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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