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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.