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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.