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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