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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
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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
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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
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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
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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
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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
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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
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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,
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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.
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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
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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.
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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.
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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.
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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
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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.
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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