) 6.2.2.

Outpatient services (Section 2110(a)(2)) 6.2.3.

Physician services (Section 2110(a)(3)) 6.2.4.

Surgical services (Section 2110(a)(4)) 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6)) 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) (Except in Plan D) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9)) 6.2.10.

Inpatient mental health services, other than services described in 6.2.18, but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state- operated mental hospital and including community-based services (Section 2110(a)(11) 6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

Disposable medical supplies (Section 2110(a)(13)) 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.16.

Abortion only if necessary to save the life of the mother or if

Effective Date: April 1, 2009

Approval Date: ____________ 33

the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.

Dental services (Section 2110(a)(17)) 6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20.

Case management services (Section 2110(a)(20)) (for chronically ill) (Plans B, C and D)

6.2.21.

Care coordination services (Section 2110(a)(21)) 6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.

Hospice care (Section 2110(a)(23)) 6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) (Plans B, C and D) 6.2.26.

Medical transportation (Section 2110(a)(26)) 6.2.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

See Attachment 6 for a detailed description of coverage, amount, duration and scope of services, as well as any exclusions or limitations.

Effective Date: April 1, 2009

Approval Date: ____________ 34

This Page Relates to Plan "D" Only

Section 6. Coverage Requirements for Children's Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.) (Plan D) See Attachment 6.

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania]. Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state- based coverage.

Effective Date: April 1, 2009

Approval Date: ____________ 35

This Page Relates to Plan "D" Only

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1. Coverage the same as Medicaid State plan 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Other (Describe)

6.2.A. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

6.2.A.1.

Inpatient services (Section 2110(a)(1)) 6.2.A.2.

Outpatient services (Section 2110(a)(2)) 6.2.A.3.

Physician services (Section 2110(a)(3)) 6.2.A.4.

Surgical services (Section 2110(a)(4)) 6.2.A.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.A.6.

Prescription drugs (Section 2110(a)(6)) 6.2.A.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.A.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.A.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

Effective Date: April 1, 2009

Approval Date: ____________ 36

This Page Relates to Plan "D" Only

6.2.A.10.

Inpatient mental health services, other than services described in 6.2.A.18, but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.A.11.

Outpatient mental health services, other than services described in 6.2.A.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) 6.2.A.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.A.13.

Disposable medical supplies (Section 2110(a)(13)) 6.2.A.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.A.15.

Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.A.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.A.17.

Dental services (Section 2110(a)(17)) 6.2.A.18. Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.A.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.A.20.

Case management services (Section 2110(a)(20)) (chronically ill) 6.2.A.21.

Care coordination services (Section 2110(a)(21)) 6.2.A.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.A.23.

Hospice care (Section 2110(a)(23)) 6.2.A.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.A.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) (Plan D) 6.2.A.26.

Medical transportation (Section 2110(a)(26)) 6.2.A.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.A.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

See NJ FamilyCare Plan D chart, Attachment 6, for detailed description of coverage, amount, duration and scope, as well as any exclusions or limitations.

Effective Date: April 1, 2009

Approval Date: ____________ 37

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28.

(Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as

Effective Date: April 1, 2009

Approval Date: ____________ 38

through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a)) 6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b)) 6.4.2.3. The state assures that the coverage for the family otherwise meets Title XXI requirements. (42CFR 457.1010(c))

Effective Date: April 1, 2009

Approval Date: ____________ 39

Section 7. Quality and Appropriateness of Care

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

The methods used to assure the quality and appropriateness of care include both internal and external monitoring. Contracted HMOs must meet stringent quality specifications detailed in the contract. The State identifies, defines and specifies the standards for quality measurement and improvement with reference to practice guidelines, the quality assessment and performance improvement program and health information systems. Pursuant to the Modified QARI/QISMC standards, the HMO must ensure that its practice guidelines be based on reasonable medical evidence, consider the needs of the enrollees, be developed in consultation with contracting health care professionals and be reviewed and updated periodically. The HMO’s quality improvement program must include annual quality improvement projects specific to measurable improvement goals. At the beginning of each contract year, the HMO must present a plan to the State for designing and implementing its strategies followed by submission of semiannual progress reports summarizing performance relative to each of the defined objectives. The HMO must have procedures in place for monitoring the quality and adequacy of medical care which would include assessing utilization of services. On an annual basis, the HMO must submit a report on quality assurance activities which demonstrate its accomplishments, compliance and/or deficiencies in meeting its previous year’s work plan and should include studies undertaken, subsequent actions, and aggregate data on utilization and clinical quality of medical care rendered.

External review of the HMOs’ provision of quality and appropriate care is accomplished through routine surveys, medical audits and other administrative functions by DMAHS staff as well as focused quality studies conducted by an external quality review organization, the Peer Review Organization (PRO). Annual evaluations of the HMOs’ performance are conducted through a joint review process with State staff and the PRO.

State staff monitoring activities of the HMOs include:

• Maintenance of a toll free hotline for HMO members for questions and complaints which are investigated and resolved. • Assurance that marketing materials, member notices, newsletters, and handbooks are accurate and complete through a review and prior approval process.

Effective Date: April 1, 2009

Approval Date: ____________ 40

• Ongoing review of provider networks to assure contract standards and requirements are met. • Monitoring access and availability of HMO providers including after hours calls. • Reviewing and analyzing HMO reports and encounter data. • Conducting routine medical audits of care and audits of contract compliance and performance. • Determining the need for corrective action for identified problems, developing (with the HMO) a corrective action plan and monitoring the results. • Providing ongoing technical assistance to and a forum for open communications with the HMOs to assure a thorough understanding of contract responsibilities. Host regular meetings with HMO medical staff. • Comprehensive review of HMO operations in conjunction with the PRO. • Conducting formal member satisfaction studies. (CAHPS is utilized.) • Continuous communication with community and advocacy groups.

External Quality Review Organization monitoring functions include:

• Random review of medical records maintained by direct service providers for overall access to care, quality of care, identification of potential areas for quality improvement. • Individual case reviews. • Focused studies of specific aspects of care. HEDIS standards are used wherever appropriate. • Joint review of HMO operations with the State. • Health Plan performance standards. • Health care data analysis. • Host focus groups (which include HMO direct service providers), with State input, to review certain aspects of managed care and the impact on the quality of care.

In addition, all HMOs are required to comply with regulations promulgated by the Department of Health and Senior Services in consultation with the Department of Banking and Insurance. These regulations address all aspects of the HMO operations and include methods for assuring the quality and appropriateness of care. The regulations, as well as the contract with the Department of Human Services, require each HMO to have an internal system for monitoring quality. The regulations also require that an HMO audit be performed every three years by an external quality review organization approved by the Department.

For commercial lines of business, the Department of Health and Senior Services has also created a data reporting system to collect standardized, reliable and comparable information about access, availability of services and quality from each HMO. This system is built around multiple data sources

Effective Date: April 1, 2009

Approval Date: ____________ 41

and methods. Every HMO is required annually to submit performance and outcome measures that objectively demonstrate the HMO’s performance in delivering health care to its members. The results of the HMO’s performance are made public by the Department of Health and Senior Services through release of a HMO “report card.” The report card will include HEDIS measures and the results from the Consumer Assessment of Health Plans (CAHPS) survey. The use of CAHPS for this purpose represents the first use of this tool for a commercial population. In the future, consideration may be given to combining the Medicaid and commercial reporting requirements.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1.

Quality standards As indicated above, routine surveys and medical audits are conducted by DMAHS staff and the PRO under contract with the State. Based on the Modified QARI/QISMC standards located in the Medicaid contract, the HMO must ensure that its practice guidelines be based on reasonable medical evidence, consider the needs of the enrollees, be developed in consultation with contracting health care professionals and be reviewed and updated periodically. The HMO’s quality improvement program must include annual quality improvement projects specific to measurable improvement goals. HMO operations are formally reviewed annually through a joint review by the State and the PRO. Accreditation is not required.

7.1.2.

Performance measurement HMOs must conduct annual member satisfaction surveys. In addition, DMAHS conducts annual consumer satisfaction surveys that address issues of access, overall satisfaction and system performance. New Jersey Medicaid is participating in CAHPS, which will be extended to cover Title XXI services. HEDIS standards for measurement are utilized for the focused studies by the PRO wherever possible.

7.1.3.

Information strategies Under the Medicaid program, New Jersey has a highly developed system for providing consumer information. These successful strategies of providing detailed information on the benefits provided, rights and responsibilities, plan benefits and plan selection/enrollment will be extended to Title XXI as much as practical. Distribution of specific member notifications and disclosure of information about benefits and member rights and responsibilities are required of the HMOs; extensive marketing/enrollment outreach and education is provided through State agents.

7.1.4.

Quality improvement strategies As indicated above, the contract specifications require that HMOs develop an approved Quality Assurance Plan, which is monitored on an ongoing basis by

Effective Date: April 1, 2009

Approval Date: ____________ 42

State and contractor staff. These contract standards will also apply under Title XXI. Other monitoring activities of State and PRO staff are listed above. The State also uses focus groups and community and advocacy committees for continuous input into the managed care program.

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495) HMO networks are reviewed by the Department of Health and Senior Services as part of the process for granting a required Certificate of Authority. The Medicaid contracts which will also be used for Title XXI coverage include additional, specific standards for network adequacy. HMO networks must be reviewed and approved by both DMAHS and HCFA prior to participation in the Medicaid program.

As part of the approval process, HMOs are granted approval to enroll beneficiaries up to a specified level of enrollment based on provider network capacity. Based upon a review of the enrollment caps and further analysis of the pediatric networks, it has been determined that the existing contract HMOs should have adequate network capabilities to serve the anticipated increased membership in 18 counties. In the three remaining counties, at least two plans have been approved in each county with sufficient capacity to serve both the Title XIX and the Title XXI beneficiaries. Ongoing access is monitored through regular reviews of any changes in the HMO network, ongoing contact with listed providers, review of grievance and complaint information, and, when appropriate, undercover operations.

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a)) The State employs methods, including monitoring, to assure access to well-baby care, well-adolescent care and childhood and adolescent immunizations.

Specifically with respect to well-baby care and immunizations provided under the plan, HMOs are contractually required to provide EPSDT screenings and preventive services under Plans A, B and C. Under NJ FamilyCare Plan D, certain preventive services are also covered, including well-baby care, immunizations and preventive dentistry for children under the age of 12. State medical staff conduct routine reviews of HMO compliance with these requirements and its operating systems to support the outreach, case management and follow-up requirements of the program. HMOs are required to submit formal studies on immunization rates. PRO staff conduct focused studies of preventive services.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

Effective Date: April 1, 2009

Approval Date: ____________ 43

Access to emergency services is monitored as part of the independent PRO review and by reviewing claim denials, complaints and grievances.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee's medical condition. (Section 2102(a)(7)) (42CFR 457.495(c)) The State employs monitoring and other methods to assure that appropriate and timely treatment is provided to enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee's medical condition. The HMO contract requires such activities. The State staff monitors contract compliance, as does the PRO.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d)) Decisions related to the prior authorization of health services are completed in accordance with state law, regulation and HMO contract provisions, or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. The State employs monitoring and other methods to assure that appropriate and timely treatment is provided to all enrollees, including those enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee's medical condition. The HMO contract requires such activities. The State staff monitors contract compliance, as does the PRO.

Effective Date: April 1, 2009

Approval Date: ____________ 44

Section 8. Cost Sharing and Payment (Section 2103(e))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1.

YES 8.1.2.

NO, skip to question 8.8.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A))

(42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

As indicated above, Title XXI coverage in New Jersey provides for coverage that serves to transition families from the traditional Medicaid program for children’s health coverage to traditional commercial coverage as income rises. The program recognizes the need for affordability and simplicity in order to encourage maximum coverage of currently uninsured children, while also valuing the need for personal responsibility. Therefore, the cost sharing requirements have been designed to complement these overall policy goals. The premiums established in the State's premium assistance program are set lower than the premiums in the NJFC program, to assist in achieving this goal.

8.2.1. Premiums: For children in families with income at or below 150% of the poverty limit, there will be no premiums. The absence of a premium requirement applies to all children covered through the Medicaid expansion and those children covered under Title XXI with income at or below the 150% level.

For children in families with gross income above 150% and at or below 200% of the federal poverty level, a monthly premium will be required. There will be a single premium of $18.50 per month that applies to all families, regardless of income and regardless of the number of children in the family. A premium structure with limited tiers promotes affordability and simplicity, which will serve to attract greater enrollment of uninsured children. A family that has a higher number of children and an income at the higher end of the allowable scale will pay less when measured as a percentage of family income, but in fixed dollar terms the premium structure does not favor higher income families over lower income families.

Effective Date: April 1, 2009

Approval Date: ____________ 45

For families with gross income above 200% and at or below 250% of the federal poverty level before the applicable disregards, the monthly premium will be $37.50 per family. For families with gross income above 250% and at or below 300% of the federal poverty level before the applicable disregards, the monthly premium will be $74.50 per family. For families with gross income above 300% and at or below 350% of the federal poverty level before the applicable disregards, the monthly premium will be $125.00 per family.

The premiums required above will be adjusted in accordance with the change in the Federal Poverty Level (FPL) for a family of 2 at 100% FPL, as compared to the previous year. In other words, as income increases with the increase in the FPL, premiums will increase by the same percentage. For example, if the income amount changes by 2%, the premium amount will also change by 2%. A notice of administrative change regarding the revised premiums will be published in the New Jersey Register, as a legal notice in the newspapers of widest circulation in cities of 50,000 or more within the State, placed on the agency's web site, distributed to the State House Press Bureau, and sent to any person who requests to be placed on a list of interested parties in regard to such changes. Each family affected by the change in premiums will receive an individual notice of the change.

Families will be granted a 30 day grace period before coverage is canceled for non-payment of premium. Given that the mechanism for determining when a family has exceeded the cost-sharing cap anticipates payment of the monthly premium for the entire year, this will not be an issue in determining when a premium payment is due.

Premiums for families participating in the State's premium assistance program are set lower than the premiums in the NJFC program, to assist in achieving the goal of encouraging families to participate in the premium assistance program.

NJ FamilyCare Premium Payments Effective July 1, 2007 Premiums for Children

Plan C 18.50 Plan D (over 200% FPL up to and including 250% FPL) 37.50 Plan D (over 250% FPL up to and including 300% FPL) 74.50 Plan D (over 300% FPL up to and including 350% FPL) 125.00

NJ FamilyCare Premium Assistance Premium Payments Effective July 1, 2007 Premiums for Children

Plan C 8.50 Plan D (over 200% FPL up to and including 250% FPL) 27.50

Effective Date: April 1, 2009

Approval Date: ____________ 46

Plan D (over 250% FPL up to and including 300% FPL) 64.50 Plan D (over 300% FPL up to and including 350% FPL) 115.00

Effective Date: April 1, 2009

Approval Date: ____________ 47

8.2.2. Deductibles: Not applicable.

8.2.3. Coinsurance or copayments: Not applicable (see below)

8.2.4. Other: For children in families with gross income at or below 150% of the poverty limit, there will be no other cost-sharing. The absence of a cost-sharing requirement applies to all children covered through the Medicaid expansion (NJ FamilyCare Plan A) and those children covered under Title XXI with gross income at or below the 150% level (NJ FamilyCare Plan B).

For children in families with gross income above 150% and at or below 200% of the poverty level (NJ FamilyCare Plan C) and above 200% but below 351% of the poverty level (NJ FamilyCare Plan D), there will be an additional charge for certain services. No cost sharing will be charged for pregnancy-related services for women eligible pursuant to Section 4.1- P.

To the beneficiaries, this charge will be in the form of a copayment. In traditional terms, a copayment is used to offset the cost of care. Under NJ FamilyCare Plan D, there will be a traditional copayment requirement. However, under NJ FamilyCare Plan C, the client cost-sharing amount will actually be an incentive payment to providers at the direct care level. The rationale for the incentive payment is that when NJ FamilyCare Plan C clients were traditionally seen by direct care providers, it was as a private pay, fee- for-service patient. Now, the provider will be seeing the children as a managed care client, with rates that take into account the purchasing power of the State. Even though the rates paid under the Medicaid managed care contracts are actuarially sound, it still represents a change in the direct service providers billing relationship with the family. In recognition of this fact, the “copayments” made by the NJ FamilyCare Plan C clients will not be used to offset the cost of care, but rather will be used to supplement the existing payments and serve as an incentive for direct care providers to continue to participate in the networks. However, for ease in terminology, the payment will continue to be referred to as a “copayment.”

The copayment under NJ FamilyCare Plan C will be $5.00 for practitioner visits (physician, nurse midwife, nurse practitioner, clinics, podiatrists, dentist, chiropractors, optometrist, psychologists) and outpatient clinic visits. There will also be a $10.00 copayment for use of the emergency room. Copayment for prescription drugs will be $1.00 for generics and $5.00 for brand name drugs.

For children in families with gross income between 201% and 350% of the federal poverty level (Plan D), the copayment will be $5.00 for most services (the $5.00 copayment applies to the first prenatal visit only). A $10.00

Effective Date: April 1, 2009

Approval Date: ____________ 48

copayment applies to primary care provider office visits rendered during off hours, home visits and for prescription drugs in excess of a 34-day supply. Mental health outpatient visits require a $25.00 copayment. The copayment for emergency room services is $35.00.

For NJ FamilyCare Plan C, no copayments will be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; lead screening and treatment; age-appropriate immunizations; preventive dental services; prenatal care; family planning visits; and pap smears, when appropriate. Other services (such as therapy visits, hearing aids, and eyeglasses) will not require a copayment. (See Attachment 6 for a detailed list of services and applicable copayment amounts).

For NJ FamilyCare Plan D, no copayments will be charged for well-child visits in accordance with the schedule recommended by the American Academy of Pediatrics; lead screening and treatment; age-appropriate immunizations; preventive dental services for children under 12; and prenatal care beyond the first visit. (See Section 6 for a detailed list of services and applicable copayment amounts).

A family that utilizes services that require copayment will pay more when measured as a percentage of family income, but in fixed dollar terms the copayment structure does not favor higher income families over lower income families.

For any family subject to cost-sharing (premiums and copayments), an annual limit equal to five percent of the family income will apply. When families reach this limit, they are no longer required to pay and will be provided with a letter to that effect, which they can use when accessing services. Please see attachment 6 for cost sharing associated with specific services.

8.3. Describe how the public will be notified, including the public schedule, of this cost-sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b)) General reference to the cost-sharing requirements will be included in all public communications concerning the Title XXI program. The specific requirements will be detailed in the implementing regulations, in all pamphlets and brochures developed for outreach purposes, on the application for participation, and as a supplement to the member’s handbook for all new plan enrollees. The letter that confirms eligibility and enrollment in the program will also address the cost-sharing requirements and indicate the family cap that applies based on reported income. Specifically, information regarding increases in cost sharing will be sent by letter to each family and will include the dollar amounts applicable to the individual family. Specific schedules will be published in the New Jersey Register, published as a legal

Effective Date: April 1, 2009

Approval Date: ____________ 49

notice in the newspapers of widest circulation in cities of 50,000 or more within the State, placed on the agency’s web site, distributed to the State House Press Bureau, and sent to any person who requests to be placed on a list of interested parties in regard to such changes.

All staff who will deal directly with the public concerning the program, including outreach and customer service staff, are trained on the cost-sharing requirement, including, but not limited to, information on who is required to participate in cost-sharing, what is the amount of the cost-sharing, how is the cost-sharing amount collected, what is the impact of failure to pay a premium timely, what is the family limit on cost-sharing and how is it applied, what services are subject to the copayment requirement, and what services are exempt from the copayment requirements. All applicants will be made aware of the cost-sharing requirements at the time of their applications.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families.

(Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3.

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.5. Describe how the state will ensure that the annual aggregate cost- sharing for a family does not exceed 5 percent of such family's income for the length of the child's eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee. (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e)) The design of the cost-sharing requirement that limits the premium to a single amount, regardless of the number of children in the family, helps to ensure that the aggregate cost-sharing cap will not be exceeded for NJ FamilyCare Plans C and D. Exceeding the family limit under NJ FamilyCare Plans C and D should be an issue only where there is significantly high utilization of non- preventive services subject to copayment.

The cost-sharing limit will be calculated annually under NJ FamilyCare Plans C and D, starting with the date of initial enrollment of any children in the family or the annual re-enrollment date. For ease of administration, premium payment will be required monthly, but the need to continue premium payment for the entire 12 month payment will be taken into account in determining when the cost-sharing cap has been exceeded.

Effective Date: April 1, 2009

Approval Date: ____________ 50

All beneficiaries and applicants subject to cost sharing under NJ FamilyCare Plans C and D will be provided written material that clearly and very specifically explains (1) the limitation on cost-sharing, (2) the dollar limit that applies to the family based on the reported income, (3) the need for the family to keep track of the cost-sharing amounts paid and (4) instructions on what to do if the cost-sharing requirements are exceeded.

Once the limits have been exceeded, a family can (1) apply for a rebate of any cost-sharing already paid in excess of the limit and (2) apply for a special membership card that documents “no copayment” status for the remainder of the 12 month period. The family status will be confirmed through review of encounter data and contact with the HMOs, as well as providers of service.

It is anticipated that the use of technology in the future (for example, the use of eligibility swipe cards) will allow changes that will simplify tracking of the cost-sharing amounts paid and very timely communication of “no copayment” status to providers. This swipe card technology will be implemented on a pilot basis during 2005.

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

The State ensures that American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing, (42 CFR 457.535), by collecting information on the application and at the time of redetermination of eligibility regarding a child’s status as an American Indian or Alaska Native. The applicant/beneficiary is asked to indicate their tribal membership by stating this on the application and by presenting the tribal membership card to the eligibility determination entity. If a beneficiary is found to be in the AI/AN category, the family is notified of the exemption.

The requirement that no AI/AN child be charged a copayment is contained in the provider manual each new fee-for-service provider receives. A provider newsletter was sent to all fee-for-service providers, with a copy to the HMOs, when the requirement was instituted. This newsletter remains in the manual issued to new providers. In addition, all providers are required to verify eligibility by checking the eligibility card, which contains a notation regarding copayment, as does the telephone eligibility verification system used by providers. In addition, the HMO contract requires that each HMO enforce this requirement with its providers, and to include copayment information on the HMO identification card. Therefore, since all providers receive these notifications, providers are aware that AI/AN children are excluded from cost- sharing provisions.

Effective Date: April 1, 2009

Approval Date: ____________ 51

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

The consequences for an enrollee or applicant who does not pay a charge, (42 CFR 457.570 and 457.505(c)), are as follows: No services are denied due to lack of a copayment. However, if required premiums are not paid, the coverage will not be continued. The state has established a process that gives beneficiaries reasonable notice of and an opportunity to pay past due cost sharing amounts (premiums, copayments, coinsurance, deductibles and similar fees) prior to disenrollment. If disenrollment occurs, the State will facilitate enrolling the child in Medicaid, or adjust the child’s cost-sharing category, as appropriate. Enrollees are notified of premiums they must pay two months in advance of the due date. If they do not pay on the date due, a disenrollment process is activated two months after the due date. There is no lock-out period for disenrollees before they can re-enroll. They can re-enroll at any time after disenrollment, if they are still eligible, but must pay what is owed for past due premiums.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee's family income has declined prior to disenrollment for non payment of cost- sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child's cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220)

8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5)

Effective Date: April 1, 2009

Approval Date: ____________ 52

(42CFR 457.224) (Previously 8.4.5)

8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1))

8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5))

8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475)

8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

Effective Date: April 1, 2009

Approval Date: ____________ 53

Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low- income children: (Section 2107(a)(2)) (42CFR 457.710(b))

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c)) See Attachment 9.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state's performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d)) See Attachment 9.

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. Immunizations 9.3.7.2. Well child care 9.3.7.3. Adolescent well visits 9.3.7.4. Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care 9.3.7.7. Other, please list: 9.3.8.

Performance measures for special targeted populations.

9.4. The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section

Effective Date: April 1, 2009

Approval Date: ____________ 54

2107(b)(1)) (42CFR 457.720)

9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state's plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750) See Attachment 9.

9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8.

The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

No federally-recognized Indian Tribes or organizations are present in New Jersey.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in 42 CFR 457.65(b) through (d).

Effective Date: April 1, 2009

Approval Date: ____________ 55

See Attachment 9.

9.9.2-P Public notice for pregnant women eligible pursuant to Section 4.1-P was provided through newspaper notice, posting in county offices and on the State website. Also, eligible pregnant women had been covered under the State’s Section 1115 waiver, prior to the enactment of CHIPRA and until March 31, 2009, with all required public notices. The transition from Section 1115 waiver to Title XXI services will be seamless for beneficiaries.

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment.

`Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

See Attachment 9. .

Effective Date: April 1, 2009

Approval Date: ____________ 56

Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1.

The progress made in reducing the number of uncovered low-income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2.

The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3.

The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

Effective Date: April 1, 2009

Approval Date: ____________ 57

Section 11. Program Integrity (Section 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue to Section 12.

11.1

The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9)

11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.

Section 1128E (relating to the National health care fraud and abuse data collection program)

Effective Date: April 1, 2009

Approval Date: ____________ 58

Section 12. Applicant and enrollee protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120. The State assures that applicants and enrollees have the opportunity for review of the following eligibility or enrollment matters specified in 42 CFR 457.1130(a): 1) denial of eligibility; 2) failure to make a timely determination of eligibility; and 3) suspension or termination of enrollment, including disenrollment for failure to pay cost sharing. Continuation of enrollment pending a decision is assured in contract and regulation.

The State assures that: enrollees have the opportunity to participate in the review process; decisions are made in writing; and impartial reviews are conducted in a reasonable amount of time and consideration is given for the need for expedited review when there is an immediate need for health services. All procedures and communications utilized by the health benefits coordinator are reviewed by the State for compliance with Federal, State and contract standards before being placed into use.

For children eligible or applying under NJ FamilyCare Plan A, the formal Medicaid fair hearing mechanism is available for appeals involving the eligibility determination and enrollment matters. For children eligible or applying under NJ FamilyCare Plans B, C and D, or who are terminated for non-payment of premium, there is a mediation mechanism conducted by the HMO, which is used as the first step in the appeal process. The HMO, the HBC and the DMAHS staff work on problem resolution once an issue is raised by a beneficiary, and attempt to secure a satisfactory resolution for the beneficiary. If the initial discussions do not produce a satisfactory resolution, the beneficiary may pursue the matter further and use the grievance/Fair Hearing process, as applicable. The HMO designee provides an impartial review.

This can be followed by a formal appeal to DMAHS, which must be submitted in writing within 20 days of the adverse notification, regardless of whether mediation is attempted. This appeal will be heard by a panel comprised of state staff, who will make recommendations to the Division Director. Within 45 days of receipt of the appeal, the DMAHS Director will issue a final agency decision, which is subject to judicial review in the Appellate Division.

Monitoring of the review process for eligibility and enrollment matters is conducted by the health benefits coordinator and by the State. The State monitors all aspects of the contract with the health benefits coordinator, including the determination and redetermination of eligibility. The State conducts reviews of customer satisfaction, and samples correspondence and telephone calls to assure that eligibility and

Effective Date: April 1, 2009

Approval Date: ____________ 59

enrollment procedures are conducted in accordance with contract, State and federal standards. Enrollees are given sufficient notice if their eligibility may be terminated if they do not take certain actions, with specific instructions on what they must do, and where they may contest any decision made by the State or the health benefits coordinator.

All applications are screened against the existing Medicaid Eligibility File.

Applications which involve family members already enrolled in the Medicaid program will be forwarded to the County Board of Social Services to be added to the existing case file. In addition, the County Board of Social Services refers any child found not eligible for Medicaid or any child losing eligibility for Medicaid to the NJ FamilyCare program. The County Board of Social Services provides the necessary application and provides assistance in completing the application.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

The State assures that the health services matters subject to review under the state health insurance law are consistent with the intent of 42 CFR 457.1130(b) and include the: (1) Delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and (2) Failure to approve, furnish, or provide payment for health services in a timely manner.

The health plans issue a State-approved document to every enrollee which delineates the enrollees’ rights and responsibilities. This document explains the review process for health services matters. This process allows for an internal review conducted by the plan and an external review conducted by the state. All reviews are conducted within the time frames stipulated in federal regulation and all decisions will be made in writing.

The State assures that enrollees receive timely written notice of any determinations that include the reasons for the determination, an explanation of applicable rights to review, the standard and expedited time frames for review, the manner in which a review can be requested, and the circumstances under which enrollment may continue pending review.

The State assures that enrollees have the opportunity for an independent, external review of a delay, denial, reduction, suspension, termination of health services or failure to approve health services in a timely manner. The independent review is available at the external appeals (State) level.

The State assures that enrollees in Plan A have the opportunity to represent

Effective Date: April 1, 2009

Approval Date: ____________ 60

themselves or have representatives in the process at the external appeals level. Plan A uses the Medicaid Fair Hearing process for health services matters.

The State assures that enrollees in Plans A, B, C and D have the opportunity to timely review of their files and other applicable information relevant to the review of the decision. While this is assured at each level of review, members will be notified of the specific timeframes for the appeals process, once an external appeal is filed.

The State assures that enrollees have the opportunity to fully participate in the review process, whether the review is conducted in person or in writing. Enrollees in Plans B, C and D have the opportunity to represent themselves or to have representation of their choosing at the HMO grievance and the external levels.

The State assures that reviews that are not expedited due to an enrollee’s medical condition will be completed within 90 calendar days of the date a request is made.

The State assures that reviews that are expedited due to an enrollee’s medical condition are completed within 72 hours of the receipt of the request.

Premium Assistance Programs

12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

Not applicable.

NEW JERSEY TITLE XXI PROGRAM & TITLE XXI AMENDMENT FACT SHEET

Name of Plan: New Jersey FamilyCare

Date Plan Submitted: February 6, 1998 Date Plan Approved: April 27, 1998 Plan Effective Date: February 1, 1998 (Medicaid Expansion)

March 1, 1998 (Separate child health program) Plan Implementation Date: February 1, 1998

Date Amendment #1 Submitted: February 9, 1999 Date Amendment #1 Approved:

May 5, 1999 Date Amendment #1 Effective:

January 13, 1999

Date Amendment #2 Submitted:

May 6, 1999 Date Amendment #2 Approved:

August 3, 1999 Date Amendment #2 Effective:

July 1, 1999

Date Amendment #3 Submitted:

September 21, 1999 Date Amendment #3 Approved:

July 7, 2000 Date Amendment #3 Effective:

July 26, 1999

Date Amendment #4 Submitted: December 18, 1999 Date Amendment #4 Approved:

March 16, 2000 Date Amendment #4 Effective:

January 1, 2000

Date Amendment #5 Submitted:

February 4, 2002 Date Amendment #5 Approved:

April 23, 2002 Date Amendment #5 Effective:

January 1, 2002

Date Amendment #6 Submitted:

May 7, 2002 Date Amendment #6 Approved:

July 22, 2002 Date Amendment #6 Effective:

August 24, 2001

Date Amendment #7 Submitted:

July 22, 2003 Date Amendment #7 Approved:

October 16, 2003 Date Amendment #7 Effective:

May 22, 2003

Date Amendment #8 Submitted:

June 29, 2004 Date Amendment #8 Approved:

September 13, 2004 Date Amendment #8 Effective:

August 25, 2001

Date Amendment #9 Submitted:

December 23, 2004 Date Amendment #9 Approved:

September 13, 2004 Date Amendment #9 Effective:

October 1, 2004

Date Amendment #10 Submitted: April 4, 2005 Date Amendment #10 Withdrawn: May 30, 2005

Date Amendment #11 Submitted: May 30, 2005 Date Amendment #11 Approved: November 22, 2005 Date Amendment #11 Effective:

July 1, 2005

Date Amendment #12 Submitted: June 12, 2009 Date Amendment #12 Approved: September 18, 2009 Date Amendment #12 Effective:

April 1, 2009

Date Amendment #13 Submitted: June 25, 2009 Date Amendment #13 Approved: May 14, 2010 Date Amendment #13 Effective:

April 1, 2009

Date Amendment #14 Submitted:

June 26, 2009 Date Amendment #14 Approved:

Pending Date Amendment #14 Effective:

May 1, 2009

Date Amendment #15 Submitted: September 25, 2009 Date Amendment #15 Approved: December 17, 2009 Date Amendment #15 Effective:

July 1, 2009

Background

• On February 6, 1998, New Jersey submitted a Children’s Health Insurance Program (CHIP) State plan with a separate child health component (NJ KidCare Plans B & C) and a CHIP Medicaid expansion component (NJ KidCare Plan A). The Medicaid expansion covers uninsured children up to age 19 with family incomes at or below 133 percent of the Federal poverty level (FPL). The separate child health program initially covered uninsured children with gross family incomes above 133 percent up to and including 200 percent of the FPL. New Jersey has had approval to cover uninsured children up to and including 350 percent of the FPL since August 3, 1999, effective as of July 1, 1999. The name of New Jersey’s CHIP plan was later changed to New Jersey FamilyCare (NJ FamilyCare) in January of 2001.

Amendments

• New Jersey submitted its first State plan amendment (SPA) on February 9, 1999, to shorten the length of time that children must be uninsured before applying for the separate child health program (Plans B & C) from 12 months to 6 months.

• The State submitted its second SPA on May 6, 1999. This SPA applied income disregards to expand New Jersey KidCare (later renamed NJ FamilyCare) to children in families with incomes through 350 percent of the FPL. The expansion, known a NJ KidCare Plan D, provided health insurance to an additional 9,000 children as of September 1999.

• The State’s third SPA was submitted September 21, 1999, and added exceptions to the required 6-month waiting period prior to application for NJ KidCare (later renamed NJ FamilyCare) Plans B, C and D.

• The State submitted its fourth SPA on December 18, 1999, allowing for presumptive eligibility determinations when staff of acute care hospitals, Federally qualified health centers, or local health departments indicate that a child meets either NJ KidCare (later renamed NJ FamilyCare) Plan A, B or C, or Medicaid program eligibility standards, and that the child is a member of a household with a gross income not exceeding 200 percent of the FPL.

• The State submitted its fifth SPA on February 4, 2002, adding an additional income disregard for applicants to NJ FamilyCare. The disregard applies to individuals earning monetary rewards paid by the Division of Medical Assistance and Health Services for information leading to the recovery of at least $100 from individuals or entities that have engaged in health care-related fraud or abuse.

• The State’s sixth SPA was submitted on May 7, 2002, and eliminated cost-sharing requirements for American Indians and Alaskan Native children.

• The State submitted its seventh SPA on July 22, 2003, to increase premiums by 10 percent for NJ FamilyCare enrollees with family incomes above 150 percent of the FPL. This amendment also included an annual increase in premium amounts in accordance with the change in the FPL.

• The State submitted its eighth SPA on June 29, 2004, to update its State plan to indicate compliance with the final CHIP regulations.

• The State submitted its ninth SPA on December 23, 2004, to allow self-declaration of income on the NJ FamilyCare “Express Enrollment” application in eight school districts within the State.

• The State submitted its tenth SPA on April 4, 2005. It was subsequently withdrawn.

• The State submitted its eleventh SPA on May 30, 2005, to make changes in the eligibility process, including reducing the required period of uninsurance from 6 months to 3 months, guaranteeing 12 months of continuous eligibility in NJ FamilyCare, and increasing the threshold of presumptive eligibility from the 200 percent of the FPL to 350 percent of the FPL.

• New Jersey submitted its twelfth SPA on June 12, 2009, to provide for coverage under New Jersey’s CHIP State plan of uninsured pregnant women having gross income above 185 percent of the FPL up to and including 200 percent of the FPL. Since January 2001, New Jersey has been covering this population with title XXI funds through section 1115 demonstration authority. Through this SPA, New Jersey is implementing the new provision permitted by section 111 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), which gives States the option to provide necessary prenatal, delivery, and

postpartum care to targeted low-income pregnant women through the title XXI State plan. New Jersey is requesting that coverage of these pregnant women be transitioned from its title XXI section 1115 demonstration to the title XXI State plan.

• On June 25, 2009, New Jersey submitted its thirteenth SPA to elect the new option permitted under section 214 of CHIPRA to eliminate the 5-year bar on eligibility and cover certain non-citizen children and pregnant women who are lawfully residing in the United States.

• On June 26, 2009, New Jersey submitted its fourteenth SPA to implement the Express Lane eligibility option for children, as permitted under section 203 of CHIPRA.

• New Jersey submitted its fifteenth SPA on September 25, 2009, to eliminate premiums for children with family incomes above 150 up to and including 200 percent of the FPL, who are covered in its separate CHIP under NJ FamilyCare Plan C, as provided by the New Jersey State Fiscal Year Appropriations Act. Copayments will remain in effect for children in Plan C. Children with family incomes at or below 150 percent of the FPL are already exempt from paying premiums and copayments (NJ FamilyCare Plans A and B).

Children Covered Under Program

• The State reported that 167,009 children were ever enrolled in its program in Federal fiscal year (FFY) 2009.

• New Jersey estimates that an additional 11,000 children will be made eligible in FFY 2010 in Medicaid and CHIP as a result of the CHIPRA section 214 eligibility expansion. Approximately 4000 of these children will be covered in New Jersey’s title XXI Medicaid expansion and separate child health program components and the remainder in Medicaid.

Pregnant Women Covered Under Program

• Enrollment of pregnant women in New Jersey’s title XXI section 1115 demonstration has remained relatively stable. Therefore, New Jersey projects an average monthly enrollment of 90 pregnant women under the title XXI State plan.

• The number of pregnant women ever enrolled in FFY 2009 was 306.

Administration

• The Division of Medical Assistance and Health Services within the New Jersey Department of Human Services administers the program.

Health Care Delivery System

• The existing Medicaid delivery system is used to provide services.

Benefit Package

• Children with family incomes at or below 133 percent of the FPL in the Medicaid expansion receive the Medicaid benefit package (NJ FamilyCare Plan A).

• Benchmark coverage equal to the FEHBP Blue Cross/Blue Shield plan is provided in the separate child health program (NJ FamilyCare Plans B & C) for children with family incomes above 133 up to and including 200 percent of the FPL.

• Benchmark coverage equal to the plan offered by an HMO that has the largest insured commercial non-Medicaid enrollment in the State is provided in the separate child health program for children with family incomes above 200 up to and including 350 percent of the FPL (NJ FamilyCare Plan D).

• Pregnant women receive Secretary–approved coverage, which is coverage that is the same as the coverage provided to pregnant women under New Jersey’s Medicaid State plan and consists of the full, comprehensive Medicaid benefit package, in addition to pregnancy- related services.

Cost Sharing

• Premiums will be required for children in families with incomes above 200 percent of the FPL (NJ FamilyCare Plan D) as follows: ° $40 per family per month for children with family incomes above 200 up to and including 250 percent of the FPL. ° $79 per family per month for children with family incomes above 250 up to and including 300 percent of the FPL. ° $133 per family per month for children with family incomes above 300 up to and including 350 percent of the FPL.

• Premiums will increase annually with the increases in the FPL.

• Copayments are required for children in families with incomes above 150 percent of the FPL (NJ FamilyCare Plans C & D) as follows: $5 for practitioner visits (including visits to physicians, nurse midwives, nurse practitioners, clinics, podiatrists, dentists, chiropractors, optometrists and psychologists); $5 for outpatient clinic visits; $10 for use of the emergency room under Plan C and $35 under Plan D; $1 for generic prescription drugs and $5 for brand- name prescription drugs in Plan C; and $5 or $10 for both generic and brand-name prescription drugs in Plan D, depending on the amount supplied (up to a 34-day supply or more than a 34-day supply).

• There are no premiums, copayments, or any cost sharing for pregnant women.

Crowd-Out Strategy

• A child with income greater than 133 percent of the FPL must have been uninsured for a minimum of 3 months before becoming eligible for coverage.

• The required period of uninsurance for the Premium Support Program is 6 months for those having access to cost-effective employer sponsored insurance.

• Exceptions to the required period of uninsurance will be made under limited circumstances.

• There is no waiting period of prior uninsurance applied to pregnant women.

Coordination Between CHIP and Medicaid

• New Jersey uses a joint Medicaid and CHIP mail-in application.

Outreach Activities

• The State plan describes a four-fold outreach effort involving: (1) public awareness, (2) targeted outreach, (3) community education, and (4) consumer education. There is also a commitment by the State to conduct outreach to special populations, including individuals with HIV and homeless families.

• All outreach workers are trained in eligibility requirements for CHIP and Medicaid programs. Bilingual staff and/or language services are offered to applicants when needed.

Financial Information

Total FFY ’09 CHIP Allotment -- $505,395,000 Total FFY ’10 CHIP Allotment -- $634,744,914 FFY ’10 Enhanced Matching Rate -- 65%

Date Last Updated: May 14, 2010

_____________________________________________________________________________

Table of Contents

State/Territory Name: New Jersey

State Plan Amendment (SPA) #: NJ-13-0019

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for New Jersey consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CANT 7500 Security Boulevard, Mail Stop: S2-26-12 CM Ss

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & ChIP seamrcES

Children and Adults Health Programs Group

APR 2 1 2014

Ms. Valerie Harr, Director

Division of Medical Assistance and Health Services New Jersey Department of Human Services

7 Quakerbridge Plaza

P.O. Box 712

Trenton, NJ 08625-0712

Jal ane Dear Ms-Hatr:

Iam pleased to inform you that the Centers for Medicare and Medicaid Services (CMS) has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number NJ- 13-0019, submitted on December 23, 2013, and related to Modified Adjusted Gross Income (MAGD Eligibility, with an effective date of January 1, 2014.

SPA number NJ-13-0019 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your title XXI project officer is Ms. Stacey Green. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Green’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Division of State Coverage Programs

Mail Stop S2-07-08

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-6102

Facsimile: (410) 786-5882

E-mail: Stacey.green@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Green and to Mr. Michael Melendez, Associate Regional Administrator (ARA) in our New York Regional Office. Ms. Melendez’s address is:

Page 2 — Ms. Valerie Harr

Centers for Medicare & Medicaid Services 26 Federal Plaza, Room 3811 New York, NY 10278-0063

If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs, at (410) 786-5920. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely,

Eliot Fishman Director

Enclosures ce: Mr. Melendez, CMS Region II, New York

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NJ.0658.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: New Jersey State Funds: $ Federal Funds: $ Submitted By: Julie Hubbs Last Revision Date: Dec 23, 2013 Submit Date: Dec 23, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NJ-13-0019 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:53 out of 2000 CHIP eligibility for Medicaid expansion program (CS3) Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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ccmMs. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/3 1/2014

CS3

Eligibility for Medicaid Expansion Program.

42 CFR 457,320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL)

+ ile 19 107 142 xX

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

APR 2 1 2014

SPA # NJ-13-0019 Approval Date: Effective Date: January 1, 2014

Page | of |

_____________________________________________________________________________

Table of Contents

State/Territory Name: New Jersey

State Plan Amendment (SPA) #: NJ-13-0021

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for New Jersey consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services (CMs 7500 Security Boulevard, Mail Stop: S2-26-12 Cc M Ss

Baltimore, Maryland 21244-1850 RE POO NEARE & MEDICAID SERVICES

CENTER FOR MEDICAID & CHIP SERVICES Children and Adults Health Programs Group

APR 1 1 cui4

Valerie Harr, Director

Division of Medical Assistance and Health Services New Jersey Department of Human Services

7 Quakerbridge Plaza

P.O. Box 712

Trenton, NJ 08625-0712

Dear Ms. Harr:

I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved New Jersey’s Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), NJ-13-0021 submitted on November 21, 2013. This SPA incorporates the MAGI-based eligibility process requirements in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA NJ-13-0021 includes full approval of your state’s alternative single streamlined paper application. The state is using an interim online alternative single streamlined application and by December 31, 2014, will implement a revised online alternative single streamlined application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following CS24 state plan pages and attachments to be incorporated within a separate section at the end of New Jersey’s approved state plan:

C824 Attachment 1 — Statement of use with respect to the alternative single streamlined online application

e Attachment 2 —NJ FamilyCare paper application

This approval and the attachments supercede the following sections of the current CHIP State Plan:

e Section 4.3: Single Streamlined Application Screen and Enroll Process e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

Page 2 — Ms. Valerie Harr

The CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your title XXI project officer is Ms. Stacey Green. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Green’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-6102

Facsimile: (410) 786-5882

E-mail: Stacey.Green@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Green and to Mr. Michael Melendez, Associate Regional Administrator (ARA) in our New York Regional Office. Mr. Melendez’s address is:

Mr. Michael Melendez

Office of the Regional Administrator Jacob K. Javits Federal Building

26 Federal Plaza, Room 3811

New York, NY 10278-0063

If you have additional questions, please contact Barbara K. Richards, Acting Director, Division of State Coverage Programs at 410-786-5920.

We look forward to continuing to work with you and your staff.

Sincerel

10t Fis. Director

Enclosure

cc: Mr. Michael Melendez, Associate Regional Administrator, CMS Region II

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services (CMs 7500 Security Boulevard, Mail Stop: S2-26-12 CM Ss

Baltimore, Maryland 21244-1850 CENTER Fm MEDICAID & Cha sesnures Children and Adults Health Programs Group APR 1 1 2014

Valerie Harr, Director

Division of Medical Assistance and Health Services New Jersey Department of Human Services

7 Quakerbridge Plaza

P.O. Box 712

Trenton, NJ 08625-0712

RE: C824 — Eligibility Process State Plan Amendment (SPA), NJ-13-0021 Dear Ms. Harr:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) NJ-13-0021, which was submitted to CMS on November 21, 2013. Our review of this submission included a review of the alternative single streamlined paper and online applications developed by the state.

The state is currently using an interim online alternative single streamlined application. On or before December 31, 2014, this interim application needs to be revised to reflect the following change.

Necessary Change: Completion Date:

December 31, 2014 Information about immigration status, which is needed to perform an electronic data match, will be requested from non-citizen applicants.

Please submit the revised alternative online application to CMS for review no later than December 1, 2014, to allow for approval by December 31, 2014.

Page 2 — Ms. Valerie Harr We continue to be available to provide technical assistance. If you have any questions about your application, please contact Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167.

We look forward to continuing to work with you and your staff.

Sincerely,

Acting Director Division of State Coverage Programs

ce: Mr. Michael Melendez, Associate Regional Administrator, CMS Region II

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NJ.0532.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: New Jersey State Funds: $ Federal Funds: $ Submitted By: Julie Hubbs Last Revision Date: Jun 5, 2014 Submit Date: Nov 21, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NJ-13-0021 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(3) and 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:46 out of 2000 CHIP General Eligiblity-Eligibility Processing Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/03/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

0 Paper Application [1 Online Application TRANSMITTAL NUMBER: STATE: NJ-13-0021 New Jersey

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference

into the state plan.

Cems. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

4)

Application Processing

Indicate which application the agency uses for individuals apply ing for coverage who may be eligible based on the applicable modified adjusted gross income standard:

oO The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with

5m LS section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the [7] agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means. (21 Other electronic means: Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low-

i income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

im Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs; and

fal Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

Ape, 2 4 2Bt4 SPA# NJ-13-0021 Approval Date: AFR TT cut Effective Date: October 1, 2013

Page 1 of 2

CHIP Eligibility

rT Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single stream lined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced

premium tax credits in accordance with section 1943(b)(2) of the SSA. No

Redetermination Processing

Redeterm inations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343:

[lM] Once every 12 months.

ww Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency.

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional [i] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42

CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42 “J CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for

CHIP.

Check all types of agencies that apply:

The Exchange

Medicaid

(C] Other agency administering insurance affordability programs

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the v requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. :

V.20130709

SPA# NJ-13-0021 Approval Date: APR i i 2014

Effective Date: October 1, 2013 Page 2 of 2

Application for Health Coverage NJ FAM LYCARE

& Help Payi ng Costs Affordable health coverage. Quality care.

THINGS TO KNOW

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710, Para obtener una copia de este formulario en Espafiol, lame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-701-0720.

NJFAMELYCARE

Affordable health caverage. Quality care.

| STE a0 Teil us about yourself.

(We need one adult in the family to be the contact person for your application.)

1. First name, Middle name, Last name, & Suffix

2. Home address (Leave blank if you don’t have one.) 3. Apartment or suite number 4, City 5. State 6. ZIP code 7. County

8. Mailing address (if different from home address) 9. Apartment or suite number 10. City 11. State 12. ZIP code 13. County

14, Phone number 15. Other phone number

( ) - ( ) -

16. Do you want to get information about this application by email? []Yes [No

Email address:

17. What is your preferred spoken or written language (if not English)?

| STEP 2 | Tell us about your family.

Who do you need to include on this application?

Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax return. (You don't need to file taxes to get health coverage).

DO Include: You DON'T have to include: » Yourself * Your unmarried partner who doesn't need health coverage * Your spouse * Your unmarried partner’s children * Your children under 21 who live with you * Your parents who live with you, but file their own tax return * Your unmarried partner who needs health coverage (if you're over 21) + Anyone you include on your tax return, even if they don’t * Other adult relatives who file their own tax return live with you + Anyone else under 21 who you take care of and lives with you

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can.

. Start with yourself, then add other adults and children. If you have more ea e pages and attach the

n m

Complete Step 2 for each person in your fami han 2 people in yo a ‘Il nee

You don't need to provide immigration status or a Social Security Number (SSN) for family members who don't need health coverage. We'll keep all the information you provide private and secure as required by law. We'll use personal information only to check if you're eligible for health coverage.

MEEG HELP WITH YOUR APPLICATION? Visit njfamilycars.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espaiiol, lame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-701-0720.

Page 1 of 7

NJFAMELYCARE STEP 2: PERSON 4 (Start with yourself) Affordable health coverage. Quality care.

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you don't file a tax return, remember to still add family members who live with you.

1. First name, Middle name, Last name, & Suffix 2. Relationship to you? SELF

3. Date of birth (mm/dd/yyyy) 4.Sex [] Male [Female

5. Social Security number (SSN) —— —— —_ - _- __- __ __

We need this if you want health coverage and have an SSN, Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who's eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity,gov. TTY users should call 1-800-325-0778.

6. Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return.)

C YES. If yes, please answer questions a-c. C1 NO. If no, skip to question c. a. Will you file jointly with a spouse? []Yes [No

If yes, name of spouse: b. Will you claim any dependents on your tax return? []Yes [No If yes, list name(s) of dependents: c. Will you be claimed as a dependent on someone's tax return? [] Yes [1] No

If yes, please list the name of the tax filer: How are you related to the tax filer?

7. Are you pregnant? []Yes [] No a. If yes, how many babies are expected during this pregnancy?

8. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.)

(1 YES. If yes, answer all the questions below. © C1 NO. If no, SKIP to the income questions on page 3. >) Leave the rest of this page blank.

9. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? []Yes []No

10. Are you a USS. citizen or U.S. national? []Yes [No 11. If you aren't a U.S. citizen or U.S. national, do you have eligible immigration status? (Yes. Fill in your document type and ID number below. a. Immigration document type b. Document ID number

c. Have you lived in the U.S. since 1996? [] Yes []No d. Are you, or your spouse or parent a veteran or an active-duty member of the U.S, military? []Yes [No

12. Do you want help paying for medical bills from the last 3 months? []Yes [] No

13. Do you live with at least one child under the age of 19, and are you the main person taking care of this child? []Yes [No

14, Are you a full-time student? []Yes C]No 15, Were you in foster care at age 18 or older? []Yes []No

16. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) (Mexican [] Mexican American []Chicano/a []Puerto Rican []Cuban [other

17. Race (OPTIONAL—check all that apply.)

1 white 0 Native American Indian [1] Filipino 0 Vietnamese (1 Guamanian or Chamorro (1 Black or African or Alaska Native O Japanese (1 Other Asian (1 samoan American 0 Asian Indian 0 Korean C1 Native Hawaiian (C1) Other Pacific Islander (J chinese (0 other

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espafiol, lame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-701-0720.

Page 2 of 7

NJFAMELYCARE

Affordable health caverage. Quality care.

| STEP 2: PERSON 4) (Continue with yourself) Current job & income Information

C1 Employed C1 Not employed OO Self-employed If you're currently employed, tell us Skip to question 28. Skip to question 27. about your income. Start with question 18. CURRENT JOB 1: 18. Employer name and address 19, Employer phone number

) -

20. Wages/tips (before taxes) [] Hourly []Weekly []Every2weeks []Twiceamonth []Monthly [1] Yearly

21. Average hours worked each WEEK

CURRENT jOB 2: (If you have more jobs and need more space, attach another sheet of paper.) 22, Employer name and address 23. Employer phone number 24, Wages/tips (before taxes) []Hourly []Weekly []Every2weeks [JTwiceamonth L]Monthly [Yearly

$i 25. Average hours worked each WEEK

26. In the past year, did you: [_] Change jobs [1] Stop working [] Start working fewer hours [] None of these

27. If self-employed, answer the following questions:

a. Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month?

$

28. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don't need to tell us about child support, veteran's payment, or Supplemental Security Income (SSI). [None

Cunemptoyment $ How often? (net farming/fishing $ How often? (Pensions $ How often? CNet rental/royalty $ How often? CsSocial Security $ How often? (other income $ How often? Retirement accounts $ How often? Type:

‘ CAlimony received $ How often?

29. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower,

NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 27b). (Alimony paid $ How often? (J Other deductions $ How often? Cistudent loan interest $ How often? Type:

30. YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip to the next person. @

Your total income this year Your total income next year (if you think it will be different)

$ $ THANKS! This is all we need to know about you.

NEEO HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espafiol, flame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-701-0720,

Page 3 of 7

c . If you have more than two people to include, make a Affordable heakh coverage. Guality care. STEP 2: PERSON 2 copy of Step 2: Person 2 (pages 4 and 5) and complete.

Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you file one, See page 1 for more information about who to include. If you don't file a tax return, remember to still add family members who live with you.

1. First name, Middle name, Last name, & Suffix 2. Relationship to you?

3. Date of birth (mm/dd/yyyy) 4,Sex []Male [_] Female

5. Social Security number (SSN) —— —— —— - —- __- _- __ __ ___ We need this if you want health coverage and have an SSN.

6. Does PERSON 2 live at the same address as you? []Yes [No If no, list address:

7, Does PERSON 2 pian to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return.)

(1 YES. If yes, please answer questions a-c. LING. If no, skip to question c. a. Will PERSON 2 file jointly with a spouse? LlYes [No If yes, name of spouse: b. Will PERSON 2 claim any dependents on his or her tax return? L]Yes [No If yes, list name(s) of dependents: c. Will PERSON 2 be claimed as a dependent on someone's tax return? L]Yes [No If yes, please list the name of the tax filer: How is PERSON 2 related to the tax filer?

8. Is PERSON 2 pregnant? [] Yes [No a. If yes, how many babies are expected during this pregnancy?

9; Does PERSON 2 need health coverage? (Even if they have insurance, there might be a program with better coverage or lower costs.)

CI ves. if yes, answer all the questions below. @ C1 No. tf no, SKIP to the income questions on page 5. Leave the rest of this page blank.

10. Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? [_]Yes []No

11. Is PERSON 2 a U.S. citizen or U.S. national? []Yes [] No

12. If PERSON 2 isn’t a U.S. citizen or U.S. national, do they have eligible immigration status? C1 Yes. Fill in their document type and ID number below.

a. Document type b, Document ID number c. Has PERSON 2 lived in the U.S. since 1996? L] Yes [] No d. Is PERSON 2, or their spouse or parent a veteran or an active- duty member in the U.S. military? L] Yes [] No 13. Does PERSON 2 want help paying for 14, Does PERSON 2 live with at least one child under | 15. Was PERSON 2 in foster care at age medical bills from the last 3 months? the age of 19, and are they the main person 18 or older? Clyes CINo taking care of this child? Clyves [INo Olyves CINo

Please answe

18. If Hispanic/Latino, eth ity (OPTIONAL—check all that apply.) [JMexican [] Mexican American []Chicano/a [] Puerto Rican [] Cuban [other

19, Race (OPTIONAL—check all that apply.)

OC white (1 Native American indian [1 Filipino O Vietnamese (J Guamanian or Chamorro 0 Black or African or Alaska Native (J Japanese (J Other Asian (J Samoan American 0 Asian Indian OO Korean ( Native Hawaiian CJ Other Pacific Islander CI Chinese C1 other

Now, tell us about any income from PERSON 2 @

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710, Para obtener una copia de este formulario en Espafiol, llame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-701-0720.

Page 4 of 7

| NJFAMELYCARE STEP 2: PE R SON 2 Affordable health coverage. Quality care.

Current job & Income Information

C] Employed C1 Not employed OO Self-employed If you're currently employed, tell us Skip to question 30. Skip to question 29. about your income. Start with question 20.

CURRENT JOB 1: 20, Employer name and address 21. Employer phone number

22. Wages/tips (before taxes) []Hourly [J Weekly []Every2 weeks []Twiceamonth []Monthly [] Yearly

$ —— 23. Average hours worked each WEEK

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.) 24, Employer name and address 25. Employer phone number 26. Wages/tips (before taxes) [] Hourly []Weekly []Every2weeks []Twiceamonth [] Monthly [Yearly

$ _ —— 27. Average hours worked each WEEK

28. In the past year, did PERSON 2: [] Change jobs [1] Stop working [Start working fewer hours [1] None of these

29. If self-employed, answer the following questions:

a. Type of work. b. How much net income (profits once business expenses are paid) will you get from this self-employment this month?

$

30, OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don't need to tell us about child support, veteran's payment, or Supplemental Security Income (SSI). [None

C1 unemployment $ How often? Cnet farming/fishing $ How often? Pensions $ How often? CNet rental/royalty $ How often? O1 Social Security $ How often? C1 Other income $ How often? (]Retirement accounts How often?. Type:

DiAlimony received $ How often?

31, BEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 29b). DAlimony paid $ How often? (J Other deductions $ How often? CStudent loan interest $ How often? Type:

32. YEARLY {NCOME: Complete only if PERSON 2's income changes from month to month. If you don’t expect changes to PERSON 2's monthly income, add another person or skip to the next section.

PERSON 2's total income this year PERSON 2's total income next year (if you think it will be different) $ $

THANKS! This is all we need to know about PERSON 2.

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espafiol, llame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need, We'll get you help at no cost to you. TTY users should call 1-800-701-0720.

Page 5 of 7

NJFAMELYCARE

Affordable health coverage. Quality care.

Native American Indian or Alaska Native (AU/AN) family member(s) 1. Are you or is anyone in your family Native American Indian or Alaska Native?

Clf No, skip to Step 4. O Yes. If yes, go to Appendix B.

| STEP 4 | Your Family's Health Coverage

Answer these questions for anyone who needs health coverage.

1, Is anyone enrolled in health coverage now from the following? (71 YES. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have. [] NO.

0 Medicaid oO Employer insurance On FamilyCare Name of health insurance: Cl Medicare Policy number:

Is this COBRA coverage? [] Yes L] No Is this a retiree health plan? []Yes [No OO other Name of health insurance:

(1 TRICARE (Don't check if you have direct care or Line of Duty)

CO vAhealth care programs

Policy number:

OO Peace Corps a . ‘ {s this a limited-benefit plan (like a school accident policy)?

ClyYes LJNo

2, Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, such as a parent or spouse.

(YES. If yes, you'll need to have your employer complete Appendix A and return to address provided. LINO. If no, continue to Step 5.

| STEPS | Select your Health Plan Y

‘ou will have to pick a Health Plan from the choices below to be enrolled. if you need assistance selecting your Health Plan, contact a Health Benefits Coordinator at 1-800-701-0710, TTY 1-800-701-0720.

(J AMERIGROUP (Available in ALL counties; except Salem County)

(€ Healthfirst NJ (Available in Atlantic, Bergen, Essex, Hudson, Mercer, Middlesex, Morris, Passaic, Somerset, Sussex, Union & Warren counties ONLY)

C2 Horizon NJ Health (Available in ALL Counties) (J UnitedHealthcare Community Plan (Available in ALL Counties)

| understand that if I'm found eligible and because | have joined a Health Plan, | must follow the rules for obtaining health care from the Health Plan. | understand that | must let my Health Plan and NJ FamilyCare know if there is any change in the number of people in my family and that any newborn children will be enrolled in my Health Plan. | understand that, unless |, or a family member, have a true medical emergency, | must call my personal doctor for medical advice, medical care or for a referral to a specialist. | understand that if |, or a family member, have a true medical emergency, | must call my personal doctor or the Health Plan as soon as possible after |, or the family member, go to the hospital. | understand that | must keep any medical appointment | have scheduled with a doctor and, if | cannot, | must call the doctor's office to cancel the appointment. | understand that if | go to a doctor other than my personal doctor | have selected, without a referral from my doctor or approval from the Health Plan, | may have to pay for that doctor's services because NJ FamilyCare will not pay for the unapproved service or visit. | understand that | may change to another Health Plan and that | can call the Health Benefits Coordinator to help me do that. | give permission for the release of my medical history and health care records and those of my family members who will be enrolled to any person(s) in the Health Plan and its providers who shall provide or coordinate health care to me and my family as long as | am a member of the Health Plan.

NEED HELP WITH YOUR APPLICATION? Visit ajfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espafiol, lame 1-800-701-0710. if you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-701-0720.

Page 6 of 7

NJFAMSLYCARE

Affordable health coverage. Quality care,

| STEP 6 | Read & sign this application.

* lunderstand that the NJ FamilyCare program may use or disclose protected health information about me or my children if Federal privacy law requires or allows it, or if State law requires it.

+ I'm signing this application under penalty of perjury which means I've provided true answers to all the questions on this form to the best of my knowledge. | know that | may be subject to penalties under federal and state law if | provide false and or untrue information.

* Iknow that | must promptly tell NJ FamilyCare if anything changes or becomes different from what | wrote on this application including changes in income, address or household size. | can visit njfamilycare.org or call 1-800-701-0710 to report any changes. | understand that a change in my information could affect the eligibility for member(s) of my household.

* 1 know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. | can file a complaint of discrimination by visiting www. hhs.gov/oer/office/file.

+ l|authorize the NJ Division of Taxation to release my tax return information to Nj FamilyCare.

* |also authorize any educational institution or school district to release my medical records or those of my child(ren) to the NJ FamilyCare program for the purpose of determining eligibility and billing the Program.

* I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If not,

is incarcerated.

(name of person)

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We'll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, NJ Division of Taxation, and/or a consumer reporting agency. If the information doesn't match, we may ask you to send us proof.

Renewal of coverage in future years

To make it easier to determine my eligibility for help paying for health coverage in future years, | agree to allow NJ FamilyCare to use income data, including information from tax returns. NJ FamilyCare will send me a notice, let me make any changes, and | can opt out at any time.

If anyone on this application is eligible for NJ FamilyCare

* 1am giving to the NJ FamilyCare agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. | am also giving to the NJ FamilyCare agency rights to pursue and get medical support from a spouse or parent.

* Does any child on this application have a parent living outside of the home? ClYes LINo

+ Ifyes, | know | will be asked to cooperate with the agency that collects medical support from an absent parent. If | think that cooperating to collect medical support will harm me or my children, | can tell NJ FamilyCare and | may not have to cooperate.

My right to appeal

If | think NJ FamilyCare has made a mistake, | can appeal its decision. To appeal means to tell someone at NJ FamilyCare that | think the action is wrong, and ask for a fair review of the action. | know that | can find out how to appeal by contacting

NJ FamilyCare at 1-800-701-0710. | know that | can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me.

Sign this application. The person who filled out Step 1 should sign this application. If you're an authorized representative you may sign here, as long as you have provided the information required in Appendix C.

Signature Date (mm/dd/yyyy)

Mall completed application.

Mail your signed application to:

Nj FamilyCare PO BOX 8367 TRENTON, NJ 08650-9802

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espaiiol, lame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-701-0720.

Page 7 of 7

Health Coverage from Jobs

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage. You need to include this page when you send in your application.

EMPLOYEE Information

1, Employee name (First, Middle, Last) 2. Employee Social Security number

EMPLOYER Information

ero

413, Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? O Yes (Continue) 13a. If you’re in a waiting or probationary period, when can you enroll in coverage?

mm/dd, List the names of anyone else who is eligible for coverage from this job. cmm/dd/yyyy)

Name: Name: Name:

CONo (Stop here and go to Step 5 in the application)

Tell us about the health plan offered by this employer.

16. What change will the employer make for the new plan year Cif known)? C1 Employer won't offer health coverage oO Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $

b. How often? C] Weekly oO Every 2 weeks Otwicea month [1 Quarterly oO Yearly

Date of change (mm/dd/yyyy):

* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

2) NEED HELP WITH YOUR APPLICATION? Visit nifamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espafiol, llame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-701-0720.

Native American Indian or Alaska Native Family Member (AI/AN)

Complete this appendix if you or a family member are Native American Indian or Alaska Native. Submit this with your NJ FamilyCare Application for Health Coverage & Help Paying Costs.

Tell us about your Native American Indian or Alaska Native family member(s).

Native American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible.

NOTE: If you have more people to include, make a copy of this page and attach.

AI/AN PERSO AI/AN PERSO 1. Name First Middle First Middle (First name, Middle name, Last name) Last Last 2. Member of a federally recognized tribe? (C1 Yes C1 Yes If yes, tribe name If yes, tribe name [CINo CINo 3. Has this person ever gotten a service from CO yes (yes the- Indian Health Service, a tribal health program, or urban Indian health program, LINo OONo or through a referral from one of these If no, is this person eligible to get If no, is this person eligible to get programs? services from the Indian Health services from the Indian Health Service, tribal health programs, or Service, tribal health programs, or urban Indian health programs, or urban Indian health programs, or through a referral from one of these through a referral from one of these programs? programs? ClYes CINo ClYes LINo 4. Certain money received may not be $ . $ counted for NJ FamilyCare. List any income (amount and how often) reported How often?. How often?. on your application that includes money from these sources: + Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties « Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations) « Money from selling things that have cultural significance

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espafiol, lame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-701-0720.

APPENDIX C NJFAMSLYCARE

Affordable heollh coverage. Guality core.

Assistance with Completing this Application

You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact the Marketplace. if you're a legally appointed representative for someone on this application, submit proof with the application.

1. Name of authorized representative (First name, Middle name, Last name)

2. Address 3. Apartment or suite number

4. City 5. State 6. ZIP code

7, Phone number CD =

8. Organization name 9. ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this agency.

10. Your signature Tl. Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for somebody else.

1. Application start date (mm/dd/yyyy)

2. First name, Middle name, Last name, & Suffix

3. Organization name 4. ID number Cif applicable)

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espafol, llame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1-800-701-0720.

_____________________________________________________________________________

Table of Contents

State/Territory Name: New Jersey

State Plan Amendment (SPA) #: NJ-13-0022

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for New Jersey consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES : Centers for Medicare & Medicaid Services (CMS 7500 Security Boulevard, Mail Stop: S2-26-12 CM Ss

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP sernnces

Children and Adults Health Programs Group

MAR 1 1 2014

Valerie Harr, Director

Division of Medical Assistance and Health Services New Jersey Department of Human Services

7 Quakerbridge Plaza

P.O. Box 712

Trenton, NJ 08625-07 12

Dear Ms. Harr:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved

your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number NJ-13-0022, submitted on February 7, 2014, and related to Modified Adjusted Gross Income (MAGI Eligibility, with an effective date of January 1, 2014.

Non-Financial Eligibility:

SPA number NJ-13-0022 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, non-payment of premiums, continuous eligibility and presumptive eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of New Jersey’s current state plan as detailed below:

New State Plan Page Impact on Current State Plan Section CS17: Non-Financial Eligibility — Residency Section 4.1.5 CS18: Non-Financial Eligibility — Citizenship Section 4.1.0; 4.1-LR; 4.1.1-LR

C819: Non-Financial Eligibility — Social Security Number_| Section 4.1.9.1

C820: Non-Financial Eligibility — Substitution of Coverage | Section 4.4.4

C821: Non-Financial Eligibility - Non-Payment of Section 8.7 Premiums

CS27: General Eligibility — Continuous Eligibility Section 4.1.8 CS28: General Eligibility - Presumptive Eligibility for Section 4.3.2 Children

C829: General Eligibility - Presumptive Eligibility for Section 4.3.2

Pregnant Women

Your title XXI project officer is Ms. Stacey Green. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Green’s contact information is as follows:

Page 2 — Ms. Valerie Harr

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Division of State Coverage Programs

Mail Stop S2-07-08

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-6102

Facsimile: (410) 786-5882

E-mail: Stacey.green@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Green and to Mr. Michael Melendez, Associate Regional Administrator (ARA) in our New York Regional Office. Mr.'Melendez’s address is:

Centers for Medicare & Medicaid Services 26 Federal Plaza, Room 3811 New York, NY 10278-0063

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely, Eliot Fishman Director Enclosures ce:

Mr. Melendez, CMS Region II, New York

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NJ.0757.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: New Jersey State Funds: $ Federal Funds: $ Submitted By: Julie Hubbs Last Revision Date: Mar 6, 2014 Submit Date: Feb 7, 2014 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NJ-13-0022 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.926 and 435. 1102; 42 CFR 457.310(b)(2) and (3), 457.320, 457.430(b), 457.342, 4 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:289 out of 2000 CHIP Eligibility-non financial eligibility including residency, citizenship/lawfully residing immigrants, social security number, substitution of coverage, premiuim lock-outs, continuous eligibility, and presumptive eligibility for pregnant women and children. (CS17,18,19,20,21,27,28,29) Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

ccms. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Separate Child Health Insurance Program CSI7 Non-Financial Eligibility - Residency

42 CFR 457.320

Residency

wl The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under “certain conditions.

A child is considered to be a resident of the state under the following conditions:

A non-institutionalized child. if capable of indicating intent and who is emancipated or married, if the child is living in the ™ state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job conmmitment or seeking employment, whether or not currently employed. [] A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state. with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1). with whom the individual resides.

ry An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[i] A child who is a ward of the state regardless of where the child lives, or

ial A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: {@] A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address. or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

wl An institutionalized pregnant woman residing in an in-state-institution. as defined in 42 CFR 435.1010. whether or not the individual established residency in the state prior to entering the institution, or

~ A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

‘The state has in place related to the residency of children and pregnant women (if covered by the state):

SPA# NJ-13-0022 Approval Date: MAR 1 L 2014 Effective Date: January 1, 2014

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cCCmMS CHIP Eligibility One or more interstate agreement(s). No |

A policy related to individuals in the state only for educational purposes. No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Separate Child Health Insurance Program : a CSI18 Non-Financial Eligibility - Citizenship .

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457,320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, [7] including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

(i) The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals: Who are citizens or nationals of the United States; or

Who are qualitied non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641). or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the Yes verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date Yes earlier than the date the notice is received by the individual. .

The date benefits are furnished is: © The date of application containing the declaration of citizenship or immigration status. © The date the reasonable opportunity notice is sent.

@ Other date, as described:

Date of HMO enrollment.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). s

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

[¥] The CHIP Agency provides assurance that lawfully aR? ye D “gre also covered under the state's Medicaid program. TF

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ccms CHIP Eligibility

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women. lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

Yes

Otherwise eligible pregnant women means pregnant women who meet the eligibility requirements of targeted low-income pregnant women with the exception of non-citizen status.

wl The CHIP Agency provides assurance that lawfully residing pregnant women are also covered under the state's Medicaid “~ program.

An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

(a

[lB] An individual is considered to be lawfully present in the United States if he or she is:

1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c):

nN

. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than | year, except for an individual paroled for prosecution. for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes: (i) Granted temporary resident status in accordance with 8 U.S.C.1160 or 1255a, respectively;

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President: (vi) Granted Deferred Action status:

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158. or for withholding of removal under 8 U.S.C.1231.or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or (ii) Is under the age of 14 and has had an application pending for at least 180 days: 6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1101(a)(27)():

8. Is lawfully present in American Samoa under the immigration laws of American Samoa: or

MAR 1 T2014

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9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)).

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15. 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. ‘

PRA_ Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response. including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form. please write to: CMS, 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

MAR 1 1 2044

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CONES 9 oe TENE RIP SENIOR

CCMS CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS19

Separate Child Health Insurance Program cs Non-Financial Eligibility - Social Security Number

42 CFR 457.340(b)

Social Security Number As a condition of eligibility. the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration. to furnish their social security number, or numbers if they have more than one number.

w The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following ~ exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

im The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[@] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited: and How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN. if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their es SSN. i

[¥] When requesting an SSN for non-applicant household members. the state assures that:

im At the time such SSN is requested. the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

ry The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs. or =" for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

SPA# NJ-13-0022 Approval Date: MAR { L 2014 Effective Date: January 1, 2014

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coms. CHIP Eligibility

According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed. and complete and review the information collection. [f you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# NJ-13-0022 Approval Date: MAR L { 2014

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cCCMS CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Separate Child Health Insurance Program

‘ 5 aie pie CS20 Non-Financial Eligibility - Substitution of Coverage 457.310(b)(2) and (b)(3). 457.320(a)(9) and 2110(b)(1)(C) of the SSA Substitution of Coverage Zl The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health “" coverage or other commercial health insurance with public funded coverage. These policies include: [i] Substitution of coverage prevention strategy: SPA# NJ-13-0022 Approval Date: MAR Effective Date: January 1, 2014

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Name of policy Description

Crowd out policy An applicant is not eligible for NJ FamilyCare if he or she:

1. Is currently covered under a non-governmental group health plan, is currently covered. or eligible for coverage. under Medicare, Medicaid or NJ FamilyCare Children's Program. or under a group health plan sponsored or self-funded by a government unit: or

2. Has been covered under a group health plan or Medicare at any time during the three-month period preceding the date of application for NJ FamilyCare; except that coverage which has lapsed within the three-month period due to the expiration of an applicant's continuation rights under the Consolidated Omnibus Budget Reconciliation Act (COBRA) or other continuation rights available under State law shall not preclude an applicant from being eligible for + NJ FamilyCare. An applicant who has lost coverage xX

under an employer's plan will also not be subject to the three-month period if the applicant becomes unemployed through no fault of his or her own. In addition, an applicant may voluntarily terminate coverage under COBRA, or any other health insurance purchased through the individual market, in order to be considered for NJ FamilyCare eligibility.

i. The exceptions noted in 2 above with respect to COBRA and purchases in the individual market shall not apply to children in families with income greater than 200 percent of the Federal poverty level.

The provisions of | and 2 above shall not apply to those parents, caretakers and children who would qualify for AFDC-related Medicaid or NJ FamilyCare Plan A but for Federal immigration residency restrictions.

A waiting period during which an individual is ineligible due to having dropped group health coverage. fres | How long is the waiting period?

€ One month

© Two months @ 90 days

C Other

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CHIP Eligibility

[i] The state allows exemptions from the waiting period for the following reasons:

iw The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income.

The child's parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP

a

accordance with 26 CFR 1.36B-2(c)(3)(v).

&

through the Marketplace because the ESI in which the family was enrolled is determined unaffordable in

The cost of family coverage that includes the child exceeded 9.5 percent of the household income.

The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan.

rl A change in employment. including involuntary separation, resulted in the child’s loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA).

{ll] The child has special health care needs.

{@] The child lost coverage due to the death or divorce of a parent.

Does the state allow other exemptions in addition to those listed above? | Yes

Describe

Eligibility for a coverage under a health insurance policy which is not readily accessible to the child. In the case of coverage under an absent parent's policy, not readily accessible means a plan defined coverage network. where the network is not accessible with 45 minutes travel time of the child's residency.

In the case where the coverage is available under an absent parent's policy, the custodial parent shall be allowed to show good cause why the coverage is not available. Good cause may include concern of physical or emotional abuse.

+

an applicant with family income below 200% FPL may voluntarily terminate coverage under COBRA. or any other health insurance purchased through the individual market. in order to be considered for NJ FamilyCare eligibility.

[7] If the state covers pregnant women, the waiting period does not apply to pregnant women.

If the state elects to offer dental only supplemental coverage, the following assurances apply:

(] The waiting period does not apply to children eligible for dental only supplemental coverage.

oO The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

SPA# NJ-13-0022

PRA Disclosure Statement

Approval Date: MAR j i 2014

Effective Date: January 1, 2014 Page 3 of 4

ccmMs CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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cems CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date; 10/31/2014

Separate Child Health Insurance Program

Non-Financial Eligibility ~- Non-Payment of Premiums Csi 42 CFR 457.570 Non-Payment of Premiums Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes | Does the state have a premium lock out period? Ves.

Please describe the lock-out period:

When a child is found eligible for CHIP. in a family with income above 200% FPL. the family must select an HMO and pay an initial premium before being enrolled. Once enrolled the family is required to pay a monthly premium. The beneficiary is noticed on the 30th day, the 60th day. and finally terminated on the 90th day if the premium payment has not been made. We have established a 90 lock-out period when a child is terminated for failure to pay the monthly premium. We will reinstate the child as soon as the premium has been paid or once the 90 lock-out period has ended if the premium has not been paid. We will notify the family in writing of the reinstatement.

What is the length of the time premium lock-out period? Select a length of time:

© One month

© Two months

c@ 90 days

«© Other (not to exceed 90 days) Are there exceptions to the required lock-out period? No

The state assures that:

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired: and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3); and

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

PRA. Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response. including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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OMB Control] Number: 0938-1148

Expiration date: 10/31/2014

Separate Child Health Insurance Program C827

General Eligibility - Continuous Eligibility

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

lhe CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier,

The CHIP Agency elects to provide continuous eligibility to children under this provision. | Yes

@ For children up to age 19

C For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[B] Atthe endofthe |12 months continuous eligibility period.

Exceptions to the continuous eligibility period: [i] The child attains the age specified by the state Agency or age 19. if] The child or child's representative requests voluntary disenrollment. [i] The child is no longer a resident of the state.

(al The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility “' because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[i] The child dies. {ii] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

(7) Other

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response. including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05. Baltimore, Maryland 21244-1850.

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OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS28

Separate Child Health Insurance Program General Eligibility - Presumptive Eligibility for Children

42 CFR 457.355 and 435.1102, 2107(e)(1)({L) and 1920A of the SSA

The CHIP Agency covers children when determined presumptively eligible by a qualified entity. | Yes

[ii] Describe the population of children to whom presumptive eligibility applies:

Children up to the age of 19 with household income up to or equal to 350% of FPL; who are residents of the state of NJ and meet all citizenship requirements.

[i] Describe the duration of the presumptive eligibility period and any limitations:

The presumptive period begins on the date the determination is made.

The end date of the presumptive period is the earlier of: the date the eligibility determination for regular Medicaid is made. if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made. if no

application for Medicaid is filed by that date.

Periods of presumptive eligibility are limited to no more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

[i] Describe the application process and eligibility determination factors used:

Income, residency, citizenship, and age are evaluated via self attestation.

[ii] The CHIP Agency uses qualified entities, as defined in section 1920A, to determine eligibility presumptively for children.

Separate Child Health Insurance Program General Eligibility - List of Qualified Entities

CS30

A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility

determinations based on an individual's household income and other requirements, and that meets at least one

of the following requirements, Select the types of entities used to determine presumptive eligibility:

iN Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan

Cy Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

oO Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

4 Aas

£4454 TV curs SPA# NJ-13-0022 Approval Date: MAR Effective Date: January 1, 2014

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Is authorized to determine a child’s eligibility to receive assistance under the Special Supplemental Food Program for Women, Infants, and Children (WIC) under section 17 of the Child Nutrition Act of 1966

Is authorized to determine a child’s eligibility under the Medicaid state plan or for child health assistance under the Children’s Health Insurance Program (CHIP)

Is an elementary or secondary school. as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs Is a state or Tribal child support enforcement agency under title 1V-D of the Act

[s an organization that provides emergency food and shelter under a grant under the Stewart B. Mckinney Homeless AssiStance Act

Is a state or Tribal office or entity involved in enrollment in the program under Medicaid. CHIP, or title IV-A of the Act

O Oooo & OO

Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other

section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C, 4101 e7 seq.)

O

[[] Any other entity the state so deems, as approved by the Secretary

The CHIP Agency assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

An attachment is submitted.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. 1f you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850,

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Separate Child Health Insurance Program

“27 General Eligibility - Presumptive Eligibility for Pregnant Women S29

2112(c) of the SSA

The CHIP Agency covers pregnant women when determined presumptively eligible by a qualified entity. | Yes

[i] Describe the population of pregnant women to whom presumptive eligibility applies:

Pregnant women up to and equal to 200 % FPL. residents of the state of NJ. must meet citizenship requirements. No age requirement.

fil] Describe the duration of the presumptive eligibility period and any limitations:

The presumptive period begins on the date the determination is made.

The end date of the presumptive period is the earlier of: the date the eligibility determination for regular Medicaid is made, ifan application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made: or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no

application for Medicaid is filed by that date.

Periods of presumptive eligibility are limited to no more than one period per pregnancy.

[li] Describe the application process and eligibility determination factors used:

Income, residency citizenship/alien status. Proof of pregnancy required and PE limited to ambulatory pre natal care.

{m] The CHIP Agency uses the following entities to determine presumptive eligibility for pregnant women.

The same qualified entities are used to determine presumptive eligibility for pregnant women as used for children. | Yes

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions. search existing data resources, gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form. please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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_____________________________________________________________________________ Table of Contents State/Territory Name: New Jersey State Plan Amendments (SPA) #: NJ-16-0024 This file contains the following documents in the order listed: 1) Approval Letter 2) Final Approved State Plan

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop $2-01-16 < M Ss Baltimore, MD 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

OCT 31206.”

Meghan Davey, Director

Division of Medical Assistance and Health Services New Jersey Department of Human Services

7 Quakerbridge Plaza

P.O. Box 712

Trenton, NJ 08625-0712

Dear Ms. Davey:

I am pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) NJ-16-0024, submitted on June 28, 2016, with additional information received on October 31, 2016, has been approved. This SPA implements four health services initiatives (HSIs) to improve the health of children by providing title XXI funding for nurses in non-public schools, assisting families with unpaid medical expenses for children with catastrophic illnesses through the state’s current program the Catastrophic Illness in Children Relief Fund, respite care services for children with developmental disabilities, and State poison control centers. The retroactive effective date for this SPA is July 1, 2015.

This SPA provides funding through the HSI option at section 2105(a)(1)(D)(ii) of the Social Security Act to use available title XXI administrative funding to pay for activities that protect public health, protect the health of individuals, improve or promote a state’s capacity to deliver public health services, or strengthen the human and material resources necessary to accomplish public health goals relating to improving the health of children, including targeted low-income children and other low-income children.

The state shall ensure that the remaining title XXI funding, within the state’s 10 percent limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of theséHSIs to the administration of the CHIP program. The state shall report annually to CMS the expenditures funded by the HSI for each federal fiscal year. CMS will work with the state to develop a simple and effective reporting process for these expenditures.

Your title XXI project officer is Ms. Kristin Edwards. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Edwards’ contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid, CHIP and Survey & Certification Mail Stop S2-01-16

7500 Security Boulevard

Page 2- Ms. Meghan Davey

Baltimore, MD 21244-1850 Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: kristin.edwards@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Edwards and to Mr. Michael Melendez, Associate Regional Administrator (ARA) in our New York Regional Office. Mr. Melendez’s address is:

Centers for Medicare & Medicaid Services Division of Medicaid and Children’s Health Jacob K. Javits Federal Building

26 Federal Plaza, Room 3811

New York, NY 10278-0063

If you have additional questions, please contact Ms. Amy Lutzky, Acting Director, Division of State Coverage Programs at (410) 786-0721.

We look forward to continuing to work with you and your staff.

Sincerely,

Anne Marie Costello Director

Enclosure

cc: Mr. Michael Melendez, Associate Regional Administrator, Region II

en a

le.

(

, MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN'S DEALTE INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Seourity Act (the Aol) by adding a new title XXI, the State Children's Health Insurance Program (SCHIP). ‘Title XX1 provides funds to states to enable them to initiate and expand the provision af child health assistance to uningnted,

Jow-income children in, an effective and efficient manner, To be elipible for funds under this propram, “states must subrait a state plan, which must be approved by the Seorstaty, A state may choose to amend its approved state plan in whole or in part at any time throwgt the submittal of a plan amendment,

This model application template ouitines the information that rout ‘be included in the state child health plan, and any subsequent amendments, It as been designetl to reflect the requirements as they oxlat tn current regulations, found st 42 CFR patt 457, These requirements are necesary for state plans and atnendiments under Title 2X1. .

The Depattment of Health and Euman Services will continue to work collabornilvely with states and other interested parties to provide spopifte puldance in key areas like applicant and enrollee protections, collection of'baseline data, and methods for preventing substitution of Federal finda tor oxisting state and private funds, As such guidance becomes available, we will work to distelbute it in a timely fashion to ‘provide assistance ag states submit their state plans and amendments,

© Btfootive Deitet Outbbar t, 2010"

_ Approval Datet -November 14, 2011

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN'S HEALTH INSURANCE PROGRAM

{Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: Now Jewey

(Name of State/Temitory) As a condition for receipt of Federal funds under Thile XXT of the Social Security Act, (42 CER, 457.40(1))

Tune 30, 2011

Jennifer Velez : Date

submits the following State Child Wealth Play for the State Children’s Health Insurance Program and hereby agreos to administer the program in accordance with the provisions of the approved State Child Health Plan, the requiremenis of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Departiwent

Ths following state offictals are responsible for program administration and financial oversight (42 CFR 457,40(¢)):

Name: Jonniter Velez Positidn/Title; Commissioner, Department of Human Services

Name: ‘Yelerle Harr Position/Title: Director, Division of Medical Assistance and Health Serviced Name: Carol Grant Posilion/Title: Chief of Operations, Division of Medical Assistance and Health Services Name: Michael P. Keevey Positlon/Title: Chief Fingnolal Officer, Division of Medical Assistance and Floulth Services

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information wnless it displays a valld OMB control munber. ‘lhe valid OMB contral nowber for this information collection is 0938-0707. The time required to complete ihig information collection is estimated (o average 160 hours (or minntes) per response, including the time to review instrnetions, search existing data resources, gather the data needod, and complete and review the bifoxmation collection. If you have any commonts concerning the aceuraty of the time ostimate(s) ox suggestions for improving this form, ploase write to: CMS, P.O, Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Attatn i Offlee of Management ond Budget, Washington, BC, 20503,

2

Ethective Datet Dotobber 1 2030 7 : Apron Date: Noventibat 4, abil

Section 1. General Description and Purpose of the State Child Health Plans. and State Child Health Plan Requirements (Section 2101)

11 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.2

13

1.4

11.1 0 Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2. O Providing expanded benefits under the State's Medicaid plan (Title XIX); OR

1.1.3. A combination of both of the above.

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS, (42 CER 457.40(d))

The State assures that it will not claim expenditures for child health assistance prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CER part 35. (42CFR 457.130)

The State assures that it complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Original Submission:

SPA# 1.

Effective Date: February 1, 1998 Implementation Date: February 1, 1998

Six-Month Rule Effective Date: January 13, 1999 Implementation Date: January.13, 1999

Effective Date: October 1, 2010 Approval Date: November 14, 2011

SPA# 2.

SPA# 3.

SPA# 4.

SPA# 5.

SPA# 6.

SPA# 7.

SPA# 8. SPA# 10.

SPA# 11.

SPA# 12.

SPA #13.

SPA #14

NJ KidCare Plan D Effective Date: July 1, 1999 Implementation Date: July 1, 1999

Crowd Out (Exceptions to 6-month period) Effective Date: July 26, 1999 Implementation Date: July 26, 1999

Presumptive Eligibility Effective Date: . January 1, 2000 Implementation Date: January. 1, 2000

No cost share for AI/AN children Effective Date: August 24, 2001 Implementation Date: August 24, 2001

Income disregard of cash rewards for reporting fraud/abuse Effective Date: February 4, 2002 Implementation Date: February 4, 2002

Premium Increases for NJ KidCare (NJ FamilyCare Children’s Program) Effective Date: May 22, 2003 Implementation Date: May 22, 2003

SCHIP Compliance SPA Effective Date: August 24, 2001

Prior Authorization for Personal Care Assistant Services Effective Date: (Withdrawn)

Substitution of Insurance; Presumptive Eligibility; Continuous Eligibility Effective Date: July 1, 2005 Implementation Date: July 1, 2005

Pregnant Women 185% to 200% FPL, CHIP Reauthorization Act 2009 Effective Date: April 1, 2009 Implementation Date: April 1, 2009

Pregnant Women and Children Exception to 5-Year Bar, (CHIPRA Section 214)

Effective Date: April 1, 2009

Implementation Date: April 1, 2009

Express Lane Eligibility

2

Effective Date: July 1, 2015 Approval Date: October 31, 2016

Effective Date? May 1, 2009 Implementation Date: May 1, 2009

SPA #15 Premium Changes July 1, 2009, Elimination of Plan C Premiums Effective Date: July 1, 2009 Implementation Date: July 1, 2009

SPA #16 Mental Health Parity, Dental Parity and Plan D Limited DME Effective Date: July 1, 2010 Implementation Date: July 1, 2010

SPA #17 Express Lane Eligibility Applications: School Lunch Program Effective Date: October 1, 2010 Implementation Date: October 1, 2010 (Pilot program) November 1, 2011 (Statewide implementation)

SPA # 15-0023 Behavioral Health Services (BHH) (Bergen and Mercer County) and Psychiatric Emergency Rehabilitation (PERS) - Effective Date: July 1, 2015 Implementation Date: July 1, 2015

Behavioral Health Services (BHH) Atlantic, Monmouth, and Cape May counties added

Effective date January 1, 2016

Implementation date January 1, 2016

SPA #16-0024 Health Services Initiatives

Effective Date: July 1, 2015 Implementation Date: July 1, 2015

3

Effective Date: July 1, 2015 Approval Date: October 31, 2016

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Section 2,

General Background and Description of State Approach to Child Health

Coverage and Coordination (Soetion 2102 (n)(1}-(3)) and (Section 2105)(0}(7)(A)-(B))

ad.

Tho desoriptions contained ia this seotlon are related to the State Child Health Tnsuranoa Progtam only. Seotlen 2 does not contain information teleted to New Jersey's 1115 demonstration. .

Deserihe the extent to which, and manner jn which, children tn the state foglading targoted low-income children and other classes of children, by income level ond other relevant factors, such at-race and ethnicity and geographic location, euxrantly have creditable health vovernge (as dedined in 43 CER457,10), To the extent feasible, multe a distinction between creditable coyerage wnder public health insurance programs and public-private partnerships (See Section 10 for annual report vequirernents), (A2 CER 457,80{a))

The shat below desetibes the extent to which children in New Jersey cumently have creditable coverage, The data for the wumber of children with enoployerrelated group coverage, with other/non-group coverage and Medicaid coverage, as well as the nuniber of uninsured children, 1s based on the Mareh 1996 Coxrent Population Survey (CPS) data For £993, While there are some known deficlencies with CPS data, it does provideforthe most consistency at thie time, The CPS data will be updated based on the March 2002 CPS. ;

~ 100% 143,337 I 133% 3,804 23,074 377,080 < 185% 19.773 23,890 43,692 200% fi 8,56)

> 200%

32,348

Bfteotive Date: October 1, 2010

9 80,606 5,4 Felt 19,160

or) A51,865 13,868 $3,041 ' 88,418

6 -12 535,381 31,905 FES99 72,982,

13-18 397,910 51,7596 84,618 68,002, 4

Approval Date: Noverober 14, 2011

American Indian or Alaskan Native

6,390 Asian or Pacific Islander 117,218 | 2,491 | 13,239 | 5,706 Black, not of Hispanic origin 127,197 | 7,268 | 67,293 | 16,804 Hispanic 148,701 | 8,330 | 84,896 | 63,167 White, not of Hispanic origin 1,086,257 | 84,792 | 57,140 | 162,945 * Includes Champus/TriCare and Medicare 5

Effective Date: July 1, 2015

Approval Date: October 31, 2016

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

Health Services Initiatives: Pursuant to Section 2105(a)(1)(D) Gi) of the Social Security Act, New Jersey will use administrative funds to offer “Health Services Initiatives” under the Plan. The programs are offered as part of these Health Service Initiatives with the overarching goal of improving the health of children. The Health Services Initiatives will be certain activities funded with state budgeted funds to the New Jersey Department of Education, Department of Human Services, Department of Children and Families, and the Department of Health as described below. Consistent with 42 CFR 433.51, the state’s funds are appropriated directly to the State agencies, are not Federal funds, and are not used to match other Federal funds.

Specific Health Services Initiatives include the following programs:

. Publicly funded school nurses at non-public schools

State funds are appropriated to the New Jersey Department of Education (DoE) to enable the provision of school nurses at non-public schools. The DoE Office of Nonpublic Schools has responsibility for the NonPublic Schools Nursing program, Each yeat DoE distributes funds to public school districts in New Jersey based on the state appropriation and the number of pupils. Consistent with State Law, and in accordance with the arrangements between each public school district and its nonpublic schools, a Board of Education of a school district may engage in a contract with nursing agency to provide nursing services to one or more nonpublic schools in the district. The State provides guidelines for appropriate selection of vendors. Pursuant to state law and regulation, the services under the auspices of the school nursing program in nonpublic schools are provided by Registered Nurses and include: health screenings, immunization related activities, distribution of health information, and distribution of information on health insurance coverage. Based on census data, the State will determine the percentage of children who have incomes within the CHIP eligibility level of 350% FPL and will pro- rate costs of providing nurses in nonpublic schools based on that percentage.

° Catastrophic [ness in Children Relief Fund

New Jersey State law and annual State budget provides for State funding of the Catastrophic Illness in Children Relief Fund (CICRF). The Fund is administered by the CICRE Commission, which is attached to the New Jersey Department of Human Services but is independent of the Department. The CICRF provides a crucial support for medical services to some of the neediest children in the State. The children are involved with catastrophic conditions which is defined in New Jersey State Law (N.J.Stat.26:2-149) as: “any illness or condition the medical expenses of which are not covered by any other State or federal program or any insurance contract and exceed 10 percent of the first $100,000 of annual income of a family plus 15 percent of the excess income over $100,000.”

6

Effective Date: Fuly 1, 2015 Approval Date: October 31, 2016

. Respite services for children with developmental disabilities.

The New Jersey Department of Children and Families (DCF) is charged with serving and safeguarding the most vulnerable children and families in the State and ensuring that service delivery is directed towards their safety, protection, permanency, and well-being. Within DCF, the Children’s System of Care (CSOC) serves children with developmental disabilities and their families; CSOC is committed to providing services based on the needs of the child and family in a family-centered, community-based environment. CSOC is responsible for the respite services for children with developmental disabilities. Respite provides family caregivers with a short period of rest or relief by arranging alternate care- giving for the family member with a developmental disability. Respite also can be provided when the family caregiver is temporarily absent or disabled for any reason, such as for a short period of hospitalization. Respite usually is provided by an agency that contracts with CSOC to provide this service, such as a home health agency. These respite services are specifically for children with developmental disabilities and these respite services are not a substitute for childcare, school, or participation in other age appropriate activities. The respite services are based on family needs and range from after-school respite to in-home respite to overnight out-of-home respite.

. Poison Control Center.

The New Jersey Department of Health receives an annual appropriation to fund the New Jersey Poison Control Center. The New Jersey Poison Control Center (also known as the New Jersey Poison Information and Education System (NJPIES) is the state's only poison control center. NJPIES serves NJ residents through its free 24/7 emergency and information hotline.

7

Effective Date: July 1, 2015 Approval Date: October 31, 2016

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

New Jersey is taking a wide variety of steps to identify and enroll all uncovered children, both those who are eligible to participate in NJ FamilyCare/Medicaid and those whose excess income makes it necessary for them to enroll in our buy-in program, NJ FamilyCare ADVANTAGE. Our ability to increase enrollment was greatly enhanced by the enactment of legislation in July of 2008 (NJ Public Law 2008 c.38) mandating that all children age 18 and under have health insurance by July 2009. Fundamental to this effort are the existing providers and social services network. Providers likely to come in contact with low-income uninsured individuals, such as hospitals and federally-qualified health centers, are aware of the NJ FamilyCare/Medicaid eligibility standards and complete Presumptive Eligibility applications.

Public health agencies are another important source of outreach and information for potentially eligible children. Staff at programs run by WIC, HeadStart and local health departments are familiar with Medicaid/NJ FamilyCare eligibility requirements and screen their clients accordingly. Programs such as Healthy Mothers, Healthy Babies send outreach workers into the community in attempts to assist pregnant women and children in getting necessary health care services.

School Outreach: NJ FamilyCare is working in conjunction with the Department of Education and individual school districts’ student rosters to help identify and outreach the uninsured. New Jersey schools incorporated the new requirements to inquire about health insurance into their existing forms and shared the information with NJ FamilyCare for follow up and outreach. School districts send an electronic mail file of their uninsured students in a prescribed file layout so the parents could be sent an application for their completion and return.

The Head Starts and child care centers ask the health insurance status of the students enrolled in their schools and regional NJ FamilyCare staff are available to provide outreach, enrollment and follow up.

We continue to use the Free and Reduced Price School Lunch application to inform families about NJ FamilyCare. An authorization form was included which gives families an opportunity to “opt out” of having their information shared.

DMAHS received the CHIPRA Outreach and Enrollment Grant Cycle I to participate ina CMS federally funded Free and Reduced Priced Lunch Express Lane Project from September 2009 to December 2011. Over that two-year period, we studied the express enrollment process and retention of those uninsured students identified. Beginning November 2011, NJ will be using the Express Lane process for the School Lunch Program (SLP) participants statewide.

8

Effective Date: July 1, 2015 Approval Date: October 31, 2016

Application Process: The eligibility and enrollment process is now simpler and faster. The application has been revised and simplified and the application is only one page. There is also an easy-to-complete online application available.

New Jersey is moving toward a paperless enrollment process, using electronic verification of income, identity, citizenship and insurance status where possible. If electronic verification is not possible, the applicant must provide sufficient documentation.

2008 Legislation: The State’s ability to increase enrollment was greatly enhanced by the enactment of legislation in July 2008 (NJ Public Law 2008 c.38) mandating that all children ages 18 and under have health insurance by July 2009. This legislation also called for the creation of a NJ FamilyCare Outreach, Enrollment and Retention workgroup of prescribed members of the Governor’s cabinet and child advocates tasked with the responsibility of developing more effective outreach, enrollment and retention of all eligible children. The workgroup has completed its report and the report was presented to the Legislature and Governor in May 2009.

Tn addition to the many recommendations presented in the report, much progress was made toward interdepartmental cooperation to increase enrollment. The Department of Human Services (DHS) has worked extensively with the Department of Health and Senior Services (DHSS) to make sure that the Federally Qualified Health Centers (FQHCs) and hospitals use the one-page presumptive eligibility (PE) application to enroll the uninsured as they present for care.

Using Tax Records to Identify the Uninsured: Beginning in 2008, New Jersey began outreaching the uninsured with the New Jersey Division of Taxation to identify uninsured children who may be eligible for NJ FamilyCare. Taxpayers who indicate on their NJ- 1040 State income tax forms that they have uninsured children in their homes are being provided an “Express Lane” NJ FamilyCare application. This simplified Express Lane application was mailed to families beginning in May 2009. DHS has taken steps to pre- screen. families to ensure that children are not already enrolled in NJ FamilyCare/Medicaid programs.

Using a Memorandum of Understanding, DMAHS has begun using data from the Division of Taxation to verify income when a valid Social Security number allows us to do so.

All NJ FamilyCare/Medicaid program rules, including, but not limited to, eligibility standards, shall apply to those individuals utilizing the Express Lane NJ FamilyCare application option.

“NJ Helps” is a social service computer network used by several state agencies.

Technology allows screening for several programs, including Medicaid/NJ FamilyCare, to take place which results in a determination of potential eligibility.

9

Effective Date: July 1, 2015 Approval Date: October 31, 2016

Back to School Fairs: NJ FamilyCare participates with the Covering Kids and Families grantees in annual back-to-school. campaigns around the state, where NJ FamilyCare giveaways (pens, pencils, lanyards, rulers) and program materials are distributed. These items are also provided to local health departments around the state, where uninsured children go for their immunizations before they start school,

Maltilingual Materials: Informational materials on NJ FamilyCare are now available in 14 different languages making it possible for outreach efforts to touch every segment of the population. These factsheets and other informational materials reminding parents of well-child services, such as blood’ lead level testing, are also available on www.njfamilycare.org. Applications are routinely available in English and Spanish. Letters and emails are received and responded to in any language used by the writer,

Primary Care Association: NJ F amilyCare meets-with the Primary Care Association which represents FQHCs in the state bimonthly to coordinate outreach efforts and to provide program updates, such as training on updated application forms.

Give Kids A Smile: Letters and materials are sent to dentists annually to encourage them to refer children for enrollment, and to provide locations for enrollment during this national event,

Conferences: Staff attend, and present information at various conferences regarding the targeted population groups.

10

Effective Date: July 1, 2015 Approval Date: October 31, 2016

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

The NJ FamilyCare website (www.njfamilycare.org) was updated to reflect not only program changes, but to include an extensive question and answer section. The most frequently asked questions and other possible issues or questions that a potential applicant might have are addressed on the web site.

Community Partnerships:

The Insure Kids Now hotline, 1-800-KIDS-NOW, is available nationwide to connect interested families to NJ FamilyCare information.

Coalition members from the Robert Wood Johnson Foundation “Covering Kids” project continue to support enrollment of eligible, uninsured children.

Over 600 application assistance sites continue to conduct outreach and enrollment activities throughout the state. They consist of community-based organizations, faith- based organizations, healthcare providers, and other governmental agencies, State staff provides training for their workers and keeps them updated as to any changes. to the program.

Medical Assistance Advisory Council (MAAC): The NJ FamilyCare Advisory Committee is a part of the MAAC, which is comprised of interested community agencies, consumers and stakeholders such as Legal Services of New J ersey and the Association for the Betterment of Citizens with Disabilities. The MAAC meets quarterly and receives information regarding NJ F amilyCare and other Medicaid programs and provides comments and input regarding the information and the programs.

Premium Support Program: The State’s Premium Support Program includes partnerships with employers to inform employees of the availability of coverage and to evaluate the employer-provided coverage for comparability.

New Jersey Department of Labor Rapid Response Team: NJ FamilyCare partners with the Department of Labor’s Rapid Response Team, which assists when plants or businesses close or lay off numbers of workers, The Rapid Response Team has agreed to include an overview of the NJ Family Care program in presentations to businesses slotted for closing or layoffs. The DMAHS association with the Department of Labor helps to facilitate the enrollment of hundreds of eligible dislocated workers, who might not be able to afford COBRA coverage.

11

Effective Date: July 1, 2015 Approval Date: October 31, 2016

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

Public health and Title V agencies: Public health agencies are an important source of outreach and information for potentially eligible children. Staff at programs run by Women, Infants and Children (WIC), Head Start and local health departments are familiar with Medicaid and NJ F amilyCare eligibility requirements and screen their clients accordingly. Programs such as Healthy Mothers, Healthy Babies send outreach workers into the community in attempts to assist pregnant women and children in getting necessary health care services, and utilize information regarding NJ FamilyCare when they contact their consumers, assisting in completion of applications. The NJ FamilyCare program partners with NJ Special Child Health Services, the Maternal Child Health Consortia, Women, Infants, and Children Program (WIC), the Child Health Regional Network (CHRN) and other Title V programs of the New J ersey Department of Health and Senior Services to assure NJ FamilyCare enrollment of all eligible children.

Presumptive eligibility, coupled with the enhanced services provided as part of the HealthStart program, such as nutrition counseling and social services, has helped assure continuity of care during pregnancy.

Sources of health benefits coverage for children:

NJ FamilyCare continues to work with the state Office of Child Support and Paternity to seek medical child support when such support is available to the child.

12

Effective Date: July 1, 2015 Approval Date: October 31, 2016

Section 3,

Methods of Delivery and Utilization Controls (Seetion 2102)(a) (AY)

Oo Check bere if the stats elects to use fundg provided under Title XXI only to provide expanded eligibility mider the state's Medioald plan, aud continne on to Section A,

a4.

Effective Date: October 1, 2010

Describe the methods of daltyery of the child health assistance using Title XXI funds to targeted low-income children, Inchide a desexiption of the cholue of fmancing and the methods for asyuxing delivery of the instance products and delivery of health care services covered by such products to the enrollees, jnclading any variations, (Beution 2102)(a)(4) 42CKR 487.490(2))

Under NY FamilyCare Plan. A, the Medicaid programm ig expanded to include all Optional ‘Targeted Low Income Children who test the Title XX1 requirements, are below the age of 19 yeats, and have family income at or below 133% of the federal poverty level, ‘Therefore, for thig group of children, the service delivery system ig the Title XIX system oftmandatory managed care using licensed HMOs, with octtain sorvloes carved outofthe managed care contracts and provided on a feo-for-service basis. The children in this gloup Will receive the services desarlbed in Attachment 6 for Plan A,

Fot the Title XX] eligible children under 19 years of age with gross family income above 133% and at or below 200% of the federal poverty level (NI FatnilyCare Plans Band C)

‘the State purchases a subset of the Medicald package from the Title XIX program, The

health benefit coverage provided under the ‘Title XXT program consists of the managed cate prodnuet offered under the Title XIX program with the addition of fee-for-service payment to existiig Medioaid participating network providers for certain benefits not included in the managed care contacts, but essential ta the cave of this population, The citilcren in this group will reoeive the sarvioes desotibed in Attachment 6 for PlangB and G.

For the Title XX1 eligible shildren under 19 years of'ape with gross family income above

200% and at or below 350% of the federal poverty level, whose-net ficome falls at ot .

below 200% of the federal poverty level after application of disregards (NJ FamilyCare Plan D), the State purchases a subset of the ‘Medlould package ftom the Title XTX program, “which consisty of a version of the managed care product under the Tithe XIX propram’ modified to mitror a commercial plan with the addition of fee-for-service payment to sxisting Medicaid pariisipating network: providers far cartain benefits riot facluded inthe imataged care contacts, but included in the commercial benchmark ‘plan, The childrenin this group will revive the acrvices descilbed in Attechinent 6 for Plat D,

Participation in the managed care contracts is limited to Heonged HMOs ands fully- capitated, tisk-based contract, Given that the cost-sharing amownls act as an incentive

. bayment to the direct sotvies provider, the managed care contract and the capltation

payment pald to the particlpatiag plans aro-not amended for the Title KX] population to avconnt for the copayments for children in families with income above 150% of the

10

ppvoval Date: November 14, 2014

. a

Effective D als; Ootobar 1, 2010

federal poverty level, Premiums ate collected by a vendor on behalf of the State and, therefore, haveno impact on managed oarerates, although the premiums help to offtiet the total cost of the program. ‘The premiums are not used as any part of the sipte share,

The servioes pald for ot 4 fee-Lot-servloe basis aro part of the purchased Mediosid package and are pot counted as a contract with providers for diteot sevicein gomputing the 10% cap. Basential, non-EIMO covered services provided under Tile XXI, however, arenot equivalent to those provided underthe Medicaid program (ses Section 6 regarding * benefits), .

There are three signiftomnt advantages to this approach. First, {¢ allows the State and Federal government to take advantage of the purchasing power ofthe Medicaid program, while providing a servive package that moves closerto or, in the case of NJ FamilyCare- Children's Progam Plan 1, equate that provided by commercial plans, Second, it tevognizes the need to develop a unified, managed cate approach to fhe catvedsout behavioral health services under the State's publicly Boanced programs. Third, tt allows the State to take advantage of the shingent consumer protections and utilization control ‘wtandatde Included in the Meclosid managed care contracts,

HMOs nee requtived to have toll free telephone numbers, 24 hows a day, 7 days a weak, for after-hours and argent cateneeds, In addition, HMOs have oase iManagemnent systems, stated by appropriate medical professionals, to qdsure that MO tnembersrecetve needed services ina supportive, effective, effictent,and cost-effectivemanner, Clase management imuist be olientcentered, goal-orionted, and oulturally competent fo assure approptiale provider/service linkages are made,

Describe tho utilization controls under the child health assistance provided nndor the plan for targeted low-income children, Dasertbe the systems designed to engi that enrollees recoiving bealth care services under the state plan reesive only appropriate and medically necessary health care consistent with the benefit package desertbed in the approved state plan, (Section FLO) 2CER 457.490)

Beoause Title XXI is not an entitlement progam, entollment and expenditures aro monitored closely against the allotment, Birollment will be stopped when total expendituras ere projected to equal the avatlable fmding level. At any time that-pointis reached, additional applicants will be-placed ona waiting list, wlth preference determined based. on date of application and income, Approptiate referrals to other gourees uf care will bomade.and enrallment willresume as quickly as feasible given that the ofxildren will be without coverage in the interim. New Jersey is aware thak ag long an the State is covering adults there will be no waiting list or exzolloent oap for ohiidren,

Under NT FarollyCare Mang B, C and D there are requirements concerning frend and abugo that do not apply under the Medicald/Plan A program. Specifically, family members may love NT FamilyCare eligibility i the tumily {x found to have engaged In progran Trand end abuse, For example, card loxhing ag a means to pay for services provided to a non-elighble child may result in disenrollmient fom the progiam, »

wv

Approval Date: November 14, 2011

. Eifective Date: Octaber 1, 2910

” For the portion of the cate covered by the managed. care contracts, the existing system of utilization controls used by the Medtonld nahaged care program will bein effect, HMOs uiust have a written Quality Management Program, which also includes a Vitizatlon Review Plan approved by the Division of Medical Assistance and Health Services. An annual External Quality Review that meets the fequirements of42 CFR 438 Subpart’ is perfotmed by a qualiiied Eatemal Quality Review Organization cach miabaged care organization. ‘

‘The administrative infustmoture, quality operating systems, provider networks and the health oare delivery system of all IMOs ara reviewed and approved before contracting, All HMOs contracting with the State have referral systems for speolalty cate and prlar anthorlzation requirements for certain éleotive services to further monitor and control unnecessary ullization of g ervices,

Clinical practice guidelines are utilized by the HMOs for their internal monitoting of the delivery of care by HMO providers,

The State, through tis ongoing inonitoring process conducts audits jointly with a

| Contracted Independent Paar Review Organization of cach HMO's utilization control systoms and contract compliance to ensure that all utilization contol standards aro met, ‘The audits are comprehensive reviews of HMO operations that: meet with the standards at 42 CER 438 Subpart B, with additional modifications to moet New Jersey's needs, Further additions are made to the review process on an individual HMO basis to address - HMO-spesific issties. and conceras identified through complaints, data fom other types of quality reviews, and member satlefaction surveys. .

The State-also collects comprehensive member and providen-speci tis encounter data trom the HMOs, Thesedata allow the State to develop uitization reports to compare services within a single HMO ‘against an accepted norm, ag well as to compare services actos all contranted LIMOs. Finanotel data reported by the plans a9 wall as onsite rovlows of financlal xevords by State staff provide the State with information on the cost efficioncias of each HMO. ;

12

Approval Date: November 14, 2011

Sectiond, —_ Eligibity Standards and Methodology. (Section 2102(h))

_{ Oo Cheek here if the stxte elects to use fonds ‘provided under Tithe XXI. only to provide expanded eligibility wader the state's Medicatd plan, and continus on te Section 3, -

ee ste

’ a 13

Effective Date: Octcher 1, 2010

Apptoval Date: Navornber 14, 2011

CEM, CHIP Eligibility

OMB Control Nunbart 099501148

4% CER 457,320(a)(2) and 3)

Moone eligibillly for children under the Nedionld Expanajon fa determined tn novordenog sith the Sollowing Inoome standards: There shanld be no overlaps-o7 gaps for the agos entoyad.

Age and Househald Inoane Ranges

Fiom Age To Age Above (% FPL) Up to & jovhiding (% PPL) 07 ae nia = an PRA Disclosure Statement,

Acconling to the Paparwork Reduction Act of 1995, io petons.ave.requltad to respond to a collection of inforiiaton unless it displays valid OMB santeol natiber, The-valld OMB control number for this information collection le 0992-1148, The tras required to complete thip Jatorrmation golfeoton ia estimated to average $0 hours per response, Inoluding tho tlms to review inatruotions, sonroh exiailng dala resourves, gathor the dain avoded, anid coniplats and review the inthiwwtlon vbtioction. Ifyou fave comments conoarning Ihe aogucaay of the time eatimatefa} or suggestions for Improving thls Form, please writs to: CMB, 7500 Seeurity Boulevard, Atins PRA Reports Giearancg Officer, Mall. Stop C4268, Baltimore, Maryland 2124461 B80,

APR 21 208 at nneyntte Effeoitve Date: Jarunuy 4,244 Pago | of 1

SRA NOD , Apprevel Dati,

4.1. The tollowing standards may be used to determine eligibility of targeted Jow-Income children for child health assistance wader thé plan, Please nota whether any of the { following standards are.used and cheek all that apply, H applicable, desorihe the oriterla that will bo wied to apply the standard, (Section 2102) DA) 2CRR. ! ' 437,308(a) and 487.320(a)) ‘

Effective Date: October 1, 2010 Approval Date: November 14, 2011

— CHIP Eligibility

<< Wr aicot)

RrrOabNTXBYy) al the SSA and 42 CPR 4s7a 10, 318 aml 320

OME Control Nurtbor: OOF ¢ UHH Explraiion dates 10/3/2014

Sonarate Child Eealth Tnswranes erogeant. : ' . cs Weligibilty ~ Texpeted Low-lncome Children ae :

Ungorae Standards

Targeted Loweltcanre Childyen « Uninsured oblldren wider age 12 whose household Income is witht ataneapes eatsolshed by the +

ae,

WZ] The CHIP Agenoy /aparaies this covered group bi accordanee with the Jollowleg provisions!

Age Must be under age 19,

Tnoome-standards ate applied stutewite. f You

Ava there hy exgeptiona, eg, populations iin county whlal play quallly under ellher a ctalowide Inoome No standard or a ecnnty Ingome atonednd? . .

Slutewlde Thoome Standards

Begin sith lowest age range Heat, :

lone note thot the lower bonne for CHIP ollgibiily should 46 thy highest atandard used lor Megloald poverty level ohtlaren for the same age group oF grotips eoteted bere.

Prom Auge , ToAge Above 1% FELT Upto & tnisladlng (% PPL) nee Ho | tba . 1380 . &qi_ | ib 1p 1a 350 x

Ago ranges may overlap diene fs en overlay, pravidle ath aplinallon Ingluile the age ranges for each Income staneland that bas overlapping yges and the reson for havlig dltverent income standayde,

Spoclal Progetp for Childiay with Disnblittiea Does the stile have a apogtal program for chtideon with dleabllitios? | Na

PRA Disclosure Statement

FEB 18 204

Bifective Dales Janay t, 2014 Page 1 of 2

APARNI-13-1048 Approval Datos

Acvording lo the Paperwork Redudlion Actot 1993 nu persons are requirgd do regpand 4 9 gollapiion of fuformalion ‘tunfens it dtaplays a vali OMB contin number, ‘The valiOMB contra} aumber for bby internation collection 18 09581148, ‘Tho thay requbped ty oumpleke (his -Intoemailan collection tx astinated to average $0 howe per responae, inoludlng the tne Lo review Instrawtions, searal extytlng dain rasoureey, gather the duta avéded, and complete enuf seview the informatton collsation. If yau have comments aunaemning the rovurayy of te Tne satimate(s) or sugeastions Por linpraving tila Ronn. please write ks OMS, 7300 Seourlly Boulevard, Atl PRA Repos Clams

Offioar, Mali Slap C4-26-05, Bullimera, Maryland 2124468350. , ‘vanran7ny

"

os

\ ; FEB 18 2004 SPAM Nd-70018 Approval i3ato: > Effective Baty; dinuary 4, 2034 Pogo 2 n°

Me ‘9! enROe Ud Bnet

CE nas, CHIP Eligibility

. OMB Control Numbers 00382 18 Exptrotton daior 10/31/2014.

ch i ‘Tenitl Tngurance Progra C814 Hitigibiiiy « Childven Insligtils for Madiegh) aa a Result of the Wimiation af Income Derogarda a"

Seation 1010) of the ACA and 42 CBR 497.5 100d)

Chien Ineligible for Modicald oy a Result of the Etimmnation of income Disregards ‘ : “f ‘The CHIP agenoy provides covernge fortitls gtoup of ebilctien ag faowa:

r ‘The sale Has rosedved approval from CME to mnafntaly Madizald oflgibtlly tor chltdren who would oth erwtze bp subject to Sootlon 21011) aueb that no vhild Inlhe state will bo aublect.to dis oraviglon,

‘Tiva slate assures that soparale CHIP coverage will bo provided-tor ohlldren inslighble for Medantd due bo she eflrslantlon of

@ incbme clisregeels [n dogordanon with 42 CPR 437.3.10(c), Coverage for this population will aease when the fast ebilt protected’ from legs of Medieatd covernge ag 4 resilt of the wllmination of tneome dlaregards has been atforded 12 mand of boverage hip septate CHIP (uxpacted to be wo lator than Apt 1,2016 3,

Desottbothe mnthodology used by éhe atnte to Ielonttty und enroll chiddren in a separate CHAP who wre 8Ubhoat I the proisction sified by Seotton 2FOL(f of the Afinudable Cave Aat

é ‘The state has comonstrated end CMS has agtoed that all chlidten qualbiyleg for seation 2101() proteotioa will qualify forthe” Mate"s existing separate CHIP, :

“The state will envott all ublldren tng separate CHP whe lnee Madloaid eligibility because of an Snerease ta Family fraome wt thelr

first tonewal applying MAG methods.

‘The stave Will envall children In 4 separate CHIP whose lutly Income filly above the converied MA GH Medioald FPL, bul a} or r bolow she followlig peraontage at FFL, The stato has detnonstinted and CMY hay agreed Hhat all of aliuostall tho ahildean who

would have maintahved Medieid-ellglbiitty Tf formar disregards were applied will be vwitle thls Income range sind cheretore

covered In the separate GELUP,

— hr ee ee

‘The state will eorofl childven In 4 spate CHIP.wito dre found to he tnoligible for’Medioald baseel on MAGI bud. hone then lly ~ Income has nokinersased slned the ablld’s last determination of Medlaald ellibliity of who would have censalned eligible for ‘ Madivald (based an the 2013 Mesioald inonme standard} it'tha value ottthelr 2013 dlaregarets had togn applied tr Ue Ranily Income ay determined by MACH methodglagy. .

C Other:

ibegesthe the beagiits provided to this popolnitore

¢° This population will he provided thesantt bowels as-are provided! Wy ebtldren tn the siate’s Medicaid plogiam, & "This population witl be provided ihe sorna baneltts ag ate provided te olildven tr the state's separate CHIP, Other (aongtslaud with Section 2103 ofthe S8A and 43 CPR AS7 Jubpytt D).

Devoribe pondiums and cont shurtng required af this population:

( Costabaring Is the gatne as Yorohileen In the Medinaid prowran. ,

FER TT ay

SAY: Nuet Ste Approval Datey Efloullve Data: January 1, 2044 , : Page Lote

“___

( ¢Crvass . CHIP Eligibility

ba SPypyn ev ir Fala

(* Prombums-and vost sharing pre the same tis for tugeted lowelneons children {n the aiuto’ separsig CHIP. No promlums, oppayrianiy, decuotlbtes, cotesuranee or otfar cost abaring fe required. “ + Other prombunas and/or costsluclag.sequizoments(conslalent with Sootion 210He} oF tha 8A and d2 CFR 437 Subpart,

PRA Disclosure Statement Ageoriling ta (he Paggiwork, Reduetton Act of 1995, no persons are required fo respond to 4 oofladilon of Information paleas It displays a, valld OMB control number, The valld OMB conlval nuntbar (oir thls information golleollon ts Ob381148, ‘The die required (0 eovaplete * thig Infoymation ollestion [4 exttvteted to avelage 40 hours par response, Including dhe Save to pavlew. Inatruwtlons, search existing tabs reaources, gather Ure data ngedud, andl complete and reviews the Infomation collection. tyou have comimenis convern{itg tha necurecy of * tho Ute oallmatoty}-or suggeyttons for Improving this form, plonse welte lot CMB, 7300 Beourliy Boulavard, Atta: PRA Ropurls Clearanee “ Ofitosy, Mall Stop 426-03, Baltimore, Marylanel 21944-18),

( FRB 49 2084

BPAHNI0920 AODOVAE DRL pct teneye tine neem Effecilva Dnfot January 1, 2014 : . Payo ? oP 2

41,4, Cy Roesourees (ateluding ay standards relating to spend downs and

disposition of resources):

‘Bolective Date: Ooteber 1, 2010

Apntoval Date: November 14, 2011

4,13. 2

Bffiective Dato: October 1, 2010

Rosidonoy (so Jong as residency requirement isnot based on length of timo in stats); .

Approval Date: November 14, 2011

4.1.6, 2 Disability Sintus (vo long as any standard relating ip disabtlity stabs does not restrict eligibitity):

Hifective Date: October 1, 2010 Approval Date; Noventber 34, 2011

Effective Date: October 1, 2016

4,17. [El Access to or coverage uniler other health coverage:

Based on guidance provided by CMS, a child who meets the eligthillty crltarle for the expanded Medicaid program (NJ FamilyCare Plan A}1s not eligible if the child is covered by other health coverage, This ineligibility for the expanded Medicaid coverage is a ‘federal statutory oxeeption to the entitlement requirements that would otherwise apply tader Title XIX, where the other insurance would be treated a a third party resource with Madioald remaining payer of last resort,

Unlike NJ FamilyCare Plans B, C ot D, under the Medionid expansion, (NY FamilyCare Plan A) there 1s no requirement that the child be uninsured fora 3 month period, ‘Thisis due to “crowd-out! belng of less conver itt the lower Income population, In addition, it tends to dimitish the disparity between the childven covered under the Medloaid expansion and other Modicald-cligtble children.

For NJ FamilyCare Plans B and C, a child must be uninsnxed fora mmdnimum of thres months, Bxoeptions are trade for children losing Medicaid oligibility and who have no other health care coverage at the tne of termination. Hxoeptions ave also made to the three-month requirement in cortatn licatted citomnstarioes (Lf for exarople, prlar coverage was lost because an employer went out of business of the etmployoe was laid off or ‘changed jobs and does not-have acess to affordable coverage in the new job) where scowd-out concerns are not an issue, Also, a child is not determined ineligible if the child was proviously covered under on individual health benefits plan or COBRA pian preceding application for NY FamilyCare and the child ‘had not bean voluntarily disentolled trom employe:-sponsored group insurance coverage ducing the three-month period prior to applying for NJ FamilyCare, , :

A child with income greater than 2.00% of the faderal povatty level who meets the otterla for NJ FamilyCare coverage under Plan, D aust be uninsured for a minimum of 3 months, Exceptions are made for children losing Medicaid eligibility and who have.no otherhealth care coverage al the time of terinination, Exoeptlons are also made to the 3 month _teguixement ib, certain limited circumstances. (if for example, priot coverage was lost

beoatse an employer went out of business or the employee was laid off or changed jabs) whore crowd-out concerns are not at issue),

Thore is no vthet requirement regarding access to other health coverage,

Approval Date: Novenibor 14, 2011

418, Bl Duration of eligibility:

Effective Date: October 1, 2016

Approyel Date: November 14, 2011

OMB Conteol Numbers 0938-1 [48 Bx lea nde, 102014

ROSANA) of thy BSA tnd 42 CPR 452.342 gid 433,926

Tha CHIP Agenoy elaots to provide continuons oligibillty to children under this proviston. [Yas |

The CHIP Agenoy muy qrovide that chlldren whe have hien-detetnined offgible under the state plan shull venialn.ellgthle, gardens oF ||" any changes in the dumily's chownstandes, duplig a continuous eligibility pastod up wl months, or unall the Ume the shild roaohes an lage spsalted by the state no} to uxoaad age 19), whichever lifentller.

@ Fox ohlldten up to age 19

¢* For ohitldren up to age el

‘The continues atigibilly perlod begins on tie effoctys date of the shild's moat Toon dotormination or redetermination of elfgtbllity, and ands:

a] Atthe end athe var months gonlinuous eligibility period.

« Bxceplions tothe vontituong eligl tility pertads [Bl Tho child attains the age apocified ty the atate Agency or ago 19, Ut The chiftd or child's tepresentarive roqnosts voluntary disenroliment, Gil The child lano lorger-a realdont of the state,

re ‘The Agenay detentinas that eligibtlliy was erroneausly granted rakithe tnbat recent detommiialiont or rengwal of efigtillty because of Agency etror or fisuc, abuse. or perjury altibuted to ahildl or oftlis representative,

Tl The ohild dies. J TT ~ [Bd Theve is 4 fallove te pay requtred pramlums or onrp!)ment tens On betialas'y child, ye provided for in the staleplan, CC) Other ,

PRA Disclosure Ratement ae

Aguording bo the Puporwutk Reduction Act ul 1993. 10 persona nre wequTved fo Reepand to a collontion of luformaudon \nless ft diaplays 0 vill OM oontrat number. ‘The valid OMB oontrol number for this lnfarmation collection Is C9984 148, ‘The tiae requirsd to penplate this Information collation La eattmnated 2 average $0 hows per tesponse, inoluding the thre to review Instructions, search exfsting dite faxourdes, gniherthe data needed, and complete and review the Infoentation ncllestiyn, H'you have comments concerning the aecuracy Of the Hine vetlnate(s) or suggestions for improving thle tim, please wille by: CMB, 7300 Security Boulevard, Attn PRA Reports Clearance Otiioe, Mall Biop C4265, Baltimore, Mayland 21244-1830,

VAMC

Estoatlve Deter Januesy #, 2014

SPAR Nd O-lO22 Approval Dates MARTE : Page J af 1

4,19, Bl Other standards {identify and deseribe):

Title XXI is a federal moans tested program and therefore subject to the same allen testrietlong og the Title XIX program, Accutdingly, benelits are available only to ehildren, who are qualified aliens, See sectlon 4.1.10.

Eligibility components under the Express Lane Eligibility Option include budget unit, hoalth insurance, oltizenship and tilentlty,’ Under the Taxation Express Lane option incomodis determined using the adjusted gross income available on thendividual’smost sooent NJ state tax filings. Express Lane applloatts are soteened to identify seli-eraployed individuals, Selfemployed individuals are required to provide additonal information/schedules of income.

All individuals completing their most recant NJ state income tax forms-nre asked to declare the health insuranoe status of each dependent in their household, The Division of Medical Assistance and Health Services (DMAHS) has entered into a Memorandum of Understanding with the Division of Taxation, which is the Express Lane Agency, “The Division of Taxation shares the addresses of thote families indicating lack of insurance for some or all dependents with DMAHS whioh, in tum, sends the Express Lane application to the families,

Under the School Lunch Program (SLP) Express Lang opilon, inital elighhility and incoine are determined by an individual's eligibility for the SLP, During the full sligibility deternination, a funtly's income, citizenship and identity are verified using LOOPS, DABS and Wages, Taxation and other available electromlo databases to eavethe ‘burden on families, Tf'income can not be yatified, (because theto is no SSN for parent, guardian or custodian relative) eelf-declaration will be accepted, A sampling of those self-declared families who had eligibility determined using SLY Express lane clighility processing will be reviewed by the State’s Quality Control Unit,

By completing and returning the Express Lane Eligibility applivations, the individuals authorize DMAUS to vetity information by accessing available clectronio databases

~ “whith includes the income information ad reported on thelr most recently filed NI stat

income tex forms,

Effcotive Date: October 1, 2010 Apptoyal Date: November 14, 2011

CoMms. CHIP Eligibility

OMB Conkol Nurtibars 0038+ [148

Az CR 487.3400b)

Savial Beswrity Nembor

Ara condition ofellgibillty, the CHIP Agenay must raqulra individuals who have aaoolal seanlty hunchor of ae eligible for one as determined by the Soctal Seourlty Adinlaigtration, to Curaish thal sqolal soourlly number, or nuxabors IF they have sore thay ong nuaber, ‘

wl Tha CHIP Agenuy requires individuals, asa condition of oligiliity, to Curash thelr sovtal aeourliy nunsberfs), with ihe follawlng T exceptions ,

Individuals refusing to obluin a soolal asourity nunaber {88N) beoauss of well astablished retlglous objections, or Individuals who are not eBglhle tor an S8N,-or Individuele who ava Issued on S81N only for a vallel son-wenk puxpose.

ti Bi cH Agonsy asslsta Indlviduaiy, who ave requlte fo provide thely SSN, to.apply fav ov obfan an SSN trom the Sout! Besurlly Administration If the fnellvidual doos not heve or dutgotthelr SSN, ' &) The CHIP Agoney informs indlviduals eaquired to provide thele BSN:

By what statulory aattority the mrinberls ‘soltotted, and

How the stata will uve the 88N.

The CHIP Agency provides assurance that itwilt verily each SSN furdahed by wnapplloant of boneltolary with the Soulat

Awoutity Adininistration, not deny or delry sorvtees to an otherwise eligible appllowst pending Issuance ve verltontion of the ite Individual's BSW hy iho Soial Security Admintutration nd thad the state's adtigntion ofthe S8Ny ts consistent with asctons 203 ~~ — ant F139 of the Sovial Beourlty Act and the Privacy Aokol 974. a

‘The stale may request romapplicunt. hovashold membery 14 valuntarlly provide their S8N, ff the slats meets he requlrementa below. a stale tequenty non-applicant houseligld menibers to volimtarily provldeshele Sgn,

i)

(21 When requesting an SSN for sor-applieant household members, the slate assures thay

i At the fine such SSN is requested, the state informa the noneapplicant that this teformation ts volumiary and provides infoxination regarding how the BEN will be used; aus!

a ‘The stats only uses the SSN tor determination of eligibility for CALP or ctor Insuemce alfexclablliyy programs, o fora purpose-dirsctly connentad with the adininfateation of the state plan,

“apa noaponds “pgproval Deter, WAR { i 20% HEffavtive ater January 1, 2014 Page 1 of2

a,

CHIP Eligibility :

Asoorelinyg to the Paperwork Reduatloa Aot of 1998, no porsorts are requlved to respond ty 8 pallention of information unteas it displays n valld OMB contol iumber, The valld OMB contol nambes tor Urls tevbortnadlon collectlon lx 093863148, ‘The tme required te ngunptete

thts Information collect “* sasiintaad, gather ble a

abs weeded;

fon Is satiated to average 5¢ hows per response, Iaoluding the ine to review Instn thong, genial exlatlig data

and wotiipiote and noviewthe information colléatton,-Hiyow have comments concerning the neouragy nf.

tha Ltrog eatlmagte(a) or suggestions for Improving this form, please weiss to; CMS, 7500 Seourlty Boulevard, Atla: PRA Reports Clearance Offioor, Mail Stop (4-26-05, Balibnors, Morylend 3 12d 830,

SPAM Nd-Ta-1022

‘ MAR. L i 20H . Effective Dates January 4, 2014

ADDER see ceca cane . Pope 2 ol'2

a

4.1-P The following standards way be used to dete income pregnant women for health assistance unde

wining éligibility of targeted low- ' the plan, (Seetion 2112),

Hifective Date: October 1, 2010

Approval Date: Novertber 14, 2014

d

““VEligihility + Targeted Lowdneonye Pregnant Women ce cme ete a enemem re ame ton on

CCAS CHIP Eligibility

oy erasTAN NTE ASIA ATT SEP

OMB Conlrol Nunnbar: QU9 +1168 Bxetratlin dake 103 vapid

Beparade Child Gealth Lnsvanep Progra : : og

Aeclion 212 ol the SSA

tc Targeted Lowelngdiie Proguant Youen « Uintasured pregnant womnda whe do no hoywnoness lo public ommpluyue coverage und veboas househtld Ineorye is within alandards established by the state, \

‘Tha CHIP Agenoy operates this covers group tn accordance with the following provialona: Age Stindards for Pregnant Women

The slate provides covainge lo pregrant.woment

Soleal an age range:

¢* Fromage 19, up to the following age: |

@@ With no aye renteictlan,

t* Another age ranges

If there ty no nga resteighon or It the age range overtopy wilh (he qualtiying ages tos children. desorlba haw dhe dalormination is made.og te whether the applicant will by privided covernge as a ohilld oy us.a pregnant woman,

The determination ly made based an the pregnancy status, NJ envolls a pregnant ehitd Inte our pregnant women progyan.

(EQ Must be pragnant oF postpartum

Incyine Suandards

Pregnant women eoverige my only bs bro Hehildvent's qualliying incon standard wader the plin fs al teual up (200% OF FPL Yor Tage ranges,

Income alundard {s applied statowldg wT

Are there any oxoeptions. ag populations In is county which muy ybality under slither a statewide income stindard ae 0 county ingome standard? J

Statewide Income Standard

“UIP covernge far pragoant women may only be provided if the qualldving inoome sandaed uncer Medicatd fox pregnant svotinn iy at Teal lip to 185%,

The highest lagame tavel for peogunel wornen waned be higher Lhas the highast income level for ebifidesn.

Above [ : “Teal isto and ineudig) +200) % FPL,

FEB TD Nd

SPANO 30018 . Approval ANS we enumunpetseee te sineenearpssnssns Effaativa DAs! deintiory 1, 20t4 , Pape) oft

oewoa

CORAS CHIP Eligibility

PRA Disoloaue Bealortont

Asordlng 6 the Paperwork Redustion Act of 1995, no porsona ure requived to reypond toa vollention of tnformatton unstsss It dlgplaye.a

“UR OME Biting Buber: “Thy valid CMB vontralnumibey-for this Information selection 44.093 861.448..Theshnarequbied lo complete

this information ul lotton Ig-estimated to average $0 Hours per responve, Including the fine to review Inetructlans, search existing data resougeda, gattior the data ngodeel, ast complete and review (he intbrnmtion collation. eyo fave somments concecalng the necuntey of tho ting oathmate(s) of uuggostlona for tenproving this form, please write ior CMS, 7500 Securtly Boutevaril, Alun PRA Reports Clearance

Offiver, Mail Slap 04-26-05, Baltintore, Maryland 2fabt+1 830, “ VAN pIE

rep 19 ate Bt Dates dana 4, a0¢4

BRAM NUlah048 ; FO ae eee nen nwcsnnne Pare 2 ol'2

414-2, 0] Resources:

Effective Date: October 1, 2010 Approval Date: November 14, 2011

4,5-P, [8] Restlancy:

, Must be 4 outrent New Jessey resident (residency requirement is not based on longth of ( time in state),

Effective Date: October 1, 2010 Approval Dato: November 14, 2011

42 CPR AB7.320

OMS Control Nurabor: 00431 M8 Pxplvation date 10/1/2014 ve

eaeelsite site :

fz]

Rositeney

‘the CHU? Agenoy provides CHFP to otherwise eligible residents of the.stalo includllag resident who are absent fron he slate uhcler corlala ocadhina,

A phild is considered to be costedont of the state under the Rollewing eonditlons:

A norrlostituignataed child, ieapnble of fndteating Intout and whe i apanolpated or nuerled, {fue aliild le Nlving lit the ‘yteter and:

1, Intends to reside in the state, ineluding withaut a fixed addrase, or

2. Has gntared the state wlth a fob comunitinent or seeking employment, whether or pot curently unplayed. [A A wonednatitutionsliged ebtid not desovtbed above anda ‘ott who Ie nola ward ofthe sinter ‘

1, Rosiding tn the utato, valli. or whhout a fired addvesy, or

an The atate of'resldenoy of the parent or cartier, in accordance will 42 CPR.4SS,.408(1)(3). with whom the individual resides,

a An fnstacionalized oblld, who ts not award of the en, it the state Is tho state of residence atthe ohild's custodial perentar sarbtaker al the time of placement, ar

[al A-ohild who ie a ware of Uhe state regardless of whore the child lives, or A shild phycloally logaied 4n the sinte when there ty a dispute with one or more statow-a8 to the ehitels agtual state on

- Yesitiones. JF ihe state covers preghans women, a pregnaht woinn ky consijerad fo bs a reakderit uncer the following condiitons;,

[9] A nondnstiiutionalized praynunt wornan who ta Hung in the state and:

, 1 Intends to reside fn te state, Inohyding without a fixed addiass, or If iaoupahte of Indloaiing intent, Js living inthe atafa, oF |

2, Botaved with s job comnilimant orsasktag stployment, whether or not anvantly employed,

i An lesthutlonal bed pregnant woman placed te en opboftatate-Inatitutton, as defined in-4 CFR 434.1010, nolodiiyg footer gate homes, by an agency of tie atu, or

iB Ali ingtituilanalizad) pregasat woman vextding In at hinstele-Instiiaton, ae definad In 42 CPR 435,010, whether op not the individual. established eeidancy In thy state priot to onteting the ihstitytion, or

al 4 pregnant woman phystoally located In the stats when thee Is a clapute with ent-or miord states 2s to the pregnant woman's actual alate of wesidenee,

‘Tha slate has [iv place related ta tho residenoy of ohildren and pregnant women GF covared by the stata}:

MAR | 120 aa Bienllve Doles danary 2, 204 Page | of 2

SPAR H44-008% Approval Daler te FD

CHIP Eligibility

‘One or move Intaustato agreartent(s). No | vm

é fement, . Avaording to the Paperwork Reduotion Ao} of 1994, no parecns neg required to texpond to & collection of information unless itellaplays v > val] OM contral nurnber, Ths valld OMB control suber for thie Informatlod collection ty D9I8-L14, The tha ragulred to euraplede this lnfbimation vollection 1s estimated to average $0 hours per reapongs, inehudlug the litte to review fistinotlans, weatoh ‘existing data resoungas, gather the lata treoded, arid complete and reviewy’the informatiow collection. Ifyou have eonments sencemtng-the novateoy of the time setmate(s) of sugsestions far improviig this fhum, please write toi CMS, 7300 Seourliy Boulevaed, Alin PRA, Reports Clearanee Olitogy, Malt Stop 6426-05, Balllmore, Marylond 2724461 840,

SPAENI1a-0n22 Approval Date: HAR LT 2 jh Slactive Dates danltary 4, 2044

Page 2 ofa

4.1.6-F. [1 Disabiliiy:

Etteotive Date: Ootober 1, 2010

Approval Date; November 14, 2011

41,7-P, Bl Aecess to ox coverage wader other health coverage:

Applicants must be uninswed, There is no asset tost ot cost’ sharing, Retroactive ( eligibility 1s available for this population,

Bffeottye Date: October 1, 2010 ‘ Approval Date: November 14, 2011

4,L8-P, [kl Duration of eligibility;

Cavatage Is provided until 60 days following delivery.

( ( >t : | ho toy | i ( Riffecthye Date; October 1, 2010 Approval Date: November 14, 2011

4,1.9-P, Bt Other standaray Gdentify and deserthe):

Title XX ds a dedéral monng tested progkam and therefore subject to the same allen reateictlons as the Title XIX progtam. Accordingly, benefits are availible only to pregnant women who are qualified aliens. See section 4.1,10,

Effective Date: Ootober 1, 2010 Approval Date: Novenber 14, 2011

CCMA, CHIP Hugibitity

OMB Control Munbers 0938} 148

Soy

plyaton date: 10/31/2014 fete

LP

Nocti iien

Sealine 2 105(G(9) nod 210700) 14) of tha SBA and 42-CFR, 457,820(b3t6), (0) and £2)

Citizenship

The CHIP Agency provides CHIP aliglttllty.in otherwige ollgible eltizens and natlondla oP the United States and cortaln nonvoktzans, G2] inelucling the tine period durlng which they ars provided with reasonable oppertunity to submalt verification of thelt oillzenshtp, national status ov satisfactory trmmlgration status, ‘ , ‘

[By Ths CHIP Agenoy provides ellglbtllty under the Plan to otherwise al ighble Inclviduates Who ave oltizans op antlonals of the United tates: or

Who aro qualified nonollizens ay dofined in asetton 43:1 af the Porsortal Rosronslbily und Work Gpporkaliy Reconelilatton Act (PRWORA) (8 U:9.0, 3.1642), or whose ollglbillty Is required by section 403(h) OFPRWORA (8 U5.€, $1612} and is no prohiblted by seotion 403 of PRAVORA (8 U,8.0, §1613K of

‘Who have duclarest themselves to bo otitzens or natlandile of the United States, oF at Inclividual having sullafaetory Inmm|gration atntus, curing @ reasonable opportunity perlod ponding vorltiaatton of thelr olidzenship, nationality, ar saliafaclory imrnlgenttan| status conslelont with requirements of 1903(s), TI7A), and 190A ee} of the Act, and 42 CER 435,406, 407, 956 and 457.980,

‘Pie reasonable opportunity period begine on and extends 90 dayn tion the date the notice of rensonable opportunity 1s 1westved by the individual, '

‘The agenay provides for an extension of the reasonable opporhintty pelod [Pthelndividual je making a good faith offer lowsalve any Ineonelsténoles or oblalu any necessary documentation, oy the agency hueds mare ime to completelhe — Yog verificaiion provess. . .

~~ "Fhe agency begs to furnish besellts to-otherwvise eligible individuals during-the-teespnsble-opportunity perind-one-date carter than the.date the mptleg Ie tecelved by the tnelividual. . '

Tha date benetied sve dinnjalvedl iss - Oho dive of applloation comtalning the declaration of oltlzenshitp or lamilgration statue. (“the data te reasonalils opportinlly notice 1s sent.

GF Other dats, a9 deseribed:

Date of HMO enrollment,

The CHP Agenuy elsots the option to provide (HIP coverage Wo wiherwlge aliglote ehildven up to age LY, lavwflly vesidlag as in the Uniled States, as provided in Sestlon 2109) 10) of the S8A (evtlon 214 oF CHIPRA 2009, PLL. [1e3), _.

Otherwise ol igible children nyatia vhlidven meating the eligibility xequlrumenty of targeted low-income children with the oxcopllon of uon-eltleen statas,

{¥] The GHP Agenoy provides assurance tha Jawdlly has sliaare ulso covered under the state's Mediontd prognin. SPAP NSO “Approeal Dates,.,..k Pe Ga Eegole Titer January y, 2UTF

* Rige } of'3

~

a CHIP Eligibility

Serenata me ONO RGD HAE IMO a

The QHIP Agenoy aloots the option io provide CLEP vovantge to otherwise allgible proytinnt women, lawéally rasldtng In the Vnltedl States, as provided In-Sootion 214 of GHIPRA 2009, PL, 111-3. Tho stale may not: seloot this apilon unless the atale also sleats ta cover lawitly residing ohtldren, A state may not seleet.this option tinlnya the state also covery Targeted Lowe

=

08.

Otherwise elfyibte pregaunt woman igany pregnant women who meet the ullgibfily requirements of targeted low-income pregnant women with the exception of non-oltlzen status,

P The CHIP Agenty provides-nssuarince that lawtutly youlding pregnant womerl aa alsn covered under the state's Madiontd program . .

te Aut Individual 1s ootsdtered to be fawluliy residing Ih the United States Ifthe op ehe ia fewfltly present and meets state tosldengy requiremonts, . .

[Bl An indivichoal is considered to be lawlilly present In the United States IP haorshe fst 1, A qualified non-oitlzen ag dafined tn § USC £64 1(b) and (2) . ot

2.8 ngnottizen in a-valld nontmmlgsant status, as defined In 8 U8,0, T101¢8)(15) or otherwise ander te Inunlgralion laws {as deflned ie 8 USC. TIMID); ‘

3 A Roncitizen who hag ioe paroled fit the United Stutas tn ancardanes with $ U.G.C11 [82¢ NCS) toe Lowe than 1 yore, exdept Yor an tndividual paroled for propoention, for deferred Inapoction or pending removal. proceedings;

4. A notealtizon Who belongs to one of the fillowing classes; () Granted terporary redident status In accordance with 4 1.8,0.L160 or 1255a, respeativelyy

Gi) Granted Temporary Protector Status (TPS) In aseordangs with 6 U.G.C. $124da, and individuals with pending uppliontions for TPS who have beyn granted enplayment authorization,

(1 Granted omploynrent autiorlaation nador & CPR. 2740. ory tiv) Pandy Usilty benallointies ia nocurdsnee with oubtiog 201 of Pub, L, 10]-649,.98 amended:

" (¥) Under Deferred Eakontod Daparturs (OED) I acoordanse with 8 devision made by the Prealdents (¥1) Granted Deferred Action slates (vii) Guanted an uemintsteative stay of vomoval under 8 CPR.2A1; ivi) Benediolany of bpproved visa, peittlon who has a ponding gpllaation fir adjustment of status:

. ke on Individual with o pending applivetion for asylorn onder 8 UBC, 1158, of for withholding of remaval wider 8 0.8.0.128 Lar under the Convention Agabist Torlure, whos

(} Has bepn granted employment authosizatlons yr (8) Is under the age of 14 ate has haetaa application pending for at lenst 180 days, 6, Has been geanted withholding oframovel under the Conventlon Agatha Torhira; 7. Is dahil who haa 2 ponding application far Spevial Lninigrant Auventle tintus ag clegoribed Ln 8 U.S.C ALOT ANI):

8. Je lawlatly present li Asvorlear Sanioa under the lyomigeaton laws cif Amurloa Samoa: oY

eat ae ee

‘ Poge 2 of 3

SPA Nd1aiha2, . . Approval Rate: “ AR yaa Flierlive Dots: January 1, 2014

Cows CHIP Eligibility — -

NG PAMRpAG FRR HY ANGE SH

ms:

9. tan vlollin of severe unifinkdig in persons, ta accordance whit the Viellns of Trafoking and Violence Protaptlon Astor 2900, Pub, Le 106-386, as annonded (22 U.B.G. 7103(b)),

£0. Bxception: As lndividal wiih deferred actlon under the Department af Homeland Seourlty’s deForvedt nation ter the childhood arrivals peocess, 98 Ges ood Id Mie Seoretary ar Nortel Seat y Moe The OLS ndemmorennd ay shia gt eer — formate bg considered to be lawfully present wlth veapedt to any of the abave oalsgorles tn paragraphs (1) through (9) of thls adctinitios,

PRA Disclosure Statement Avcording fo die Paperwork Radgotlon Act of 199%, no persone ere requir ed to reapoiid &) 9 collention of infommatlon UNlsst ti digptayas o vatid OMB control number. ‘The valld OMB dantrel number for this Iloematton collection is OO98-t 48, The tng eaquleed to complele: * this Informniton voflectlon is eutlmited to average 50 hours por responad, Including ihe thie to teview Instuotons, aenrch gxdstng date fesourses, gather the date needed, and complete and review the Informatton callaction, Jtyoy hive comments conoamnhng the acoaracy oF the She eatiinate(s) ov suggestlons for initwaying this foam, please write tor GMS, 7500 Seowlty Bontavard, Attu PRA Reports Clearance

Ovo, Mall Stop 4-26-05, Baltimore, Mavyland 212441830,

t wan 44 2014

SHAR ND (8.0022 Approval Dates, psn etd Aifeotive Bate: demvary 1, 2044

Pago 3 of 3

Section 4,110 Elgibilliy Standards and Methodology — ‘Expanding Coverage to Individuals Lawfully Rosiding tn the Tid

A110, 2X Cheek tf the State fs electing the option ander section 214 of the Children’s Health Insurnnee Program Reauthorization Act of 2009 (CUPRA) to provide coverage to the following otherwise sligible individuals Jawially vesting in the United States:

(1) “Qualified aliens” otherwise subject fo the 3-yeat waiting period per section 403 of the Personal Responsibility and Work Opportunity Reoonelflation Act af 1996 (PRWORA):

(2) Citizens of a Compact of Free Asscolation State (Le, Feduinted States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau) who havo bean adinitted to the United States (U.8,) as non-immigrants and are permitted by the Departinemt of Homeland Secutity to reside permanently of indefinitely ia the U.8.;

(3) Individuals described in 8 CFR 163,12(a) C4) who do not haye B permanent residence tn the country of their nationality and are in statuses that permit them to remain in the U.S. for ah indefinite period of thme pening adjustment of status, ‘These individuals include:

(a) Individuals currently in temporary resident status ag Atnesty beneBolacies pursuant to section 210 or 245A of the tmumipration and Nationality Act (INA);

(6) —_Tadtividuals currently under Temporary Protected Status pursuant to seotlon 244 of the INA: :

(co) Family Unity beneficiaries pursuant to section 301 of Public Law 101-649 ag atianded, ag well as pursuant to section 1504 of Pub. L. 105-554:

() Individuels currently under Deferred Enforced Dapariurs parsuant to a decision made by the President; and -

(#) Individuals who are the sponse or child ofa U.S. citizen whose visa petition has been : approved and who has a pending application for adjustmont of status; aud (4 Individuals ih non-diemmigéarit classttications under the INA who ate permitiod to remain tn ‘the U.S, for an indefinite patiod, including the Tollowing who ate specified tn section 101315) of the INAS : . * Pavonta or children of individuals with special Immigrant status under dection LOL{ay(27) of the TA ns permitted under section 101 (Q)(LS\QN) of the INA;

* Fianoder ofa citizen as permitted under section 101(a(13)(K) of the INA: Religions workers under section 101 (@)(15)0); :

* Individuals assiating the Depattmont of Justice in, accimtnel investigation as peemitted

tudor seotion 101Ca)(15)(8} of the INA:

* Battered aliens under sevtlon 101(a)(15)(U} (see also geotion 431 as amended by PRWORA) and :

* Individuals with « potltion pending for 3 years or more as permitted under seotlon TOTAL) of the INA.

_&. The State elects the CHIPRA seotion 214 option for children ‘ap fo aga 19

—~te. The State elevis the CLOAPRA, seotlon 214 optlon for pregnamt worm through the 60-day postpartum period

Effective Date: Ootdber 1, 2010 Apptoval Date: November 14, 2014

rie

41.101 X "Tho State provides naswranes fhat for individuals whom it enxolls in CHIP under the CHIPRA section 214 option that it has verified, both at tho time of the individual’s initial eligibility determination and at the tine of the eligibility redetermination, that the individual soniinnes to be lawfully residing in the United States, The State will fivst attempt to verify this status sing information provided at the thne of initial application, ithe State cannot do so from the infoxmation rendily available, it will require the individual to ‘ provide documentation ox further evidence to verity satisfactory fmunigration. status in the same mannor ag it would for anyon olga claiming satisfactory inmmigration status ander section 1137(d) of the At,

Béfecttve Datet October 1, 2010 Approval Date: November 14,2011

4.2, ‘Tho state assures that it has made the following Endings with respect to the aligibility standards in. its pli: (Section 2102)(b)(D(B)y (42CER 487,320), Tho State makes the same assurances ay to praguant yoren eligible pursuant to Section

{ AMP

42.1. [xt 4.2.2,

4.2.3,

*

These standards do not discrimtunte on the basis of diagnosis, Within a defined group of covered targeted low-income children, these standards do not cover childven of higher income families without covering childron with a lower fimily income

Those standards do not deny eligibility baved on. a child having apre- existing medical condition,

Effective Date: Qotobar 1, 2010 Approval Date: November 14, 2011

43,

“+

Describe the methods of establishing eligibility and. sontinning enrollment, (Seetlon 2102)(b)(2)) 42CER 457.350)

An application can be requested. via 4 toll-troe mumber operated under contract for the state or obtained through an ontreach source, ot obtained fom the county welfate agencies, The application is the same for those applying for NJ FatnilyCare Plan A (Medioaid expansion) or NJ FamilyCare Pleny B, Cand D, The form is designed to ensure all federal requirements ate met, but the application process is simplified as:much as posalble,

For children eligible under the Modicaid expansion (NJ FamilyCare Plan A), the application can be mailed in to a state vendor or the County Welfare Agencies ot submnitied online at www.njfamilysars.org or the client inay complete the application through the face-to-face process at the County Welfare Agencies, If the applination ig tnatled in, itis soreatied for completencss, [incomplete, any missing informaton will be requested. Potential baneficiaties who do notrespond to the request. within 60 days, will be outtaaghed by tail, If there is no response witirin 30 days, they will be xeferred to an outreach wotker for a telephone fellow-np., The stato makes a final determination regarding completed. applications processed by the vendor,

Bligibility under the Medicaid expansion (NJ FamilyCare Plan A) is applied back to the date of the application. Eligibility is effective the first day of the first month in which the person is found eligible, Reitoattive eligibility is available to covet-unpaid medical bills Por the three months prior to the dete of application if the requirements for eligibility are imetin each of'the threes months. (NOTE: Retroactive sligibility is not available forany ‘period prior to the start ofthe program,) Health Benefit Mdantificatlon (IBID) cards and BID Emergency Serylees Letters are issued in accordance with existing Metioaid practices, The BID card and Emergency Service Lotter aes for identification purposes only; providers must verify eligibility: aovordence with N.LA.C, 10:49-2 bolore they provide services, .

During the period of time whan the ehild is choosing and being enrolled in a specific HMO, all seivices are available on # fee-for-service basis, ‘The fumily will be asked to select ftom patticipaling HMOs covering the-comnty in which the obitd resides, Jeno selection is made, the NJ Care 2000 default agalynment roles will apply.

For childsan cligible only under Title X30 (NI FamilyCare Plans B, C and D), the application can be mailed fo.a state-venlor or subtoltted online at www ffamilyears.org the client can request assistanee from. one of tho servicing sites in the commnnity. Asslstaace Is also available through state fleld offices and county offices, Ifnoomplete, the application will be rotuned. by the venlor. Patentlal beneficiaries who have an application retuned to theta and do not resubmit within 60 days, will be outtesched by mall. [there is no response within 30 days, they will ba referred to ah outreach worker for either an aftempt at telephone or face-to-face follow-up,

Po Effective Date: October 1, 2010 Approval Date: November 14, 2011

Achild who presents himgelffhargelfat an acute carehospitdl, a federally quatifled health -conter or local health departenont that agress to be a presuinptive eligibility determination agenoy, is doomed prosymipt!vely eligible for all covered NJ FamilyCare program setylees ifapreliminary determination, by the staff of the fhoility indicates that the child meets NJ FamtlyCare program eligibility standards for'NT PanrilyCare Plan A, B, C or D and the ohild is a rember.of a housshold with a gross income hot exceeding 350% of the fedoral poverty level. Documentation must be provided by the child (if appropriate), child’s parent, gvatdian of eatetaler, no later than the end of the month following the month in which presumptive eligibility is determined. Presumptive eligibility applies to NI FamilyCate Plan.A, B, Cand D children,

The state vendor is responsible fot inaking the final determination of all atbtity for Title XXL State ataff montiory the performanoo of the vendor on an ongoing basis to ensure the adequacy and acourasy of the cligibility process, Stair staffis also responsible for certain income verificatlon activities,

Eilglble benofalories under NJ FatdllyCare Plans B, C and D are subject to a managed cate approach that mictors the commercial insurance environment. Under such matastream plans, enrollment is not effective until the application prodeds is complete and the individual 1s enrolled inthe managed care plan, Therefore, retroactive ell gibility docs

not apply,

There is an exception to this prooess, however, for newborns, To enstre that newborns arenot denied needed services, including those associated with birth, for newborns who ate desmud potentially eligible based on initial screening, services will be eovered on a feo-for-servies basis until the end of the month following the month of birth.

Fanuilies may choose among participating HMOs in their county of residence to provide coverage Tor all the children in the family. ‘The effective date of eligibility is the date the

child is enrolled in -9-participating HMO. Entoliment usually occurs botwaon 15 and 45 ” days of the date thet eligibility for the program is doteumined, Children. ate allowed to

change plang onve every 12 months, unless there is good cause fora change to coout

eatller,

A. permanent, plastic HID card will be issued to each client. The HBID card is for identification purposes only; providers must verlfy elighhility in accordance withN,LA,C. 10:49-2 before they provide services.

, For childron atigibly nndet the Medivald éxpansion (NJ FamilyCare Plan A), the formal

fair hearing mechanism, is avuileble for appoely involving the eligibility determination. Por the childsen denied cligibility under Title XX1 (NI FamilyCare Plans B, C and) or who are tertainated fornon-payment of premiura, there la amiediatlon mechanism used as the first step in tho appeal process. This oan be followed bya formal appeal to DMAHS, which must be aubmitiedda writhg within 20 days ofthe adverse notification, regardless of whether mediation is attempted. This apperl will be heard by a panel comprised of

2

Effective Date: October 1, 2070 Approval Date: November 14, 2014

ee

state staff, who will malearecommandations to the Division Ditector, Within 45 days of. receipt of the appeal, the DMAHS Ditestor will Issue a final agency decision, which ie subject to Judicial review in the Appellate Division.

Applications that involve family members already entolled in the Medicaid program will ‘be forwarded to the County Welfare Agency to he added to the existing cand, In eddition,. the County Welfare Agency vefors any obiid found not eligible for Meclicald or any child losing eligibility for Medioaid to the NJ FamilyCare program. The County Welfare Agency provides the necessary application and assistance in completing it,

Hach agentis required to talutata records supporting thelr determinations (marmal md/or electronic). A system for tracking the case disposition is avallable to respond to inquiries fom the client or the state, as appropriate.

Albmantbers are required to report changes that altoot eligibility to their respeotive intake | agent, A unique code bas besn identified that allows agenoles with access to the file to identify the responsible eligibility agent,

Béfective Date: October ‘l, 2010

Approval Date: November 14, 2011

! i I { t

Cenas. CHIP Eligibility

‘ OME Contr! Numbers Q0ag> 1 (48 Usvtraton dates 10/31/2014

Separate Chitd Hoalth Inauvance Progen . CRIS MAGI Based tnconte Mothodaingles ‘

2102 MA EMY) oP tho SSA andl 42 CPR STATA

‘Tho CHIT Agonoy will apply Modiited Adtusted Qrous Income methodaloglas lar) Separate CHAP covered gruupa, ae hee, below, and vonstatent will 42 CFR 457.13 and 438.603(b) through (1),

Th fhe que l'determining yagoing efigthility tor enroiees detuned aligthle for CHIP an og before December 31, 2013. MAGE baged Iricome methadelogtes will not be applied unt! Marah 31, 2014 or the next regulazly-scheduled renowal af eligibility, whloliover ts ater,

If che state pover's prognant women, in-detetnining filly sae for the ellgbilily determination an pregnant wom, she fk eountet! a8 hersell plus oaoh af thevhildcenaiy 19 expeotid ty deliver,

Lo detwrntining fanatly atve for tho ellglbiitty determination of the othor indlviduale Jn a household thet Taolades « pragnant womans C The ppregaant sonra fy counlad Just 4s herselh, "the pregnant woman fs counted just as herelf. phi ones . ” ‘Che pregnnnt woiten ts canted as herself, plug the number of children sho. 9 expected to deliver. Finanefal esigitiliy is daternitned eonstatent with the following rovigigna: When cotennining sligtbilley for now applicants, tinanalel ellgtotllty 1s bused on currentimonthly Incomeand dunlly alzs, When detownlnlgy ellgibillty for current benalelarioy, (nancial aligibitity ls based ont @ Coent nsonthly household facome and faruily alze,

{* Projected annual househald income ibe the zamalning months of she current eslendar year ond tually ake,

1 deferring aurent mouthly or profegted annual havashold ingore, the étdte will ude veasonable methadls bye [Sp inalude a proroced portlon ofthe reasonably predictable Inereass tn {uiurs faeinre andlor Fal ly slze, (S] Account thea resgonably predictable decrease in [oture Income andor Rally slze,

Bxoept og provided a4 CPR 447,314 and 43$.003(12) theoagh (4), heusholel ineome is dhe am atthe MAT btasod lneorae of vary Tnellyldual inoluded fy the individual's household,

Household income Ineludesaniually ayatlable-cash support. exevcding nominal amounts, provided by the person olaivating un tndlvidunl cbssetnod a1 $493,603 02)t1 at 6 tax dependent,

rel ‘The CHIP Agsaey cerlifies (ith it hag sulatipled and recelyed appiyvel forthe coaverston sor all separate CHIP euyerall grow? Income standards io MAGIseerdyalent standards,

Ves

An aitadionantt Js aubyiitiod,

“a Ly. a

BPA Abed 80018 Approval Dates Effesiive Hate: Januay}, 2014 Pagn 1 af

CEHMS . CHIP Bligibility

Agaprding to the Paperwork Reduotion Act of 1993, no porsons uve required Ww respond to a oollegtfon of information unless (¢ dlaplaya v. yalld OMS eondral number. ‘The vald OMB eontrol gamber foe this Informatton collection {sy 0938-1148, “The Hime requitest Lo eontplete: this information sullection is estimated W average 80 hours por regnonsd, Inaluding the Hnete review Institutions, aoaral extelling clots resuioes, gather the data needed, ara vomplete end review the Information collection, Hyon have gomments rancynntay ihe acusauy ot the ise ogtiinatarg) or suagestione for improving thls soem, please wile fo) OMS, 7300 Seuurlty Boulevard, Atlns PRA Reports Clearance Ofteer, Mail Stop 04-26-05, Balthmore, Maryland 2 L244-1850,

SPAE Nea ga Approval Data}. saeco Bifeoliva Bates January 4, 2044 Pogo 2 of

CEMA CHIP Eligibility:

OMB Coatrol Numbart 0938+] [48 i Expiration dates 10/3120) 4 !

ME esis

Sepatate Child Honith Insnraice Program Lelivibility - Geamed Newboras ve

Section 211 2(8) of tha SSA aunt 42 CER 487,360

ra Boonsed Nowbouns « Children born Lo iargeled lowslnoume pregnant wenn ere deemed (o have applied dor and be ellpthle for CLIP | or Madtowtd intl the child turns ane. :

f] ‘The state operates thls covered group In agcordance with the following provistons:

[Bl The child wos born 10 an ellgtile largated loweneonte prygnant yauten under aeation 2112 ofthe SBA,

‘She obttd ig deettied ly have applied tor.and beon Pound ellgtbla for CMI or Madtveld. as nppropriate, as of haddie of the ~ ghild's birth. and rematns elfgihle without regard to changes 1 olroumatances until the chtld's frst birthday,

‘The state elects the followlng npélonty):

ra The stale oleols To cover ps b deemed newborn v chlid bon 49 4 motte who Ip covered as a targeted Jow-inenme ablid under {us state's sepprnte CHIP on Ihe date of the sewborn!s birth,

ial ‘The alate oleota to recognize a child's deemed rewbdrn stulus from another slate and provides benofita Inaeenrdanee with the — cequivemants of sectlon 2112) af the SHA,

a ‘The state sleds (o voveras a deained newborn a-ehild born bo a molher suite ts oovertd under Medloaid or CHIP through the ~" suithoriy of the slates section 1115 demonstration op the date of the newborn's birth,

>, —- BRA Disvloaure Statement . According to (he Paperwork Reduction Avtol (995, ao persona are required to sesppod ta-a collerfion of information ntess it displays 4 . valid OMB enol! qumber. ‘the eat OMB conte! number for thia information collection 1g 0038-1148, The time vequiced fe completa thts information colleclan is astlnated to average 50 hows por reaponse, lndtuding thertlae to review Lustructlons, searett exlsling dats —-regouroes, gather the. date neaded, and com plele-and.raview the Infavmatton-scilleationlyyou-bave- comments coneenning-the-ancumoy-0F tha dive oot ateld) or stiggoslions for improving this fone. ploase write to: CMS, 700 Security Boulevard, Alin: PRA Reporte Cleavanes COfioar, Mit Bop Cad, Balliinore Maryland 3124461830, .

" . q SPAR NI 1B-1078 Approval Dates, FEB 18 a Fnaliva Date: January 4, 2014

Page Taf]

4,3,1 Degerlbe tho state's polloles governing eur ollment caps and walting ets (if ( ' any), (Section 2106(b)(7)) (42CFR 457,308(b)}

le] Check here if this section does not apply to your state,

New Jersey ia aware that us long ay the State is covering adults there will be no walting

list or enrollment cap for children,

Effective Date: October 1, 2010 . Approval Date: Noveniber 14, 2011

| L Seen enna

*

CERES CHIP Eligibility

' OMB Control Numbert 0938-1 148 Exptmlan dato, wan. Sea

42.CRR 437,359 end 435.1102, 2107{9){1)(L,) and 1920A of the 834

The CHI Agenoy sovers hidiwn whan determined presumptively ellglois by a qualified entliy, [yes {i8] Dosertbe the population of chifeeer lo whom presumpllve ellgiblity applian:

» — fOhileven up fo the age GE 19 whit household income Xap Uo on see ty 350% of FPL who ave residents of the atals of NI and raeet all oltizehship requirements,

TE] Desovloe dhe duration of she presumptive oligibtiiy period and any limitations:

The promunpilys potlod begins on the date the determinailon 1s made,

The end cate ofthe prasumptive parlod fs the carler of the date the eligibility determination tor regular Medttoald Is made. it'an

Baplication for Medtedd ta Aled by tha last day of thertronth follewlag the month in whioh the doterininallan of presomptive ellatbllliy is mades or.

‘The last day of thecndath fotlowlag the mouth tn whieh the Hetecminstion of presumptive ellgthllity Is made. ithe

Jappltcution for Mediaald ja filed by that date,

Perlods of presumptive elslbtiliy ard Tialted! to no more than one porlod withli.o twolveemonth perlod, starting with tho -

affeotive date of the inltlal prasumplive aligtbillty perlad.

il Kesoribe he applicailen process and sllgtiility dstomaination Inytore vewdi

Income, residenay, oltizenshtp, rind ape ara-avatuated vie selfatastation,

Si The cH Ip Aganey 0 tse crulfied ponies, ny detined insedtion 1D20A, ty dee = proaunpiively for children,

A, qhalftied anlify 1s at itty thut is determined by the agency & be cupable af making presumpl)ve oltgtbility doterninutions based on en individual's household income and other xequiraments, and that meets at least ems of din following raquhentents, Scleut the types of extitles used to detenatae presuinptive sliglbllity:

re Furnishea health oaro items and servines caiverod uncer the approved plan and Is eligible to redalye S! payinente under the approved plan ee Is authorlzed to doterng]ua 4 obild's ollglbility to participate in s Head Start program under the Blend Start

, o ie authorized to determing a olilld's eflgtbillly ty reaslvg-obitld one serviogs for hich Finanolal assjstance ta provides unstor the Child Care and Developrieut Block Grant Act of 1996

HART +208

SPANO 81022 AAO eS anmmesttd remy in Effective Dates tantiaiy 1,2014 . Page 1 oft

( Ce hvess, CHIP Eligibility

Cl Ip authorized fo determing a ahlld's oflgibillty to revolve easleiange under the Speclal Supplemental Food Programm tor Woman, Ingaats, and Children (WIC) under section 17 of the Chi Nutltion Act of L966

re Is authorized to deterratng a obtld’s otigiollity under the Medioald state plan or he ehikel health assistance t under the Calldrei’s Health Insuranee Program (CHIP) ~

ry (san aleraentary vr ascondary school, wa definad In section 14101 af'the Elementary and Seconstary 1 Bdkiontlan Act of 1965 (20 U.8.C, 8801)

{C] Won sfamentary or secondary schoot operated or supported) by the Boreay of Indian Atfhirs . 17] Isa stats ov Telbel child suppart ‘enforaetnent agency under tide Wel) of the Age

‘f : ry ts an Organiantion Bit provides emergency food aud shelter ander grant under the Stewart B. Mot lenny : . Homeless Assibianes Act

| TJ Is. a state or Tidal offiee or ntlty Invedved In enrollment tn the progeass amder Medicald, CHIP, of tlile : [Vo of tho Aat

Ioan organization that iletermInes ollgibillty for any asslatanse-or banefits provided under any prograntot Dot cl publla or agalsted Housing that sevelves Pedra! finds, including dye progam under seotion B or aly other

i : tod action of tho United States Housing Act of 1937 (42 U.S.C. 14375 or under the Natlye Amerlean Housiag ‘ Assistance and Self Determination dwt of 1906 (25 U.S, 4101 er seq.y

("1 Any other entity the etate so dooms, ax approved by the Seorelury

rot “The CHIP Agehoy nesures that thas communtonted the dequlrementy for qualified entities, at ASQ0ACE) Poy at [Z| ofthe Act, ond provided adequate tralalng to fhe entitles end organizations Involved, A apy ofthe’ boa tralnhig materials has boen Included.

"hadihibnddtnhiet.,

PRA Disolomre Statement

valld OMB dontrel mumber, ‘The valid OMB oontrol number for this information. golleation Is 0998-1148, ‘The time reculred to onniplele this Information Gofluation fs esthnaled to average 30 hours per response, ineltdiing she Une to review Instetetions, ssarch extalg data regonveus, gatler the data needed, amd complete and review the informallon oollzetion. If you have comments oonvetalng she sesurany oF poy! the tleve astinvatels) or suggestions for Improving Usls form, plone welts tor CMS, 7500 Seoutly Boulevard, Atte: PRA Reporis Clearanes Po Offioar, Mail Stop 4-26-04, Battinora, Maryland 212441850.

Vv mi3070

. . wan 14 20th

SPAR Rating Approval Det ensure tnt uenagenqene Bxlective Rate: January 1, 2044 Page Sa

Aecardlng to the Papervark Reduction Aat of 1995, no persona aie tagutred to respantl Lo ¢ collection of laomnation unless tillsplayan

OMB Control Numba 0698-148. Explrnthyy dato: 10/31/2014

alt cmd

211240} of the 884,

Fhe CHIP Apansy aovers pregnant women When detstmlned presumplively ellalble by «quelled entity. [Yes | [B) Desorlde the population af pregnant women to whom presuniplive ellglollty applies:

‘JPrognant warn ap to'end equal to 200 % FPL, residents of tho stage Of NY, nae) moot oltzenghip requirements, No age requirement, :

[8] Desertbe the auvation o the prayamiptive ollgloliity pariod-and any Rnittettons:

The presuinpiive perlod baging on the date the determination Ja made, Tho ensl dale of the presumpilya perlod ie the eanller of the date the cligibilfty deternsination for regular Medlonid Is nda, If a4 Application toe Medicaid Is Sled by dhe Jost day of the sionth Following the month in whlol the determination of preaumptive olytbility ts mades or ' ‘Phe Taal day affshe mont followlng the menth in wilelt ehe-deteminetion of presumptive ellatbility is made, \F no application for Madi caid ig fled by that date, . Periods of prasmnplive allgititlty ave Hinged to ng nyore than ane period por pregnanay,