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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