DEPARTMENT OF HEALTH & HUIvIAN SERVICES Centers for Medicare & Medicaid Seroices Jacob K. Javits Federal Building 26 Federal Plaza Room 37-100 New York, New York 10278-0063 June 23, 2009 John R. Guhl, Director State ofNew Jersey Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712 Trenton, New Jersey 08625-0712 Dear Mr. Guhl: c.r s CENTERSforMEO/C4RE IHED/CA/ OSERV/CES .' We have completed our review ofNew Jersey State Plan Amendment submittal 09-03- MA, Express Lane Eligibility Option" (Section 2.1, pages l lb, l lc, and l ld) and find it acceptable for incorporation into New Jersey's Medicaid Plan, effective May 1, 2009. Enclosed please find copies of State Plan Amendment 09-03- MA and Form HCFA-179. Please note that we have made the pen and ink changes to the HCFA 179 as per the State's June 16, 2009 e- mail to our office. Ifyou have any questions or wish to discuss this further, please contact Patricia Ryan of my staff at 212-616- 2436. Sincerely, eKely Associate Regional Administrator Division of Medicaid and Children's Health

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fEF` ti i" P f_= N T IF N:Ei-,. E`-I Alj !1Itv1f J .' i.( i1i: E i; Eit ii' R:'; 3= 0 rf ts1Et? iC'r. E Mtt) iC:itl, SER.3 ES TRAriSIU! lTTAL 13it) TiE F PPRQ1lAL UF STAT P'LAN M7E 1. . fld CtUT FS 7R MEl71GAR & MEUlCAlL1 ERf ES Ft• r1f+ PPE t) t f: i:) h1B tJt,) (x93- f1; i Th'r' dS'tl{ TTi- NUh16E L =:`t:. TE_ 0-i 3- Nll Iel Jersey PF20GRa 3ENT11 i0l. TiT;.E X : Ti~IE SCiAL SEC..1RiTY tCT 'iPy'IEC7 Ci3C31 Tt" REGINHL iCftll lISTRIT R _ , p,P, rP(? SFf CFFECTIVE C7,7E GNTE fi F{? R Eal,t RE MEGIC.1D SEd/ ICES Pv1ly 1, 2{0 IF; ( ItE'1° i" C7 #- IEiLTki qNi F-il M SERL' lCES iYE = 'L;; tV TEiiF lult r? e) • fiS;ELV siT' E F=_=; 3 , , iLl' IUC3JIEI T T E :C?tlal3t RED ;S Iv;'' F= L ati ' 1 IIE.NC:+ PIENT C) MPLE7: rt; S THf;I '; If TNIS IS rN 1d1EN ifIEANT Sp3r at Tt, ti aFrttal fcr' er' arnex, intj __ f EDEP. L STlTUTCfF EGULA Ii7N ITTIO I. ;; FERAL BI;G u? iMT,.C1T G}- IlPRA ,OC ction Q; Sacial curity Act ; a. =F' OJ . lth; ov+n t this time Set cn_'! 02_ ( 13 ._--. _._... ____ __.. _ _ _.._ _ b___ u tJr#r vr t iis tir 3 AG NUtr1 E? t= s-? E L1R EG'iION {7F'. ? GE 111B f Cf Tl- SUE.. F? SED= D '' 1_? N TT.Ctit+ lEhl7 ' SEC1 3({ . , T7t 1-l EiJT (i> >';`,.` bb! ej Stfi Pln Sctit r 2. }ac ` 11 . 1 , 1 1 i I: vy SEE REMARKS 0 5u,+r Ett j. i 7. Express Lane HgiJity Ot Un 1 ;'/ ERN(R S ftV Evhl r' hec# c t7}. _ i__. 1 01 h3V?R` S +' JFiCE EPORTE JG CIvIMEN° l" ': C'N r. fS S' ClFIED. tUN1 iEtlTS F £ VNC P'S = FIE Ehd LSED t. tu rer LrsU nt i ; ? 4 ^f the 'Ir RP Y ? Er'iVEG I4'3'' HiN CzYS FiUf3PJ11 TA,L S;v; 1- l;{? F= nr Tt.E , r- _ . _ __ ._ _ _ _ _ ENC'Y O-t ICl1L - r RE : a JUh,I G:ai' DiruGiO,' T E Ct I, J nnf'' Vle ___ ti, ; a ._ r __._. _ _--- . _... _._---- ivisn ci if1 ii rss stric ,rcit Srvi. r, s 14 t.. E r ssii er, __ _ _ (' ; ox ?'I f:ii .31e #2 Lt rt?` l It unlat 'irviees _ , Trprtton fl 8 ;- i71,r 5 C, t 7Si11` r1 v: F'3R REGIC3A. { 3FFiCE t. 15 {}Y ___._. 17 iTC R'.. E"/ E 3 C)Aiv .FjF:t`. t( . e Pi.AN APPRVEt — NE GC3F'Y Aa' 1 F= ECTiVF_ Cn f" E ? F ,PPRC'ED MftTA iL 1. 2YW 2C S1Gi " i ;: E tLtiC9/ 1L. e • rn 2 . TYPD N1ME: - _.._ _ .. _.... 3 G_ TIT ociate egionai A _ inistor ___ _ .._ of 14ledicaid and 23. RERIARi: Note Pen & Ink change to HCFA 179 to reflect the following in box 7: FFY 09 -$1, 000, 884 and FFY 10 -$4, 160, 402 FtI i G11s1-? s9 ;tJi-;}"') trstr cticr s tsr ack

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services Cf. AY Jacob K. Javits Federal Building

26 Federal Plaza CENTERS for MEDICARE & MEDICAID SERVICES Room 37-100

New York, New York 10278-0063

February 8, 2012

Valerie Harr, Director

State of New Jersey

Department of Human Services

Division of Medical Assistance and Health Services P.O. Box 712

Trenton, New Jersey 08625-0712

Dear Ms. Harr:

We have completed our review of New Jersey State Plan Amendment submittal 11-06, “Express Lane Eligibility Option” (Section 2.1 pages 11e, 11f, and 11g) and find it acceptable for incorporation into New Jersey’s Medicaid Plan, effective April 1, 2011. Enclosed please find copies of State Plan Amendment 11-06 and Form CMS-179.

Please note that as agreed, we have substituted the originally submitted pages with the revised pages that New Jersey transmitted to our office via e-mail on January 26, 2012.

If you have any questions or wish to discuss this further, please contact Patricia Ryan of my staff at 212-616-2436.

Sincerely,

Associate Regional Administrator Division of Medicaid and Children’s Health

Enclosures

DFFICIAL

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: New Jersey

Page lle

SECTION 2 - COVERAGE AND ELIGIBILITY

Citation(s) 2.1 Application, Determination of Eligibility and Furnishing Medicaid (Continued) 1902(e)(13) of x| (e) Express Lane Option. The Medicaid State agency elects the the Act option to rely on a finding from an Express Lane agency when

determining whether a child satisfies one or more components of Medicaid eligibility. The Medicaid State agency agrees to meet all of the Federal statutory and regulatory requirements for this option. This authority may not apply to eligibility determinations made before April 11, 2011 or after September 30, 2013.

(1) The Express Lane option is applied to: IX |initial determinations [1] Redeterminations [J Both

(2) Achild is defined as younger than age: Cig L) 20 x1

(3) The following public agencies are approved by the Medicaid State agency as Express Lane agencies:

New Jersey Department of Agriculture as administered by and through the New Jersey Department of Education

11-06-MA

TN No.: 11-06 Approval Date FEB 0 8 2012, EffectiveDate APR O 1 2011.

New

DFFICIAL

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: New Jersey

Page lif

SECTION 2 —- COVERAGE AND ELIGIBILITY

Citation(s)

2.1 Application, Determination of Eligibility and Furnishing Medicaid (Continued)

(4) The following component/components of Medicaid eligibility are determined under the Express Lane option. Also, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between Medicaid eligibility determinations for such children and the determination under the Express Lane option.

The components of Medicaid eligibility under this Express Lane option are income and residency.

Under this Express Lane option, income is determined by individual eligibility for Free lunch within the School Lunch Program (SLP), which has an income threshold of 130% FPL. The SLP determines income using adjusted gross income. This is different because without the Express Lane option, earned income disregards, the child support disregard and child care deductions would have been used when calculating financial eligibility for Medicaid.

Residency is accepted based on the child’s status as a student in the school district, as determined by the Express Lane Agency. This is different because without the Express Lane option,

families must provide proof of residency by submitting documentation such as school records or utility bills.

Full eligibility is then determined by: -verifying citizenship and identity using available electronic data bases -determining family size using our subsequent application.

(5) Check off which option is used to satisfy the Screen and Enroll requirement before a child may be enrolled under title XXI.

C] (a)Screening threshold established by the Medicaid agency as:

(| (i)___ percentage of the Federal poverty level (exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points); or

11-06-MA TN No.: 11-06 Approval DateFFR 0.8 2012Fffective Date APR-0- 1 208.

OFFICIAL

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: New Jersey

New Page 1lg

SECTION 2 —- COVERAGE AND ELIGIBILITY

Citation(s)

LJ (ii)___ percentage of the Federal poverty level (that reflects the value of any differences between income methodologies of Medicaid and the Express Lane);

CT] (b) Temporary enrollment pending screen and enroll.

ix] (c) State’s regular screen and enroll process for CHIP.

2.1 Application, Determination of Eligibility and Furnishing Medicaid (Continued)

[\6) Check off if the State elects the option for automatic enrollment without a Medicaid application, based on data obtained from other sources and with the child’s or family’s affirmative consent to the child’s Medicaid enrollment.

[](7)Check off if the State elects the option to rely on a finding from an Express Lane agency that includes gross income or adjusted gross income shown by State income tax records or returns.

11-06-MA TN No.: 11-06 Approval Date FEB0O-8 2012: Effective Date APR 0 J 2011,

New

EPARTMENT OF HEALTH ANO HUMAN SERVICES FORM APPROVED ENTERS FOR MEDICARE & MEDICIAD SERVICES conndMB NO, 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | 7. TRANSMITTAL NUMBER: 2, STATE STATE PLAN MATERIAL 11-06-MA New Jersey

FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE April 1, 2011

5. TYPE OF PLAN MATERIAL (Check One):

(1 NEW STATE PLAN

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

) AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: CHIPRA 2009 Section 203; Social Security Act Section 1902 (e) (13)

7. FEDERAL BUDGET IMPACT. a. FFY 2011 $0 b. FFY 2012 $6,366,239 (cost) See attachment

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

State Plan Section 2.1 pages 11e, 11f, 11g

** SEE REMARKS

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

New

10. SUBJECT OF AMENDMENT:

Express Lane Eligibility Option

11, GOVERNOR'S REVIEW (Check One): [] GOVERNOR'S OFFICE REPORTED NO COMMENT (] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

[-] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

%] OTHER, AS SPECIFIED: Not required, pursuant to 7.4 of the Plan

12 wi AGENCY OFFICIAL:

43. TYPED Nap “Pennie t Velez

44. TITLE: f~ rey uman Services

45, DATE ee

16. RETURN TO

Valerie Harr, Director

Division of Medical Assistance and Health Services P.O. Box 712, Mail Code #26

Trenton, NJ 08625-0712

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE BEbFuary 8, 2012

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APR MATERIAL:

20. SIGNATURE OF REGIONAL OFFICIAL:

21. TYPED NAME: Michael Melendez

Associate Regional Administrator Division of Medicaid and State Operations

22. TITLE:

23. REMARKS:

** By means of this SPA, the State of New Jersey is electing the option to rely on a finding from an Express Lane agency (NJ Free Lunch Program) when determining whether a child satisfies one or more components of Medicaid eligibility. (CHIPRA 2009 Section 203, Section 1902(e)(13) of the Social Security Act).

ORM CMS-179 (07-92)

instructions on Back

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services CAAS Jacob K. Javits Federal Building

26 Federal Plaza CENTERS for MEDICARE & MEDICAID SERVICES Room 37-100

New York, New York 10278-0063

March 27, 2012

Valerie Harr, Director

State of New Jersey

Department of Human Services

Division of Medical Assistance and Health Services P.O. Box 712

Trenton, NJ 08625-0712

Dear Ms. Harr:

We have completed our review of New Jersey State Plan Amendment submittal 11-18, “Eligibility under 42 CFR 435.222 and 1905(a)(i) of the Act” (Supplement 8a to Attachment 2.6-A page 4 and Supplement 8b to Attachment 2.6-A page 2) and find it acceptable for incorporation into New Jersey’s Medicaid Plan, effective October 1, 2011. Enclosed please find copies of State Plan Amendment 11-18 and Form CMS-179.

Please note that as requested, we have substituted the originally submitted plan pages (Supplement 8d to Attachment 2.6-A page 1 and Supplement 8e to Attachment 2.6-A page 1) with revised pages submitted to our office via email on January 25, 2012. We have also substituted the originally

submitted CMS-179 with the revised CMS-179 submitted to our office via email on March 16, 2012.

If you have any questions or wish to discuss this further, please contact Kanoena Cook of my staff at 212-616-2210.

Sincerely,

Michael Melendez Associate Regional Administrator Division of Medicaid and Children’s Health

Enclosures

grr

SUPPLEMENT 8a to ATTACHMENT 2.6-A Page 4

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: New Jersey

MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902(r) (2) OF THE ACT*

Section 1902(f) State X __ Non-Section 1902(f) State

For all applicants and recipients described on page 12 of Attachment 2.2-A and as specified in 42 CFR 435.222 who would qualify but for income, New Jersey will disregard earned income between the AFDC standard in effect as of 7/16/96, and 133% of the FPL.

*More liberal methods may not result in exceeding gross income limitations under section 1903(f).

11-18-MA(NJ)

TN No. 11-18-MA (NJ) Approval Date: MAR 2 7 2012 Supersedes : New got Effective Date: get g 1 2011

OFFICIAL SUPPLEMENT 8b to ATTACHMENT 2.6-A

Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: New Jersey

MORE LIBERAL METHODS OF TREATING RESOURCES UNDER SECTION 1902(r) (2) OF THE ACT

Section 1902(f) State Xx Non-Section 1902(f) State

For all applicants and recipients described on page 12 of Attachment 2.2-A and as specified in 42 CFR 435.222 who would qualify as specified in 42 CFR 435.222 but for resources, New Jersey will disregard all resources.

11-18-MA(NJ)

TN No. 11-18-MA (NJ) Approval Date: MAR 2 7 2012' Supersedes : New New Effective Date : OCT o 1 201

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES

1, TRANSMITTAL NUMBER: 2, STATE

11-18-MA New Jersey

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE . October 1, 2011

5. TYPE OF PLAN MATERIAL (Check One):

(J NEW STATE PLAN (] AMENDMENT TO BE CONSIDERED AS NEW PLAN {] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 435.222 and Social Security Act Section 1905(a)(i)

7. FEDERAL BUDGET IMPACT a. FFY 2012 $0 b, FFY 2013 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Supplement 8a to Attachement 2.6-A page 4 Supplement 8b to Attachement 2.6-A page 2

** SEE REMARKS

9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

New

New

10. SUBJECT OF AMENDMENT: Eligibility Standards

11, GOVERNOR’S REVIEW (Check One): (J GOVERNOR’S OFFICE REPORTED NO COMMENT (]) COMMENTS OF GOVERNOR’S OFFICE ENCLOSED (1) NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

{] OTHER, AS SPECIFIED: Not required, pursuant to 7.4 of the Plan

12. SIGNATURE OF STATE AGENCY OFFICIAL: i FENCY OFFIC

—- re

14, TITLE: _Sgormissioner \ a

15. DATE SUBMITTED:

16. RETURN TO:

Valerie Harr, Director

Division of Medical Assistance and Health Services P.O, Box 712, #26

Trenton, NJ 08625-0712

G: 4 i efional xaininistrator ivision of f Medicaid and State Operations

sey Proposes, as of October 1, 2011, to come into compliance

s applied to individuals specified

‘€xpect an increase in the number of potential covering this population. The State provided

number of insured individuals in this

FORM CMS-179

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

New York Regional Office

26 Federal Plaza, Room 37-100

New York, NY 10278 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID AND CHILDREN’S HEALTH OPERATIONS DMCHO: VH

September 12, 2013

Valerie Harr

Deputy Director

State of New Jersey

Department of Human Services Quakerbridge Plaza

Building 7 PO Box 712

Trenton, New Jersey 08625-0712

Dear Ms. Harr:

We have completed our review of New Jersey State Plan Amendment (SPA) 13-06-MA, which we received on June 26, 2013, and find it acceptable for incorporation in New Jersey’s Medicaid State Plan.

The SPA reflects that New Jersey’s Medicaid program covers and reimburses all United States Preventive Services Task Forces (USPSTF) grade A and B preventative services, approved vaccines and their administration recommended by the Advisory Committee on Immunization Practices (ACIP) in the standard Medicaid benefit package without cost-sharing.

This SPA is in accordance with section 4106(b) of the Affordable Care Act (ACA) which establishes a one percentage point increase in the Federal Medical Assistance Percentage (FMAP) applied to expenditures for adult vaccines and clinical preventive services to states that cover, without cost sharing, a full list of specified preventive services and adult vaccines.

Please note the approval date of this SPA is September 12, 2013 with an effective date of April 1, 2013. Copies of the approved State Plan pages and the signed CMS 179 are enclosed

If you hay any questions or wish to discuss this SPA further, please contact Vennetta Harrison at (212) 116-14.

MicHael Melende: Acting Associate Regional Administrator Division of Medicaid and Children’s Health Operations

Enclosures

oo

ro Addendum to Attachment 3.1 A

Page 13(c)(1)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

Limitations on Amount, Duration and Scope of Services Provided to the Categorically Needy

13(c) Preventive Services

All United States Preventive Services Task Force (USPSTF) grade A and B preventive services, approved vaccines and their administration recommended by the Advisory Committee on Immunization Practices (ACIP) are covered and reimbursed in the standard Medicaid benefit package without cost-sharing. These preventive services specified in section 4106 of the Affordable Care Act are all available under the state plan and covered under the physician, clinics, and other licensed practitioner service benefits and reimbursed according to the methodologies provided in Attachment 4.19 B for such services.

Appropriate procedure codes, modifiers, and/or diagnosis codes are available for providers to utilize a crosswalk from those procedure codes, modifiers and diagnosis codes to the USPSTF and ACIP recommendations, as well as a financial monitoring procedure to ensure proper claiming for federal match.

Utilization review and approval procedures conform to USPSTF and ACIP periodicity and indications where specified.

Documentation is available to support the claiming of federal match for such services including coding, crosswalk, and controls procedures.

Coverage and billing codes will be updated accordingly as changes and updates are made to USPSTP or ACIP recommendations on their respective websites found at

http://www.uspreventiveservicestaskforc.org/uspstf/topicsprog.htm

and http://www.cdc.gov/vaccines/schedules/hcp/adult.html

13-06-MA (NJ) TN: 13-06-MA New Approval Date: SEP 12 2. Supersedes: NEW Effective Date:__APR 0 1 2013

ro

Addendum to Attachment 3.1 B Page 13(c)(1) STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

Limitations on Amount, Duration and Scope of Services Provided to Medically Needy Groups

Pregnant Woman, Dependent Children, and the Aged, Blind, or Disabled13(c) Preventive Services

All United States Preventive Services Task Force (USPSTF) grade A and B preventive services, approved vaccines and their administration recommended by the Advisory Committee on Immunization Practices (ACIP) are covered and reimbursed in the standard Medicaid benefit package without cost-sharing. These preventive services specified in section 4106 of the Affordable Care Act are all available under the state plan and covered under the physician, clinics, and other licensed practitioner service benefits and reimbursed according to the methodologies provided in Attachment 4.19 B for such services.

Appropriate procedure codes, modifiers, and/or diagnosis codes are available for providers to utilize a crosswalk from those procedure codes, modifiers, and diagnosis codes to the USPSTF and ACIP recommendations, as well as a financial monitoring procedure to ensure proper claiming for federal match.

Utilization review and approval procedures conform to USPSTF and ACIP periodicity and indications where specified.

Documentation is available to support the claiming of federal match for such services including coding, crosswalk, and controls procedures.

Coverage and billing codes will be updated accordingly as changes and updates are made to USPSTP or ACIP recommendations on their respective websites found at

http:/Awww.uspreventiveservicestaskforc.org/uspstf/topicsprog.htm

and http://www.cdc.gov/vaccines/schedules/hcp/adult.html

13-06-MA (NJ)

new SEP 1 2 2013.

Approval Date: APR 0 1 2013

TN: 13-06-MA

Supersedes: NEW Effective Date:

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES

STATE PLAN MATERIAL

FORM APPROVED : OMB NO. 0938-0193 2. STATE

— : i i

13-06 MA NJ New Jersey

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO. REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES

DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE

April 1, 2013

8. TYPE OF PLAN MATERIAL (Check One):

(J AMENDMENT TO BE CONSIDERED AS NEW PLAN

{ AMENDMENT

HRU 10 1F THIS

s AN AMENDMENT (Separate Transmitt:

for each amendment)

6. FEDERAL STATUT! TATION: 1908(b) and 1905(y) of the Sacial Security Act

7. FEDERAL BUDGET IMPACT a. FFY 2013: $223k b. FFY 2014: $446k

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Addendum to Attachment 3.1A page 13(c)1

Addendum to Attachment 3.1B page 13(c)1 **Please see remarks

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

New page

New page

10. SUBJECT OF AMENDMENT: ACA Section 4106 Preventive Services 1% FMAP increase

“11. GOVERNOR'S REVIEW (Check One) (] GOVERNOR’S OFFICE REPORTED NO COMMENT (] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED (] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

(OTHER, AS SPECIFIED: Not required, pursuant to 7.4 of the Plan

. 12. SIGNATURE OF STATE AGENCY OFFICIAL:

i THLE:

15. DATE SUBMITTED: Gf OL 4

16. RETURN TO:

Valerie Harr, Director

Division of Medical Assistance and Health Services P.O. Box 712, #26

Trenton, NJ 08625-0712

FOR REGIONAL OFFICE USE ONLY

17, DATE RECEIVED;

18. DATE APEREN BD: eptember 12, 2013

PLAN APPROVED ~ ONE COPY ATTACHED Qh j

. 19. EFFECTIVE DATE OF APPROVED MATERIAL: April 01, 2013

AS [eed vas FFICT Velno 4

21. TYPED NAME: Michael Melendez

22. TITLE: Associate Regional Administrator

“33. REMARKS:

Division of Medicaid and State Operations.

**This SPA proposed to reflect that New Jersey Medicaid covers and reimburses all United Stated Preventive Services Task

Force(USPSTF) grade A and B preventative services, approved vaccines and their administration recommended by the -

Advisory Committee on Immunization Practices (ACIP) in the standard Medicaid benefit package without cost-sharing. This

amendment is in accordance with section 4106(b) of the Affordable Care Act (ACA) which establishes a one percentage

point increase in the Federal Medical Assistance Percentage (FMAP) applied to expenditures for adult vaccines and clinical __ preventive services to states that cover, without cost sharing, a full list of specified preventive services.and.adult vaccines

FORM CMS-179

Table of Contents

State/Territory Name: NEW JERSEY State Plan Amendment (SPA) #: 13-011-MM1 This file contains the following documents in the order listed:

1) Approval Letter

2) CMS 179 Form/Summary Form 3) Superseding Pages Notice

4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

New York Regional Office

26 Federal Plaza, Room 37-100

New York, NY 10278

CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID AND CHILDREN’S HEALTH OPERATIONS

February 28, 2014

Valarie Harr, Director

State of New Jersey

Department of Human Services

Division of Medical Assistance and Health Services P.O. Box 712

Trenton, New Jersey 08625-0712

Dear Ms. Harr:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number NJ-13-0011-MM1. This SPA incorporates MAGI-Based Eligibility Groups — and AFDC Income Standards into New Jersey’s state plan in accordance with the Affordable Care Act.

Please be informed that this State Plan Amendment was approved on February 28, 2014 with an effective date of January 1, 2014.

We are enclosing the summary page (formerly CMS 179) and the amended plan pages (S14, S25, $28, S30, S32, $33, $50, $51, S52 , S53, S54, S55, S57, S59).

Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Patricia Ryan at 212-616-2436 or Patricia.Ryan@cms.hhs.gov.

Sincerely, /s/

Michael Melendez

Associate Regional Administrator

Division of Medicaid and Children’s Services New York Regional Office

Enclosure

NJ.0661.R00.00 - Jan 01, 2014 Page 1 of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: New Jersey

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NJ-13-0011

Proposed Effective Date 01/01/2014 (mn/dd/yyyy)

Federal Statute/Regulation Citation _ a —_ 42 CFR 435.110; 42 CFR 435.116; 42 CFR 118; 42 CFR 435.150; 1902(a)(10)(A)(i)(1) and (III) and (VI) and (’

Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $1358612473.00 Second Year 2015 $2459401376.00

Subject of Amendment Mandatory MAGI based eligibility groups

Governor's Office Review Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal ‘® Other, as specified

Describe:

Not required pursuant to section 7.4 of the plan.

Signature of State Agency Official

Submitted By: Julie Hubbs Last Revision Date: Mar 4, 2014 Submit Date: Dec 23, 2013

http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 03/04/2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0011MM1

STATE:

New Jersey

Pages or sections of pages being superseded by $25, S28, $30, S51, S52, S53, S54, S55, S57 and S14 and related pages or sections of pages being deleted as

obsolete State Plan Section Complete Pages Removed Partial Pages Removed Page 1 Page 2, A.2.b&c Page 3 Page 2a, A.3 Page 3a Page 5, A.10 Page 4 Page 9c, B.1 remove Page 4a “Caretaker Page 12 relatives” and Page 13 “Pregnant women” Page 13a Page 17b, B.13 Attachment 2.2-A Page 14 Page 20, B.14 Page l4a Page 23c, B.20 Page l7a Page 25, C.4 Page 17b-1 Page 21 Page 23 Page 23b, B.20 Page 23d Page 23f 5 upp roment 1 to Attachment Page 1 Page 3b Page 1, A.2.a(i) and Page lla (iii) Page 19 Page 6 related to Page 19a AFDC recipients, Page 19b pregnant women, Attachment 2.6-A Page 21 infants, and children Page 7, 1l.a(1) and (2) Page 12, C.1.e(2) Page 18, C.5.e Page 25, C.11l.a(3) Supplement 1 to Attachment Pages 1, 2, 2a, 3, and 4 2.6-A Supplement 2 to Attachment

2.6-A

Pages 1, la, 2-5

Page 4 Page 2, 1%

Page 5 disregard for AFDC- Supplement 8a to Attachment related groups 2.6-A Page 3, for AFDC-

related groups

Supplement 8b to Attachment Page 2 2.6-A Supplement 12 to Attachment Page 2, 3, 3a, 3b 2.6-A Addendum Page 1 Supplement 14 to Attachment Page 1

2.6-A

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

1902(a)(10)(A)(ii)(XXT) 42 CFR 435.214

Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214.

C Yes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey S59 Page 1 of 1

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

42 CFR 435.226 1902(a)(10)(A)(Gi)(XVIT)

Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226.

@ Yes (C No The state attests that it operates this eligibility group in accordance with the following provisions: Pp Individuals qualifying under this eligibility group must meet the following criteria: q [M] Are under the following age @ Under age 21 C Under age 20 C Under age 19 [] Were in foster care under the responsibility of a state on their 18th birthday. [m] Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. [@] Have household income at or below a standard established by the state.

aw MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. @ Yes (© No

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes (CC No

The state covers children under this eligibility group, as follows (selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most

a) liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013):

@ All children under the age selected C A reasonable classification of children under the age selected: [ml] Income standard used for this eligibility group

[®] Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in $14 AFDC Income Standards.

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey S57 Page | of 2

Medicaid Eligibility

[=] Maximum income standard

No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes (C No

rl No income test was used (all income was disregarded) for this eligibility group under (check all that apply):

[IX] The Medicaid state plan as of March 23, 2010. [IX] The Medicaid state plan as of December 31, 2013. [C A Medicaid 1115 demonstration as of March 23, 2010. (1 A Medicaid 1115 demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded).

[| Income standard chosen

Individuals qualify under this eligibility group under the following income standard: This eligibility group does not use an income test (all income is disregarded).

[®] There is no resource test for this eligibility group.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey S57 Page 2 of 2

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

1902(a)(10)(A)(ii)(XID 1902(z)

Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services.

C Yes @ No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey $55 Page | of 1

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

1902(a)(10)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B)

Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229.

C Yes @ No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014

New Jersey $54 Page 1 of |

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

42 CFR 435.227 1902(a)(10)(A)(ii)(VIIT)

Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227.

@ Yes (C No The state attests that it operates this eligibility group in accordance with the following provisions:

[BM] Individuals qualifying under this eligibility group must meet the following criteria:

i The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care;

(m) Are under the following age (see the Guidance for restrictions on the selection of an age): @ Under age 21 C Under age 20 C Under age 19 C Under age 18

i MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes C No

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes C No

i Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement.

The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan

as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

C Yes @ No

[®] There is no resource test for this eligibility group.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail i StoR C4- eK Kae. Baltimore, Maryland 21244-18

Approval Date: 02/28/2014 Effective Date: 01/01/2014 Now Jersey $53

Page 1 of 1

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

42 CFR 435.222 1902(a)(10)(A)(ii)(1) 1902(a)(10)(A)(ii)(1V)

Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222.

C Yes @ No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey $52 Page | of 1

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

42 CFR 435.220 1902(a)(10)(A)(ii)(1)

Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220.

C Yes @ No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey $51 Page 1 of 1

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218

Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218.

C Yes @ No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey S50 Page | of 1

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

42 CFR 435.150 1902(a)(10)(A)(i)(LX)

iw Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care.

The state attests that it operates this eligibility group under the following provisions:

[) Individuals qualifying under this eligibility group must meet the following criteria: [M] Are under age 26. rl Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group.

Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state

[@] plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program.

The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system.

C Yes @No

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

C Yes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0011-MM1 Approval Date: 02/28/2014

Effective Date: 01/01/2014 New Jersey $33

Page 1 of 1

See

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

1902(a)(10)(A)(i)(VIIT) 42 CFR 435.119

The state covers the Adult Group as described at 42 CFR 435.119. @ Yes (CNo

[m] Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. The state attests that it operates this eligibility group in accordance with the following provisions: [@ Individuals qualifying under this eligibility group must meet the following criteria: [Ml Have attained age 19 but not age 65. [@) Are not pregnant.

[Are not entitled to or enrolled for Part A or B Medicare benefits.

aw Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B.

Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible.

[@] Have household income at or below 133% FPL.

im MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state.

[M] There is no resource test for this eligibility group.

Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is

[m] receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4.

C Under age 19, or

@ A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: C Under age 20 @ Under age 21

[| Presumptive Eligibility

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

@ Yes C No

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014

New Jersey $32 Page 1 of 3

Medicaid Eligibility

[M) The presumptive period begins on the date the determination is made.

[Mi] The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

[Ml Periods of presumptive eligibility are limited as follows: C No more than one period within a calendar year. C No more than one period within two calendar years.

~ No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

C Other reasonable limitation:

The state requires that a written application be signed by the applicant or representative. @yYes CNo @ The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included.

[m) The presumptive eligibility determination is based on the following factors: [B) The individual must meet the categorical requirements of 42 CFR 435.119. [] Household income must not exceed the applicable income standard described at 42 CFR 435.119. J] State residency.

[X] Citizenship, status as a national, or satisfactory immigration status.

m= The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group.

A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group:

4 Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan

Oo Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

TN -43-6O44-IiItt Approvat Date: 02/28/2014 Effective Date: 01/01/2014

New Jersey $32 Page 2 of 3

Medicaid Eligibility

Oo Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental (1 Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

R Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

Oo Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C: 8801)

[1 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs (1 Isa state or Tribal child support enforcement agency under title IV-D of the Act

Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

oO Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act

Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any

O other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

oO Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization

LJ Other entity the agency determines is capable of making presumptive eligibility determinations:

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey $32 Page 3 of 3

Ss Medicaid Eligibility

Creme roe were ane & we Der AD LNCS

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

42 CFR 435.118 1902(a)(10)(A)(i\(IMD), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX)

1931(b) and (d)

wl Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group.

The state attests that it operates this eligibility group in accordance with the following provisions: [) Children qualifying under this eligibility group must meet the following criteria: [mM] Are under age 19

Im] Have household income at or below the standard established by the state.

aw MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

[m] Income standard used for infants under age one

[&) Minimum income standard

The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so.

C Yes @ No

The minimum income standard for infants under age one is 133% FPL.

[®) Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one.

The state's maximum income standard for this age group is:

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(I1) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related

@ infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

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Medicaid Eligibility

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II1) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related

C infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C 185% FPL

Enter the amount of the maximum income standard: |194 % FPL

[B) Income standard chosen The state's income standard used for infants under age one is: @ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IIT) (qualified children), 1902(a)(10)

C (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IIT) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(1X) (optional poverty level-related infants) and 1902(a)( 10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31 , 2013, converted to a MAGI-equivalent percent of FPL.

Cc Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010.

[m] Income standard for children age one through age five, inclusive

{®] Minimum income standard

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Ss Medicaid Eligibility

(Cremean rom wate Ane @ asec aun RC

The minimum income standard used for this age group is 133% FPL. [=] Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for children

age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five.

The state's maximum income standard for children age one through five is:

The state's highest effective income level for coverage of children age one through five under sections 1931 (low-

@ income families), 1902(a)(10)(A)(i)CII) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's highest effective income level for coverage of children age one through five under sections 1931 (low-

Cc income families), 1902(a)(10)(A)(i)(I1) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(iiIV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGIT-equivalent percent of FPL.

Cc The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Enter the amount of the maximum income standard: |142 % FPL

[) Income standard chosen The state's income standard used for children age one through five is: @ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II) (qualified children),

C 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II]) (qualified children),

c 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

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Medicaid Eligibility

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

Cc Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. [M] Income standard for children age six through age eighteen, inclusive [) Minimum income standard The minimum income standard used for this age group is 133% FPL.

fm] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen.

The state's maximum income standard for children age six through eighteen is:

The state's highest effective income level for coverage of children age six through eighteen under sections 1931

Cc (low-income families), 1902(a)(10)(A)(i)(IIT) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 e (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty

level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect

under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C 133% FPL

Enter the amount of the maximum income standard: |142 % FPL

[) Income standard chosen

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CMS Medicaid Eligibility

(Cone poe water ane @ operas EVE

The state's income standard used for children age six through eighteen is:

@ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children),

C 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(TV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(I1) (qualified children), 1902(a)(10)(A)(i)(VIT) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 201 3, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010.

[] There is no resource test for this eligibility group. [m] Presumptive Eligibility The state covers children when determined presumptively eligible by a qualified entity.

@ Yes C No

1902(a)(47) 1920A

42 CFR 435.1101 42 CFR 435.1102

im The state provides Medicaid coverage to children when determined presumptively eligible by a qualified entity under the following provisions:

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Ss Medicaid Eligibility

(CENTOI PON META ARS 4 seer AUD RRVICR

If the state has elected to cover Optional Targeted Low-Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the higher of the standard used for Optional Targeted Low-Income Children or the standard used for Infants and Children under 19 (42 CFR 435.118), for that child’s age.

If the state has not elected to cover Optional Targeted Low Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the standard used under the Infants and Children under Age 19 eligibility group (42 CFR 435.118), for that child’s age.

[m] Children under the following age may be determined presumptively eligible:

Under age |19

[M] The presumptive period begins on the date the determination is made.

[lM] The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made. if no application for Medicaid is filed by that date.

[m] Periods of presumptive eligibility are limited as follows: C No more than one period within a calendar year.

C No more than one period within two calendar years.

@ No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

C Other reasonable limitation:

The state requires that a written application be signed by the applicant, parent or representative, as appropriate. @ Yes CNo @ The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

The state uses a separate application form for Presumptive eligibility, approved by CMS. A copy of the application form is included.

[M] The presumptive eligibility determination is based on the following factors:

Im] Household income must not exceed the applicable income standard described above, for the child's age.

[X] State residency

EX] Citizenship, status as a national, or satisfactory immigration status

iw The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group.

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Cnr rhe Mert Ane 4 ue ORCAI EVE

A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group:

® Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan

oO Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

oO Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental CD Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

id Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

oO Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

(7 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs (7 Isa state or Tribal child support enforcement agency under title IV-D of the Act

oO Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

oO Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act

Is an organization that determines eligibility for any assistance or benefits provided under any program

oO of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

oO Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization

(Other entity the agency determines is capable of making presumptive eligibility determinations:

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

PRA Disclosure Statement

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NNN ne

cms Medicaid Eligibility

According to the Paperwork Reduction Act of 1995, no persons are re

valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data

resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

quired to respond to a collection of information unless it displays a

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OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

1 tote 9 sm cs ahh cb BS

42 CFR 435.116

1902(a)(10)(A)(i)(HII) and (IV) 1902(a)(10)(A)(ii)(1), (IV) and (IX) 1931(b) and (d)

“ 1920

[m] Pregnant Women - Women who are Pregnant or post-partum, with household income at or below a standard established by the state. The state attests that it operates this eligibility group in accordance with the following provisions: [Ml Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other

Caretaker Relatives at 42 CFR 435.110.

@ Yes C No

wl MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state.

[@] Income standard used for this group

[®) Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.)

The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as. of July 1, 1989, had authorizing legislation to do so.

C Yes @No The minimum income standard for this eligibility group is 133% FPL.

[B] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group.

The state's maximum income standard for this eligibility group is:

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income

families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-

related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) ° (A)(ii)() (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(TV)

(institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

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Ceremran erie aaroer ans 4 ener AUD REECE

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IIT) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)( 10)(A)(ii)(TX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(D) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for any population of pregnant women under a Medicaid 11 15 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for any population of pregnant women under a Medicaid 11 15 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C 185% FPL

The amount of the maximum income standard is:]194 % FPL

[mg] Income standard chosen Indicate the state's income standard used for this eligibility group: C The minimum income standard @ The maximum income standard C Another income standard in-between the minimum and maximum standards allowed. [lM] There is no resource test for this eligibility group. [i] Benefits for individuals in this eligibility group consist of the following: @ All pregnant women eligible under this group receive full Medicaid Coverage under this state plan.

Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services.

[ml] Presumptive Eligibility

The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity.

@ Yes CNo [@] The presumptive period begins on the date the determination is made.

[lM] The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

[m] There may be no more than one period of presumptive eligibility per pregnancy.

A written application must be signed by the applicant or representative.

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(AE pre MeeDAC ARE A aes DerAIG SEENON

@ Yes C No

@ The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included.

peta eabmte:

[M) The presumptive eligibility determination is based on the following factors:

{m] The woman must be pregnant [m] Household income must not exceed the applicable income standard at 42 CFR 435.116. EX] State residency

EX] Citizenship, status as a national, or satisfactory immigration status

ry The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group.

A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group:

® Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan

oO Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

oO Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental CD Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

= Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

oO Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

(7 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs C1 Isa state or Tribal child support enforcement agency under title IV-D of the Act

Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

Oo Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act

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s Medicaid Eligibility

Cea re mere ane 6 EDEL LMC

Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any

0 other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization

O

L) Other entity the agency determines is capable of making presumptive eligibility determinations:

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no Persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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CC __E_—_—_ ee

ROM fe mene ass & wscerD MCT

42 CFR 435.110

1902(a)(10)(A)(i)(1) 1931(b) and (d)

wl Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state.

The state attests that it operates this eligibility group in accordance with the following provisions: [™] Individuals qualifying under this eligibility group must meet the following criteria:

aw Are parents or other caretaker relatives (defi

ined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Sp

ouses of parents and other caretaker relatives are also included. The state elects the following options:

This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old,

IX] provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training.

EX] Options relating to the definition of caretaker relative (select any that apply):

oO The definition of caretaker relative includes the domesti

ic partner of the parent or other caretaker relative, even after the partnership is terminated.

Definition of domestic partner:

oO The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage.

Description of other relatives:

® The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care.

] Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that

@ care by reason of the death, physical or mental in least one parent.

a dependent child must be deprived of parental support or capacity, or absence from the home or unemployment of at

The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies):

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[mM] Have household income at or below the standard established by the state.

= MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

[m) Income standard used for this group

[®) Minimum income standard

The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in $14 AFDC Income Standards.

The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard.

I] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group.

The state's maximum income standard for this eligibility group is:

@ The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Cc The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 C demonstration as of March 23, 2010, converted to a MAGIT-equivalent percent of FPL or amounts by household size.

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 C demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

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CO ee

Ss Medicaid Eligibility

Crom roe weecans 4 ener ECE

CA percentage of the federal poverty level: %

@ The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in $14 AFDC Income Standards.

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage C increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in $14 AFDC Income Standards.

The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in $14 Cc AFDC Income Standards.

C Other dollar amount

[M] Income standard chosen: Indicate the state's income standard used for this eligibility group: C The minimum income standard @ The maximum income standard

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage C increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards.

C Another income standard in-between the minimum and maximum standards allowed [) There is no resource test for this eligibility group. [m] Presumptive Eligibility

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

@ Yes CNo

[m] The presumptive period begins on the date the determination is made.

[| The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

[M] Periods of presumptive eligibility are limited as follows: C No more than one period within a calendar year.

C No more than one period within two calendar years.

> No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey $25 Page 3 of 5

rts

Ss Medicaid Eligibility

EAE Foe Mec AR & operas NRVC

C Other reasonable limitation:

The state requires that a written application be signed by the applicant or representative.

@ Yes CNo

@ The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

application form is included.

[m) The presumptive eligibility determination is based on the following factors: [lM] The individual must be a caretaker relative, as described at 42 CFR 435.110. [®] Household income must not exceed the applicable income standard described at 42 CFR 435.1 10.

IX] State residency

KX] Citizenship, status as a national, or satisfactory immigration status

The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the

The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group.

A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group:

m= Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan

oO Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

oO Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental

CD Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

® Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

oO Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

(7 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs

[7 Isa state or Tribal child support enforcement agency under title IV-D of the Act

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey S25

EES $5 hl ee

Page 4 of 5

Ss

ROTM Fe mee ARS 4 ODEO EEVICRE

Medicaid Eligibility

Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

oO Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title TV-A of the Act

Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any

O other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

oO Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization

( Other entity the agency determines is capable of making presumptive eligibility determinations:

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and

has provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 N-w Jersey $25

ris

~ge 5 of $

Medicaid Eligibility

(Cmem FOe eoac Ase @ ao 0er AND RrRVCH

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

Enter the AFDC Standards below. All states must enter:

MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996

Entry of other standards is optional.

The standard is as follows: @ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

Additional incremental amount Household size | Standard ($) @ Yes CNo +1 223 > 4 Increment amount $ 163 +2 421 x 3 508 xX +4 585 x +]5 658 x #16 729 xX +7 795 xX ae] 5 859 Bd

The dollar amounts increase automatically each year C Yes @No

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey $14 Page 1 of 6

ee

(Ror roe mene an 6 ueDer AUD LMNCTY

The standard is as follows: @ Statewide standard C Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

Household size | Standard ($) */1 185 x *)2 369 X +/3 443 xX #4 507 xX #5 567 x +] 6 624 x +7 677 x + 8 728 x

s Medicaid Eligibility

Additional incremental amount @ Yes (CC No

Increment amount $ |50

C Yes @No

The dollar amounts increase automatically each year

The standard is as follows: @ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014

New Jersey

$14

Page 2 of 6

Medicaid Eligibility

Cree Foe Mera ARE & ME DECAUD EVIE

Additional incremental amount Household size | Standard ($) @ Yes CNo

ey 223 x Increment amount $ |63 +)2 421 xX

+3 508 x

+4 585 xX

#5 658 x

#]6 729 xX

+7 795 X

+] 859 xX The dollar amounts increase automatically each year

C Yes @ No

The standard is as follows: @ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey $14

ee

Page 3 of 6

Ss Medicaid Eligibility

Creme roe ener ans 4 ueosrau ACTS

Additional incremental amount Household size | Standard ($) @ Yes CNo +1 185 x Increment amount $ |50 +2 369 X +)3 443 x +4 507 x +]5 567 x +6 624 xX +7 677 x +s 728 x

The dollar amounts increase automatically each year C Yes @No

The standard is as follows: C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year C Yes @No

TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey $14

Page 4 of 6

ee

Medicaid Eligibility

The standard is as follows: C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year C Yes @No

The standard is as follows: C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year C Yes @No

The standard is as follows: C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year C Yes @No

PRA Disclosure Statement

TN: 13-0011-MM1 New Jersey $14

ee

Approval Date: 02/28/2014 Effective Date: 01/01/2014

Page § of 6

Medicaid Eligibility

~ TN: 13-0011-MM1 Approval Date: 02/28/2014 Effective Date: 01/01/2014 New Jersey $14 Page 6 of 6

EE

Table of Contents

State/Territory Name: New Jersey

State Plan Amendment (SPA) #: 13-0016-MM3

This file contains the following documents in the order listed:

1) Approval Letter

2) Summary Forn, | a: 3) Superseding Pages Notice “~~

4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services mn“

New York Regional Office :

26 Federal Plaza, Room 37-100 ‘

New York, NY 10278 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID AND CHILDREN’S HEALTH OPERATIONS

December 3, 2013

Valerie Harr, Director

State of New Jersey

Department of Human Services

Division of Medical Assistance and Health Services P.O. Box 712

Trenton, New Jersey 08625

Dear Ms. Harr:

Enclosed is an approved copy of New Jersey’s state plan amendment (SPA) 13-0016-MM3, which was submitted to CMS on November 6, 2013. SPA 13-0016-MM3 incorporates the MAGI-Based Income Methodologies into New Jersey’s state plan in accordance with the Affordable Care Act. This SPA was approved on December 3, 2013. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages to be incorporated within a separate section at the back of New Jersey’s approved state plan:

e $10, Pages $10-1 and S10-2

In addition, enclosed is a summary of state plan pages which are superseded by SPA 13-0016-MM3, which should also be incorporated into a separate section in the front of the state plan:

e Superseding Pages of State Plan Material, 13-0016-MM3

Notwithstanding any other provisions of the New Jersey Medicaid state plan, the financial eligibility methodologies described in SPA 13-0016-MM3 will apply to all MAGI-based eligibility groups covered under New Jersey’s Medicaid state plan. The MAGI financial methodologies set forth in 422 CFR §435.603 apply to everyone except those individuals described at 42 CFR §435.603(j) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid state plan only with respect to the MAGI-based eligibility groups.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Patricia Ryan at 212-616-2436 or Patricia.Ryan@cms.hhs.gov.

Sincerely, /s/

Michael Melendez

Associate Regional Administrator

Division of Medicaid and Children’s Services New York Regional Office

Enclosure

NJ.0475.R00.00 - Jan 01, 2014 Page 1 of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: New Jersey Transmittal Number:

Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NJ-13-0016

Proposed Effective Date 01/01/2014 (mn/dd/yyyy)

Federal Statute/Regulation Citation 1902(e)(14) and 42 CFR 435.603

Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00

Subject of Amendment MAGI-Based Income Methodology

Governor's Office Review Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

‘®: Other, as specified Describe: Not required pursuant to section 7.4 of the State plan.

Signature of State Agency Official

Submitted By: Julie Hubbs Last Revision Date: Nov 14, 2013 Submit Date: Nov 6, 2013

http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.... 12/03/2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: NJ 13-0016 New Jersey

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S10 - MAGI Income Methodology

PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Notwithstanding any other provisions of the New Jersey Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment NJ 13-0016 will apply to all MAGI-based eligibility groups covered under New Jersey’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Medicaid Eligibility

OMB Control Number 0938-1148

2014

OMB Expiration date: 10/3

1902(e)(14) 42 CFR 435.603

42 CFR 435.603.

In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date.

In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman:

C The pregnant woman is counted just as herself. C The pregnant woman is counted as herself, plus one.

@ The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions:

When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size.

When determining eligibility for current beneficiaries, financial eligibility is based on:

@ Current monthly household income and family size

C Projected annual household income and family size for the remaining months of the current calendar year

In determining current monthly or projected annual household income, the state will use reasonable methods to:

[X] Include a prorated portion of a reasonably predictable increase in future income and/or family size.

{] Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d).

Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent.

ia The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with

@ Yes (No TN: 13-0016 MM APPROVAL DATE: 12/03/2013 EFFECTIVE DATE: 01/01/2014 NEW JERSEY $10

Paae 1 nf?

Medicaid Eligibility

[iM] The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is:

C Age 19

@ Age 19. or in the case of full-time students, age 21

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments conceming the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0016 MM APPROVAL DATE: 12/03/2014 EFFECTIVE DATE: 01/01/2014 NEW JERSEY S10 tr

TABLE OF CONTENTS

STATE/TERRITORY: NEW JERSEY

STATE PLAN AMENDMENT (SPA)#: NJ--13-0017-MM6

This file contains the following documents in the order listed:

1) Approval Letter 2) Summary Form 3) Approved SPA pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

New York Regional Office 26 Federal Plaza, Room 37-100 New York, NY 10278 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID AND CHILDREN’S HEALTH OPERATIONS

February 5, 2014

Valarie Harr, Director

State of New Jersey

Department of Human Services

Division of Medical Assistance and Health Services P.O. Box 712

Trenton, New Jersey 08625-0712

Dear Ms. Harr:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number NJ-13-0017-MM6. With this SPA, the State affirms citizenship regulations, specifies reasonable opportunities options, and specifies policy options related to immigrant eligibility in

accordance to the Affordable Care Act.

Please be informed that this State Plan Amendment was approved on February 5, 2014 with an effective date of January 1, 2014.

We are enclosing the summary page (formerly CMS 179) and the amended plan pages.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Patricia Ryan at 212-616-2436 or Patricia.Ryan@cms.hhs.gov.

Sincerely, /s/

Michael Melendez

Associate Regional Administrator

Division of Medicaid and Children’s Services New York Regional Office

Enclosure

NJ.0513.R00.00 - Jan 01, 2014 Page 1 of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: New Jersey

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NJ-13-0017

Proposed Effective Date 01/01/2014 (mm/dd/yyyy)

Federal Statute/Regulation Citation . oe 1902(a)(46)(B); 8 USC 1611, 1612, 1613, and 1641; 1903(v)(2),(3) and (4); 42 CFR 435.4, 435.406, and 435.95

Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00

Subject of Amendment Non-financial elgibility-Citizenship and Non-Citizen Eligibility (S89)

Governor's Office Review Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal ‘O: Other, as specified Describe: Not required pursuant to section 7.4 of the State Plan.

Signature of State Agency Official

Submitted By: Julie Hubbs Last Revision Date: Dec 18, 2013 Submit Date: Nov 15, 2013

http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 02/10/2014

(CMS Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 3 sp

1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4)

42 CFR 435.4

42 CFR 435.406

42 CFR 435.956

Citizenship and Non-Citizen Eligibility

The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status.

The state provides Medicaid eligibility to otherwise eligible individuals: 8) [HM] Who are citizens or nationals of the United States; and

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity [Reconciliation Act (PRWORA) (8 U.S.C. $1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or C satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406,

and 956.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process.

@ Yes CNo

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual.

@ Yes (No The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

C Other date, as described:

TN: 13-0017-MM6 Approval Date: 02/05/2014 Effective Date: 01/01/2014 New Jersey $89 Page | of 3

Medicaid Eligibility

The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613).

@ Yes CNo

The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act.

@ Yes (No [) Pregnant women ] Individuals under age 21: @ Individuals under age 21 C Individuals under age 20 C Individuals under age 19

a An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan.

[Ml] An individual is considered to be lawfully present in the United States if he or she: 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1 182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. Is a non-citizen who belongs to one of the following classes: [] Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively;

Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

Granted employment authorization under 8 CFR 274a.12(c);

Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

aon

Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; [| Granted Deferred Action status;

[@] Granted an administrative stay of removal under 8 CFR 241;

[lM] Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who -

[M] Has been granted employment authorization; or

[Ml] Is under the age of 14 and has had an application pending for at least 180 days; TN: 13-0017-MIvi6 Approvat Date> 62/65/2644 New Jersey S89 Page 2 of 3

te: 91/01/2014

Medicaid Eligibility

6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b));

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

( Other

The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following

individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN:

[@) Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613;

iw Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:.PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0017-MM6 Approval Date: 02/05/2014 Effective Date: 01/01/2014 New Jersey $89 Page 3 of 3

EES ro rr

ATTACHMENT 2.6-A

OFFICIAL sun

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of New Jersey

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

This page intentionally left blank. See template S89.

13-0017-MA (NJ)

TN No: __ 13-0017 Effective Date JAN 0 1 2014

Supersedes TN No. 09-04 Approval Date FEB 0 5 2014

$$ Y|' ee OO ae

OFFICIAL ATTACHMENT 2.6-A

Page 2b

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of New J ersey

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

This page intentionally left blank. See template S89.

13-0017-MA (NJ)

TN No: _13-0017 Effective Date SAN O 1 2014

Supersedes TN No. _09-04 Approval Date FEB 0 5 2014

EE: ~—e

ATTACHMENT 2.6-A Page 2c

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of New Jersey

oo

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

This page intentionally left blank. See template S89.

13-0017-MA (NJ)

TN No: __ 13-0017 Effective Date JAN O 1 2014

_____________________________________________________________________________

Table of Contents

State/Territory Name: New Jersey

State Plan Amendment (SPA) #: NJ-13-0018

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for New Jersey consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services Cc RA &&

7500 Security Boulevard, Mail Stop: S2-26-12 sae” Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 19 2014

Ms. Valerie Harr, Director

Division of Medical Assistance and Health Services New Jersey Department of Human Services

7 Quakerbridge Plaza

P.O. Box 712

Trenton, NJ 08625-0712

Dear Ms. Harr:

Iam pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers NJ-13-0018 and NJ-13-0020, submitted on November 21, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility, have been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number NJ-13-0018 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups, using the approved MAGI conversion plan income thresholds. The state indicates on page CS7 that it will cover targeted low-income children, and indicates on page CS8 that it will cover targeted low-income pregnant women. On page CS13 the state elects to cover as deemed newborns children born to mothers enrolled as targeted low-income children in CHIP. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan. A copy of the approved CS8 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1-P, 4.1.2- P and 4.1.3-P of the current CHIP state plan. A copy of the approved CS13 is attached and should be incorporated under Section 4.3 of the state’s approved CHIP state plan.

Establish 2101(f) Group:

SPA number NJ-13-0020 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page CS14 is attached, and should be incorporated within a separate subsection under Section 4.1 of New Jersey’s approved CHIP state plan.

Page 2 — Ms. Valerie Harr

Your title XXI project officer is Ms. Stacey Green. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Green’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Division of State Coverage Programs

Mail Stop S2-07-08

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-6102

Facsimile: (410) 786-5882

E-mail: Stacey.green(@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Green and to Mr. Michael Melendez, Associate Regional Administrator (ARA) in our New York Regional Office. Ms. Melendez’s address is:

Centers for Medicare & Medicaid Services 26 Federal Plaza, Room 3811 New York, NY 10278-0063

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely,

Eliot Fishman Director

Enclosures cc: Mr. Melendez, CMS Region II, New York

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NJ.0530.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: New Jersey State Funds: $ Federal Funds: $ Submitted By: Julie Hubbs Last Revision Date: Nov 21, 2013 Submit Date: Nov 21, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NJ-13-0018 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2112, 2112(e), and 2102(b)(1)(B)(v) of the SSA; 42 CFR 457.310, 315, 320, and 360 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:53 out of 2000 CHIP MAGI Eligibility and Methods (CS7,CS8,CS13,CS15) Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 09/11/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 09/11/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

ccms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/3 1/2014

CS7

Separate Child Health Insurance Program Eligibility - Targeted Low-Income Children

2102(b)(1(B xv) of the SSA and 42 CFR 457.310, 315 and 320

(a Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the state.

[7] The CHIP Agency operates this covered group in accordance with the following provisions: Age ,

Must be under age 19. Income Standards

Income standards are applied statewide. | Y

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard? Statewide Income Standards Begin with lowest age range first. Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here. From Age To Age Above (% FPL) Up to & including (% FPL) + flo I 194 350 x * ly 19 142 350 x Age ranges may overlap. If there is an overlap. provide an explanation. Include the age ranges lor each income standard that has overlapping ages and the reason for having different income standards. Special Program for Children with Disabilities Does the state have a special program for children with disabilitics? [3 PRA Disclosure Statement SPA# NJ-13-0018 Approval Date: Effective Date: January 1, 2014

Page | of 2

According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed. and complete and review the information collection, Ifyou have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form. please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05. Baltimore. Maryland 21244-1850.

CHIP Eligibility

V 201307090

FEB 19 2014

SPA# NJ-13-0018 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

ccms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Separate Child Health Insurance Program C88 Eligibility - Targeted Low-Income Pregnant Women .

Section 2112 of the SSA

rl Targeted Low-Income Pregnant Women - Uninsured pregnant women who do not have access to public employee coverage and whose household income is within standards established by the state.

[v] The CHIP Agency operates this covered group in accordance with the following provisions: Age Standards for Pregnant Women The state provides coverage to pregnant women:

Select an age range:

C From age 19. up to the following age:

(@ With no age restriction. © Another age range:

If there is no age restriction or if the age range overlaps with the qualifying ages for children. describe how the determination is made as to whether the applicant will be provided coverage as a child or as a pregnant woman,

The determination is made based on the pregnancy status.

J enrolls a pregnant child into our pregnant woman program.

[@) Must be pregnant or post-partum

Income Standards

Pregnant women coverage may only be provided if children's qualifying income standard under the plan is at least up to 200% of FPL. tor all age ranges.

Income standard is applied statewide

Are there any exceptions. ¢.g. populations in a county which may qualify under either a statewide income standard or a Ni . . tt) county income standard?

Statewide Income Standard

CHIP coverage for pregnant women may only be provided if the qualifying income standard under Medicaid for pregnant women is at least up to 185%.

The highest income level for pregnant women cannot be higher than the highest income level for children.

Above 194) % FPL up to and including | 200] % FPL

FEB 19 2014

SPA# NJ-13-0018 Approval Date:

Effective Date: January 1, 2014

Page | of 2

CCmMS CHIP Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number, The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. [f you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form. please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V 20130709

SPA# NJ-13-0018

Approval Date: FEB { 9 2014

Effective Date: January 1, 2014

Page 2 of 2

ccmMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

2813

Separate Child Health Insurance Program Eligibility - Deemed Newborns

Section 2112(e) of the SSA and 42 CFR 457.360

Deemed Newborns - Children born to targeted low-income pregnant women are deemed to have applied for and be eligible for CIHP or Medicaid until the child turns one.

[ig] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

aw The child is deemed to have applied for and been found eligible for CHIP or Medicaid. as appropriate, as of the date of the child's birth, and remains eligible without regard to changes in circumstances until the child's first birthday.

The state elects the following option(s):

x The state elects to cover as a deemed newborn a child born to a mother who is covered as a targeted low-income child under the state's separate CHIP on the date of the newborn's birth.

oO The state elects to recognize a child's deemed newborn status from another state and provides benefits in accordance with the —~ requirements of section 2112(e) of the SSA.

Oo The state elects to cover as a deemed newborn a child born to a mother who is covered under Medicaid or CHIP through the ~~ authority of the state’s section 1115 demonstration on the date of the newborn's birth.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response. including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form. please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,. Baltimore, Maryland 21244-1850.

SPA# NJ-13-0018 Approval Date: FEB { 9 2014

Effective Date: January 1, 2014

Page | of I

em

ccms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Child Health Insurance Program

Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards csi4

Section 2101(f) of the ACA and 42 CFR 457.3 10(d)

[i] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

co The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(/) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of .. income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected ** from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1. 2016 ).

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101() of the Affordable Care Act:

The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

@

‘a The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therelore covered in the separate CHIP.

% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family ‘income has not increased since the child's last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

Other.

Describe the benefits provided to this population:

© This population will be provided the same benefits as are provided to children in the state’s Medicaid program. é@ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

© Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

© Cost sharing is the same as lor children in the Medicaid program.

FEB TS 2014

SPA# NJ-13-0020 Approval Date: Effective Date: January 1, 2014

Page I of 2

cCMS. CHIP Eligibility

© Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

@ No premiums, copayments, deductibles. coinsurance or other cost sharing is required.

© Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. Ifyou have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form. please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

FEB 19 2014

SPA# NJ-13-0020 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

ccCmMsS CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Separate Child Health Insurance Program

MAGI-Based Income Methodologies SIS

2102( by 1)(B)(v) of the SSA and 42 CFR 457.315

The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups. as described below, and consistent with 42 CER 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013. MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility. whichever is later.

If the state covers pregnant women. in determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus cach of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: © The pregnant woman is counted just as herself. © The pregnant woman is counted just as herself. plus one. fe ‘The pregnant woman is counted as herself. plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries. financial eligibility is based on: @ Current monthly household income and family size. © Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income. the state will use reasonable methods to: XJ Include a prorated portion of the reasonably predictable increase in future income and/or family size. X] Account fora reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Houschold income includes actually available cash support. exceeding nominal amounts. provided

by the person claiming an individual described at §435.603(1)(2)(i) as a tax dependent. “s

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group ~ income standards to MAGI-equivalent standards.

An attachment is submitted.

PRA Disclosure Statement

FEB 19 2014

SPA# NJ-13-0018 Approval Date: Effective Date: January 1, 2014

Page | of 2

coms CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources. gather the data needed. and complete and review the information collection. Ifyou have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05. Baltimore. Maryland 21244-1850.

SPA# Nu-13-0018 Approval Date: FEB 19 204

Effective Date: January 1, 2014

Page 2 of 2

Table of Contents State/Territory Name: State Plan Amendment (SPA) #: NEW JERSEY NJ-13-0023-MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) CMS 179 Form/Summary Form 4) Superseding Pages Notice Approved SPA Pages 5) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services New York Regional Office 26 Federal Plaza, Room 37-100 New York, NY 10278 DIVISION OF MEDICAID AND CmLDREN'S HEAL1H OPERATIONS March 18, 2014 Valarie Harr, Director State ofNew Jersey Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712 Trenton, New Jersey 08625-0712 Dear Ms. Harr: CENTERS FOR MEDICARE & MEDICAID SERVICES Enclosed is an approved copy ofNew Jersey's state plan amendment (SPA) 13-0023-MM2, which was submitted to CMS on December 18,2013. SPA 13-0023-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into New Jersey's Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013. The approval of SPA NJ-13-0023-MM2 includes full approval of your state's alternative single streamlined paper application. The state is using an interim online alternative single streamlined application and by October 31, 2014 but no later than December 31, 2014 will implement a revised online alternative single streamlined application that addresses CMS concerns outlined in the companion letter issued with this SPA approval. Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the end of New Jersey's approved state plan: • S94, pages S94-1 and S94-2 • Attachment 1- NJ FamilyCare paper application • Attachment 2 - Statement of use with respect to the alternative single streamlined online application CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions about your application, please contact Dena Greenblum

Valarie Harr, Director Page2 at (410) 786-8684, or by email at Dena.Greenblum@cms.hhs.gov. If you have any questions concerning this SPA, please contact Patricia Ryan at (212) 616-2436 or at Patricia.Ryan@cms.hhs.gov. Sincerely, /s/ Michael Melendez Associate Regional Administrator Division of Medicaid and Children Health Enclosure

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services New York Regional Office 26 Federal Plaza, Room 37-100 New York, NY 10278 CENTERS FOR MEDICARE & MEDICAID SERVICES IJMSION OF MEDICAID AND CHILDREN'S HEALTH OPERATIONS March 18, 2014 Valarie Harr, Director State of New Jersey Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712 Trenton, New Jersey 08625-0712 Dear Ms. Harr: This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) NJ-13-0023-MM2, which was submitted to CMS on December 18, 2013. Our review of this submission included a review of the paper and online alternative single streamlined applications developed by the state. The state is currently using an interim online alternative single streamlined application. On or before December 31, 2014, this interim application needs to be revised to reflect the following change. The estimated completion date for this change is October 31, 2014. Necessary Change: Completion Date: Information about immigration status, which is needed to perform an October 31,2014 electronic data match, will be requested from non-citizen applicants. Please submit the revised alternative online application to CMS for review no later than October 1, 2014 to allow for approval by October 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Greenblum at (410) 786-8684 or Dena.Greenblum@cms.hhs.gov. If you have any other questions, please contact Patricia Ryan at (212) 616-2436 or at Patricia.ryan@cms.hhs.gov. Sincerely, Is/ Michael Melendez Associate Regional Administrator Division of Medicaid and Children Health . :

NJ.0620.ROO.OO- Oct 01, 2013 Page 1 of2 Medicaid State Plan Eligibility: Summary Page (CMS 179) Statefferritory name: New Jersey Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered NJ-13-0023 Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435, Subpart J and Subpart M Federal Budget Impact Federal Fiscal Year First Year 20 14 Second Year 2015 Subject of Amendment Amount $0.00 $0.00 Medicaid Eligibility -general eligibility requirements and eligibility process.(S94) Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal @> Other, as specified Describe: Not required pursuant to section 7.4 of the State Plan. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Julie Hubbs Mar 18,2014 Dec 18,2013 http:/1157.199.113.99/MMDL/faces/protected/mac/cOl/print/PrintSelector.jsp 03/27/2014

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION 0 Paper Application 1:&1 Online Application TRANSMITTAL NUMBER: STATE: 13-0023-MM2 New Jersey Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state's application. The revised application will be incorporated by reference into the state plan.

~·~ (( .!:;.!!f.ll_fi. Medicaid Eligibility OMB Control Number 0938-1148 OMB Ext>iraltion CFR 435, Subpart J and Subpart M Eligibility Process IZJ The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. O The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) ofthe 181 Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the 0 agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and 0 approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. l8l An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: (' Yes (i No TN: 13-0023-MM2 New Jersey 594 Approval Date: 03/18/2014 Effective Date: 10/1 /2013 Page 1 of2

~­ (( ~.!!f.ll_!i" Medicaid Eligibility The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility 1ZJ groups listed below at locations other than those used for the receipt and processing of applications for the title IV -A program, including Federally-qualified health centers and disproportionate share hospitals. Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing IZJ Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ~ Once every 12 months ~ Without requiring information from the individual if able to do so based on reliable information contained in the individual's • account or other more current information available to the agency If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional ~ information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ~ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross • income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ~ Once every 12 months D Once every 6 months D Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between IZJ Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: 13-0023-MM2 New Jersey 594 Approval Date: 03/18/2014 Effective Date: 10/1 /2013 Pa11;e 2 of2

Application for Health Coverage & Help Paying Costs J FAMCLYCl'lRE Affordable health coverage. Quality care. s 0 z ~ 0 1- l/) I..!J z I 1- • • • 0 Use this application to see what coverage choices you qualify for Who can use this application? Apply faster online What you may need to apply Why do we ask for this information? c What happens next? Get help with this application • Free or low-cost insurance from Medicaid or the Children's Health Insurance Program (CHIP), known as NJ FamilyCare • Private health insurance plans that offer comprehensive coverage to help you stay well • A new tax credit that can help pay your premiums for health coverage • Use this application to apply for anyone in your family. • Apply even if you or your child already has health coverage. You could be eligible for lower-cost or free coverage. • If you're single, you may be able to use a short form. Visit njfamllycare.or:a. • Families that include immigrants can apply. You can apply for your child even if you aren't eligible for coverage. Applying won't affect your immigration status or chances of becoming a permanent resident or citizen. • If someone is helping you fill out this application, you may need to complete Appendix C. Apply faster online at njfamilycare.or& . • Social Security Numbers (or document numbers for any legal immigrants who need insurance) • Employer and income information for everyone in your family (for example, from paystubs, W-2 forms, or wage and tax statements) • Policy numbers for any current health insurance • Information about any job-related health insurance available to your family We ask about income and other information to let you know what coverage you qualify for and if you can get any help paying for it. We'll keep all the information you provide private and secure, as required by law. To view the Privacy Act Statement, go to njfamilycare.or:a. Send your complete, signed application to the address on page 7. If you don't have all the information we ask for, sign and submit your application anyway. We'll follow-up with you within 1-2 weeks. You'll get instructions on the next steps to complete your health coverage. If you don't hear from us, visit njfamllycare.or& or caii1-80G-701.0710. Filling out this application doesn't mean you have to buy health coverage. • Online: njfamilycare.or& • Phone: Call our Help Center at 1-800-701.0710. • In person: There may be counselors in your area who can help. Visit our website or call1-800-701.0710 for more information. • En Espaf'iol: llame a nuestro centro de ayuda gratis al 1-800-701.0710. NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.or& or call us at 1-80G-701..()710. Para obtener una copia de este formulario en Espai'iol, llame 1-80G-701..()710. If you need help in a language other than English, caii1-80G-701..()710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TIY users should call1-800-701..()720. .. I

FAM~LYcrutE Affordable health coverage. Quality care. Tell us about yourself. (We need one adult in the family to be the contact person for your application.) 1. First name, Middle name, Last name, & Suffix 2. Home address (Leave blank if you don't have one.) 3. Apartment or suite number 4. City 5. State 6. ZIP code 8. Mailing address (if different from home address) 9. Apartment or suite number 10. City 12. ZIP code 14. Phone number 1 5. Other phone number ( ) ( ) 16. Do you want to get information about this application by email? 0 Yes 0 No Email address: ____________________________ _ 17. What is your preferred spoken or written language (if not English)? Tell us about your family. Who do you need to include on this application? Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax return. (You don't need to file taxes to get health coverage). DO Include: • Yourself • Your spouse • Your children under 21 who live with you • Your unmarried partner who needs health coverage • Anyone you include on your tax return, even if they don't live with you • Anyone else under 21 who you take care of and lives with you You DON'T have to include: • Your unmarried partner who doesn't need health coverage • Your unmarried partner's children • Your parents who live with you, but file their own tax return (if you're over 21 ) • Other adult relatives who file their own tax return The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can. Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than 2 people in your family you'll need to make a copy of the paps and attach them. You don't need to provide immigration status or a Social Security Number (SSN) for family members who don't need health coverage. We'll keep all the information you provide private and secure as required by law. We'll use personal information only to check if you're eligible for health coverage. NEED HELP WITH YOUR APPLICATION? Visit n.jfamilycare.or& or call us at 1-800.701..0710. Para obtener una copia de este formula rio en Espaflol, llame 1-800.701..0710. If you need help in a language other than English, caii1-80G-701-G710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should caii1-80G-701-G720. Page 1 of7

FAM~LY~ STEP 2: PERSON 1 (Start with yourself) Affordable health cowrage. Quality care. Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you don't file a tax return, remember to still add family members who live with you. 1. First name, Middle name, Last name, & Suffix 2. Relationship to you? SELF 3. Date of birth (mm/dd/yyyy) 4. Sex D Male D Female 5. Social Security number (SSN) ___ - __ - ___ _ We need this If you want health coverage and have an SSN. Providing your SSN can be helpful if you don't want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who's eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.&ov. TTY users should call1-800-325-0778. 6. Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return.) D YES. If yes, please answer questions a-c. D NO. If no, skip to question c. a. Will you file jointly with a spouse? DYes D No lfyes,nameofspouse: __________________________________________________________________________ __ b. Will you claim any dependents on your tax return? DYes D No If yes, list name(s) of dependents:--------------------------------------------------------------- c. Will you be claimed as a dependent on someone's tax return? DYes D No If yes, please list the name of the tax filer:-------------------------------------------------------------- How are you related to the tax.filer? --------------------------------~------------------------------- 7. Are you pregnant? DYes D No a. If yes, how many babies are expected during this pregnancy? Due Date 8. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.) D YES. If yes, answer all the questions below. 0 D NO. If no, SKIP to the income questions on page 3. C) Leave the rest of this page blank. 9. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing. dressing, daily chores, etc) or live in a medical facility or nursing home? DYes D No 10. Are you a U.S. citizen or U.S. national? DYes D No 11. If you aren't a U.S. citizen or U.S. national, do you have eligible immigration status? DYes. Fill in your document type and ID number below. b. Document ID number--------------------- a. Immigration document type--------------------- c. Have you lived in the U.S. since 1996? DYes D No d. Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military? DYes D No 12. Do you want help paying for medical bills from the last 3 months? DYes D No 13. Do you live with at least one child under the age of 19, and are you the main person taking care of this child? DYes D No 14. Are you a full-time student? DYes D No 15. Were you in foster care at age 18 or older? DYes D No 16. If Hlspanlc/Latlno, ethnlcity (OPTIONAL-check all that apply.) D Mexican D Mexican American D Chicano/a D Puerto Rican D Cuban D Other 17. Race (OPTIONAL-check all that apply.) D White D Native American Indian D Black or African or Alaska Native American D Asian Indian D Chinese D Filipino D japanese D Korean D Vietnamese D Other Asian D Native Hawaiian D Guamanian or Chamorro D Samoan D Other Pacific Islander D Other NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.or& or call us at 1-800-701..0710. Para obtener una copia de este formula rio en Espai'lol, llame 1-800-701..0710.1fyou need help in a language other than English, call1-800-701..0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800-701..0720. Page2of7

FAMCLY~ STEP 2: PERSON 1 (Continue with yourself) Affordable health coverage. Quality care. Current job & Income Information 0 Employed If you're currently employed, tell us about your income. Start with question 18. CURRENT JOB 1: 0 Not employed Skip to question 28. 0 Self-employed Skip to question 27. 18. Employer name and address 19. Employer phone number ( ) 20. Wages/tips (before taxes) 0 Hourly . 0 Weekly 0 Every 2 weeks 0 Twice a month 0 Monthly 0 Yearly $ 21. Average hours worked each WEEK CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.) 22. Employer name and address 23. Employer phone number ( ) 24. Wages/tips (before taxes) 0 Hourly 0 Weekly 0 Every 2 weeks 0 Twice a month 0 Monthly 0 Yearly $ 25. Average hours worked each WEEK 26. In the past year, did you: 0 Change jobs 0 Stop working 0 Start working fewer hours 0 None of these 27. If self-employed, answer the following questions: a. Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? $ ______ _ 28. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don't need to tell us about child support, veteran's payment, or Supplemental Security Income (SSI). 0None 0 Unemployment $ How often? 0 Net farming/fishing $ 0 Pensions $ How often? 0 Net rental/royalty $ 0 Social Security $ How often? 0 Other income $ 0 Retirement accounts $ How often? Type: 0 Alimony received $ How often? 29. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. How often? How often? How often? If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 27b). 0 Alimony paid $ How often? 0 Other deductions $ How often? ____ _ 0 Student loan interest $ How often? Type: _________ _ 30. YEARLY INCOME: Complete only if your income changes from month to month. If you don't expect changes to your monthly income, skip to the next person. C) Your total income this year Your total income next year (if you think it will be different) $ $ THANKS! This is all we need to know about you. NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.or& or call us at 1-800.701..0710. Para obtener una copia de este formula rio en Espailol, llame 1-800.701..0710. If you need help in a language other than English, call1-800.701..0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800.701..0720. Page3of7

NJFAMCLY~ STEP 2: PERSON 2 If you have more than two people to Include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete. Affordable health coverage. Quality care. Complete Step 2 for yourself, your spouse/partner. and children who live with you and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you don't file a tax return, remember to still add family members who live with you. 1. First name, Middle name, Last name, & Suffix 2. Relationship to you? 3. Date of birth (mm/dd/yyyy) 5. Social Security number (SSN) ___ - __ - ___ _ We need this if you want health coverage and have an SSN. 6. Does PERSON 2 live at the same address as you? DYes D No If no, list address: 4. Sex D Male D Female 7. Does PERSON 2 plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don't file a federal income tax return.) DYES. If yes, please answer questions a-c. D NO. If no, skip to question c. a. Will PERSON 2 file jointly with a spouse? DYes D No If yes, name of spouse:----------------------------------- b. Will PERSON 2 claim any dependents on his or her tax return? DYes D No If yes, list name(s) of dependents:------------------------------- c. Will PERSON 2 be claimed as a dependent on someone's tax return? DYes D No If yes, please list the name of the tax filer:---------------------------- How is PERSON 2 related to the tax filer? 8. Is PERSON 2 pregnant? DYes D No a. If yes, how many babies are expected during this pregnancy? Due Date 9. Does PERSON 2 need health coverage? (Even if they have insurance, there might be a program with better coverage or lower costs.) D YES. If yes, answer all the questions below. O D NO. If no, SKIP to the income questions on page 5. A Leave the rest of this page blank. W 1 0. Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing. dressing, daily chores, etc) or live in a medical facility or nursing home? DYes D No 11. Is PERSON 2 a U.S. citizen or U.S. national? DYes D No 12. If PERSON 2 Isn't a U.S. citizen or U.S. national, do they have eligible immigration status? D Yes. Fill in their document type and ID number below. a.Documenttype ____________ _ b. Document ID number------------- c. Has PERSON 2 lived in the U.S. since 1996? DYes D No d. Is PERSON 2, or their spouse or parent a veteran or an active- duty member in the U.S. military? DYes D No 13. Does PERSON 2 want help paying for medical bills from the last 3 months? DYes DNo 14. Does PERSON 2 live with at least one child under the age of 19, and are they the main person taking care of this child? DYes 0No Please answer the following questions If PERSON 2 Is 22 or younger: 16. Did PERSON 2 have insurance through a job and lose It within the past 3 months? DYes D No a.lfyes, end date: b. Reason the insurance ended: 17. Is PERSON 2 a full-time student? DYes D No 18. If Hispanlc/Latino, ethnicity (OPTIONAL check all that apply.) 15. Was PERSON 2 in foster care at age 18 or older? DYes DNo D Mexican D Mexican American D Chicano/a D Puerto Rican D Cuban D Other ______ _ 19. Race (OPTIONAL-check all that apply.) D White D Native American Indian D Black or African or Alaska Native American D Asian Indian D Chinese D Filipino D japanese D Korean D Vietnamese D Other Asian D Native Hawaiian D Guamanian or Chamorro D Samoan D Other Pacific Islander D Other Now, tell us about any income from PERSON 2 C) NEED HELP WITH YOUR APPLICATION? Visit njfamilycare,ora or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espai'lol, llame 1-800.701-0710. If you need help in a language other than English, caii1-80G-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800-701-0720. Page4of7

l'lJFAM~LYCME Affordabk! health coverage. Quality core. Current job & Income Information D Employed If you're currently employed, tell us about your income. Start with question 20. CURRENT JOB 1: D Not employed Skip to question 30. D Self-employed Skip to question 29. 20. Employer name and address 21. Employer phone number ( ) 22. Wages/tips (before taxes) D Hourly D Weekly D Every 2 weeks D Twice a month D Monthly D Yearly $ 23. Average hours worked each WEEK CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.) 24. Employer name and address 25. Employer phone number ( ) 26. Wages/tips (before taxes) D Hourly D Weekly D Every 2 weeks D Twice a month D Monthly D Yearly $ 27. Average hours worked each WEEK 28. In the past year, did PERSON 2: D Change jobs D Stop working D Start working fewer hours D None of these 29. If self-employed, answer the following questions: a. Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? $ ______ _ 30. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don't need to tell us about child support, veteran's payment, or Supplemental Security Income (SSI). 0None D Unemployment $ How often? D Net farming/fishing $ D Pensions $ How often? D Net rental/royalty $ D Social Security $ How often? D Other income $ D Retirement accounts $ How often? Type: D Alimony received $ How often? 31. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. How often? How often? How often? If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You shouldn't include a cost that you already considered in your answer to net self-employment (question 29b). D Alimony paid $ How often? D Other deductions $ How often? ____ _ D Student loan interest $ How often? Type: _________ _ 32. YEARLY INCOME: Complete only if PERSON 2's income changes from month to month. If you don't expect changes to PERSON 2's monthly income, add another person or skip to the next section. PERSON 2's total income this year PERSON 2's total income next year (if you think it will be different) $ $ THANKS! This is all we need to know about PERSON 2. NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espaf'iol, llame 1-800-701-0710. If you need help in a language other than English, call1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800-701-0720. Page 5 of7

FAMCLYcrutE Affordable health coverage. Quality care. Native American Indian or Alaska Native (AI/AN) family member(s) 1. Are you or is anyone in your family Native American Indian or Alaska Native? D If No, skip to Step 4. DYes. If yes, go to Appendix B. lji:IIJ Your Family's Health Coverage Answer these questions for anyone who needs health coverage. 1. Is anyone enrolled in health coverage now from the following? D YES. If yes, check the type of coverage and write the person(s)' name(s) next to the coverage they have. D NO. D Medicaid ________________ _ D Employer insurance _____________ _ D NJ FamilyCare _______________ _ D Medicare _________________ _ D TRICARE (Don't check if you have direct care or Line of Duty) D VA health care programs ___________ _ D Peace Corps----------------- Name of health insurance: ___________ _ Policy number:---------------- Is this COBRA coverage? DYes D No Is this a retiree health plan? 0 Yes D No D Other Name of health insurance:------------ Policy number:---------------- Is this a limited-benefit plan (like a school accident policy)? DYes 0No 2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, such as a parent or spouse. DYES. If yes, you'll need to have your employer complete Appendix A and return to address provided. D NO. If no, continue to Step 5. Select your Health Plan Choose a Health Plan from the list below. If you do not choose now, you will have an opportunity to select a Health Plan before enrollment occurs. You must be enrolled in a Health Plan to receive all of the services offered through NJ FamilyCare. The Health Plan selected only applies if you are eligible for NJ FamilyCare. If you need assistance selecting your Health Plan, contact a Health Benefits Coordinator at 1-800-701-0710, TTY 1-800-701-0720. D Amerigroup New jersey, Inc. (Available in ALL counties; except Salem County) D Healthfirst Health Plan of New jersey (Available in Atlantic, Bergen, Essex, Hudson, Mercer, Middlesex, Morris, Passaic, Somerset, Sussex, Union & Warren counties ONLY) D Horizon Nj Health (Available in ALL Counties) D UnitedHealthcare Community Plan (Available in ALL Counties) D WeiiCare Health Plans of New jersey (Available in Essex, Hudson, Middlesex, Passaic, & Union counties ONLY) I understand that if I'm found eligible and because I have joined a Health Plan, I must follow the rules for obtaining health care from the Health Plan. I understand that I must let my Health Plan and NJ FamilyCare know if there is any change in the number of people in my family and that any newborn children will be enrolled in my Health Plan. I understand that, unless I, or a family member, have a true medical emergency, I must call my personal doctor for medical advice, medical care or for a referral to a specialist. I understand that if I, or a family member, have a true medical emergency, I must call my personal doctor or the Health Plan as soon as possible after I, or the family member, go to the hospital. I understand that I must keep any medical appointment I have scheduled with a doctor and, if I cannot, I must call the doctor's office to cancel the appointment. I understand that if I go to a doctor other than my personal doctor I have selected, without a referral from my doctor or approval from the Health Plan, I may have to pay for that doctor's services because NJ FamilyCare will not pay for the unapproved service or visit. I understand that I may change to another Health Plan and that I can call the Health Benefits Coordinator to help me do that. I give permission for the release of my medical history and health care records and those of my family members who will be enrolled to any person(s) in the Health Plan and its providers who shall provide or coordinate health care to me and my family as long as I am a member of the Health Plan. NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.or& or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espaiiol,llame 1-800-701-0710. If you need help in a language other than English, call1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800-701-0720. Page6of7

FAMCLYcrulE Affordable health coverage. Quality core. Ill jill Read & sign this application. 1 understand that the NJ FamilyCare program may use or disclose protected health information about me or my children if Federal privacy law requires or allows it, or if State law requires it. 1 authorize my employer to release health benefits information to the NJ FamilyCare Office of Premium Support. 1 know that I must promptly tell NJ FamilyCare if anything changes or becomes different from what I wrote on this application including changes in income, address or household size. I can visit njfamilycare.ors or call1-800-701-0710 to report any changes. I understand that a change in my information could affect the eligibility for member(s) of my household. I know that under federal law, discrimination isn't permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.sov/ocr/office/file. 1 authorize the NJ Division of Taxation to release my tax return information to NJ FamilyCare. I also authorize any educational institution or school district to release my medical records or those of my child(ren) to the NJ FamilyCare program for the purpose of determining eligibility and billing the Program. I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If not, --------:----::-----:-------is incarcerated. (name of person) We need this information to check your eligibility for help paying for health coverage if you choose to apply. We'll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, NJ Division of Taxation, and/or a consumer reporting agency. If the information doesn't match, we may ask you to send us proof. Renewal of coverage in future years To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow NJ FamilyCare to use income data, including information from tax returns. NJ FamilyCare will send me a notice, let me make any changes, and I can opt out at any time. If anyone on this application is eligible for NJ FamilyCare I am giving to the NJ FamilyCare agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I am also giving to the NJ FamilyCare agency rights to pursue and get medical support from a spouse or parent. Does any child on this application have a parent living outside of the home? DYes D No If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell NJ FamilyCare and I may not have to cooperate. My right to appeal If I think NJ FamilyCare has made a mistake, I can appeal its decision. To appeal means to tell someone at NJ FamilyCare that I think the action is wrong, and ask for a fair review of the action. I know that I can find out how to appeal by contacting NJ FamilyCare at 1-800-701-0710. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me. Estate Recovery NJ FamilyCare Medicaid benefits received after the age of 55 may be reimbursable to the State of New jersey from the member's estate. The recovery may include premium payments made on behalf of the beneficiary. For more information about Estate Recovery, visit http://www.state.nj.us/humanservices/dmahs/clients/The_NJ_Medicaid_Program_and_Estate_Recovery_What_ You_Should_Know.pdf Sign this application. The person who filled out Step 1 should sign this application. If you're an authorized representative you may sign here, as long as you have provided the information required in Appendix C. Signature I Date (mm/ddlyyyy) Jill ill Mail completed application. Mail your signed application to: NJ FamilyCare PO BOX8367 TRENTON. NJ 08650-9802 If you are not registered to vote where you live now. would you like to apply to register to vote? Applying to register or declining to register to vote will not affect the amount of assistance you will be provided by this Agency. For more information on the Notice of Your Opportunity To Vote Ri~hts visit the link below: http://www.state.nj.us/state/electlons/nvra-forms/nvra-opportunlty-form-081810.pdf For more information on the Voter Re~jstratjon Application visit the link below: http://www.state.nj.us/state/electionslvotlng-lnformatlon-voter-reglstration-forms.html (Fill in the required information, print as a two-sided document. and fold to mail). If you would like a Voter Registration Application mailed to you. please check this box D. NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.or& or call us at 1-800-701-0710. Para obtener una copia de este formulario en Espaiiol,llame 1-800-701-0710.1fyou need help in a language other than English, call1-800-701-0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1-800-701-0720. Page7of7

APPENDIX A NJFAM~LYCJ.!dll Affordable health coverage. Quality care. Health Coverage from Jobs You DON'T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage. Tell us about the job that offers coverage. You need to include this page when you send In your application. EMPLOYEE Information 1. Employee name (First, Middle, Last) 2. Employee Social Security number ----------- _____________ ., _________________________ L.__ _______________ _ EMPLOYER Information 9.ZIPcode 13. Are you currently eligible for coverage offered by this employer, or will you become eligible In the next 3 months? DYes (Continue) 13a. If you're in a waiting or probationary period, when can you enroll in coverage?------:-----;-::-:-;-----,---- (mm/dd/yyyy) List the names of anyone else who is eligible for coverage from this job. Name: ___________ __ Name: ___________ __ Name: ____________ _ D No (Stop here and go to Step 5 in the application) Tell us about the health plan offered by this employer. ,..i·~theemploYeroftw ahealth~'tiat·~~~:~~~Yt$ 0 No ts~;:;~~~~:~~- _·_ ....• --~-- >·~:,C:~"~~~t:"~~~~~: · . ~fpr anytclbacco.cessat~Qn~JIIhcf.Qil:Jflt)t~:. ·--~-on wellness programs . . :.;:::::.'Q::~~'!~~;~- [)Veady 16. What change will the employer make for the new plan year (if known)? 0 Employer won't offer health coverage 0 Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard. • (Premium should reflect the discount for well ness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $ ____ _ b. How often? 0 Weekly 0 Every 2 weeks 0 Twice a month 0 Quarterly 0 Yearly Date of change (mm/dd/yyyy): • An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) ft NEED HELP WITH YOUR APPLICATION? Visit nifamilycare.org or call us at 1·800·701·0710. Para obtener una copia de este V formula rio en Espaiiol, llame 1·800·701·0710. If you need help in a language other than English, call 1·800·701·0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1·800·701·0720.

FAMCLY~ APPENDIX B Affordable health coverage. Quality core. Native American Indian or Alaska Native Family Member (AI/AN) Complete this appendix if you or a family member are Native American Indian or Alaska Native. Submit this with your NJ FamilyCare Application for Health Coverage & Help Paying Costs. Tell us about your Native American Indian or Alaska Native family member(s). Native American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. NOTE: If you have more people to include, make a copy of this page and attach. AI/AN PERSON 1 I AI/AN PERSON 2 I 1. Name First Middle First Middle (First name, Middle name, Last name) Last Last 2. Member of a federally recognized tribe? DYes DYes If yes, tribe name If yes, tribe name DNo DNo 3. Has this person ever gotten a service from DYes DYes the Indian Health Service, a tribal health program, or urban Indian health program, DNo DNo or through a referral from one of these If no, is this person eligible to get If no, is this person eligible to get programs? services from the Indian Health services from the Indian Health Service, tribal health programs, or Service, tribal health programs, or urban Indian health programs, or urban Indian health programs, or through a referral from one of these through a referral from one of these programs? programs? DYes DNo DYes DNo 4. Certain money received may not be $ $ counted for NJ FamilyCare. List any income (amount and how often) reported on your application that includes money How often? How often? from these sources: . Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties . Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations) . Money from selling things that have cultural significance A NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1·800·701·0710. Para obtener una copia de este V formulario en Espaflol, llame 1·800·701·0710. If you need help in a language other than English, call 1·800·701·0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call 1·800·701·0720.

FAM~LYcatE APPENDIX C Affordable health coverage. Quality care. Assistance with Completing this Application You can choose an authorized representative. You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an "authorized representative." If you ever need to change your authorized representative, contact NJ FamilyCare. If you're a legally appointed representative for someone on this application, submit proof with the application. 1. Name of authorized representative (First name, Middle name, Last name) 2. Address 3. Apartment or suite number 4. City 15. State 6. ZIP code 7. Phone number ( ) 8. Organization name 9. ID number (if applicable) By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this agency. 10. Your signature 11. Date (mm/dd/yyyy) For certified application counselors, navigators, agents, and brokers only. Complete this section if you're a certified application counselor, navigator, agent, or broker filling out this application for somebody else. 1. Application start date (mm/dd/yyyy) 2. First name, Middle name, Last name, & Suffix 3. Organization name 4. ID number (if applicable) NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1·800·701·0710. Para obtener una copia de este formulario en Espafiol, llame 1·800·701·0710. If you need help in a language other than English, call 1·800·701·0710 and tell the customer service representative the language you need. We'll get you help at no cost to you. TTY users should call1·800·701·0720.

TABLE OF CONTENTS

STATE/TERRITORY: NEW JERSEY

STATE PLAN AMENDMENT (SPA)#: NJ--13-0024-MM5

This file contains the following documents in the order listed:

1) 2) 3) 4)

Approval Letter Summary Form Superseding Pages Notice Approved SPA pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

New York Regional Office

26 Federal Plaza, Room 37-100

New York, NY 10278

CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID AND CHILDREN’S HEALTH OPERATIONS

March 18, 2014

Valarie Harr, Director

State of New Jersey

Department of Human Services

Division of Medical Assistance and Health Services P.O. Box 712

Trenton, New Jersey 08625-0712

Dear Ms. Harr:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number NJ-13-0024-MMS. This SPA incorporates that the State affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options into the New Jersey State

plan in accordance with the Affordable Care Act.

Please be informed that this State Plan Amendment was approved on March 17, 2014 with an effective date of January 1, 2014.

We are enclosing the summary page (formerly CMS 179) and the amended plan pages (S88).

Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Patricia Ryan at 212-616-2436 or Patricia.Ryan@cms.hhs.gov.

Sincerely, /s/

Michael Melendez

Associate Regional Administrator

Division of Medicaid and Children’s Services New York Regional Office

Enclosure

NJ.0621.R00.00 - Jan 01, 2014 Page 1 of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: New Jersey

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NJ-13-0024

Proposed Effective Date 01/01/2014 (mn/dd/yyyy)

Federal Statute/Regulation Citation 42 CFR 435.403

Federal Budget Impact

Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00

Subject of Amendment Medicaid eligibility -non financial eligibility-State residency S88

Governor's Office Review

Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

Other, as specified Describe: Not required pursuant to section 7.4 of the State Plan.

Signature of State Agency Official

Submitted By: Julie Hubbs Last Revision Date: Feb 28, 2014 Submit Date: Dec 18, 2013

http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 03/18/2014

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0024 MM5 New Jersey

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S88 Non-Financial Eligibility- State Residency

PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Section 2: Page 13, Item 2.3, TN 87-14 Attachment 2.6-A: Page 3, TN 09-04

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 SAMS

42 CFR 435.403

State Residency

The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

Individuals are considered to be residents of the state under the following conditions:

im Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and:

[m] Intends to reside in the state, including without a fixed address, or

[| Entered the state with a job commitment or seeking employment, whether or not currently employed.

aw Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live.

[@] Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: [lM] Residing in the state, with or without a fixed address, or

im The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides.

ml Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married:

i Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or

Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's = placement, or

If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the [] institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is

institutionalized in the state.

Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state,

fm) unless another state made the placement. [M] Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. im Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state. [Ml] IV-E eligible children living in the state, or TN: 13-0024-MM5 Approval Date: 03/18/2014 Effective Date: 01/01/2014 New Jersey S88

Page 1 of 4

coms Medicaid Eligibility

[@] Otherwise meet the requirements of 42 CFR 435.403.

TN: 13-0024-MMS5 Approval Date: 03/18/2014

Effective Date: 01/01/2014 New Jersey S88

Page 2 of 4

Medicaid Eligibility

Meet the criteria specified in an interstate agreement.

@ Yes

C No

[®) The state has interstate agreements with the following selected states:

i}

KK] Alabama — Alaska

] Arizona & Arkansas XX) California —X] Colorado Connecticut [X] Delaware District of Columbia KX] Florida Georgia KK) Hawaii

KK) Idaho

KK] Illinois

&] Indiana — Iowa

— Kansas

KX] Kentucky IX] Louisiana KK Maine

—X) Maryland IX] Massachusetts KK] Michigan KX] Minnesota KK] Mississippi KK] Missouri

I] Montana

—X Nebraska

KK] Nevada

—X] New Hampshire 1 New Jersey —X New Mexico (1 New York

] North Carolina ] North Dakota & Ohio

IX] Oklahoma

] Oregon

] Pennsylvania

OWMRNRBWARARRKRAKRD

Rhode Island South Carolina South Dakota Tennessee Texas

Utah Vermont Virginia Washington West Virginia Wisconsin

Wyoming

The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency

status and criteria for resolving disputed residency of individuals who (select all that apply):

KK] Are IV-E eligible

( Are in the state only for the purpose of attending school

(D Are out of the state only for the purpose of attending school

( Retain addresses in both states

(1 Other type of individual

The state has a policy related to individuals in the state only to attend school.

C Yes

[™] Otherwise meet the criteria of resident, but who may be temporarily absent from the state.

@ No

The state has a definition of temporary absence, including treatment of individuals who attend school in another state.

@

Yes (C No

TN: 13-0024-MM5 New Jersey

Approval Date: 03/18/2014

S88

Effective Date: 01/01/2014 Page 3 of 4

Medicaid Eligibility

Provide a description of the definition:

A beneficiary may leave the State temporarily with no resultant effect on Medicaid eligibility as long as their intent is ito return to NJ.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: 13-0024-MM5 Approval Date: 03/18/2014 Effective Date: 01/01/2014

New Jersey S88 Page 4 of 4

Table of Contents

State/Territory Name: New Jersey State Plan Amendment (SPA) #: NJ-13-0025-MM4

This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data)

3) Superseding Pages Notice (delete if not applicable)

4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

New York Regional Office

26 Federal Plaza, Room 37-100

New York, NY 10278

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID AND CHILDREN’S HEALTH OPERATIONS

August 25, 2014

Valarie Harr, Director

State of New Jersey

Department of Human Services

Division of Medical Assistance and Health Services P.O. Box 712

Trenton, New Jersey 08625-0712

Dear Ms. Harr:

Enclosed is an approved copy of New Jersey’s state plan amendment (SPA) 13-0025-MM4, which was submitted to CMS on December 20, 2013. SPA 13-0025-MM4 incorporates the Single State Agency SPA into New Jersey’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a

separate section at the end of New Jersey’s approved state plan:

. A1-A3, pages 1 to 8

. Attachment 1— Attorney General Certification ° Attachment 2 - DMAHS Division Organizational Chart . Attachment 3 — DHS Organizational Chart

In addition, enclosed is a summary of state plan pages which are superseded by SPA 13-0025- MM4.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Patricia Ryan at (212) 616-2436 or at Patricia.Ryan@cms.hhs. gov.

Sincerely, /s/

Michael Melendez Associate Regional Administrator Division of Medicaid and Children Health

COCO OOOO OOOO OOO EEE ——E—EOEO_————_eESeeeVvOO_O—_—_—_eee SSS...

NJ.0653.R00.00 - Oct 01, 2013 Page | of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: New Jersey

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

NJ-13-0025

Proposed Effective Date 10/01/2013 (mm/dd/yyyy)

Federal Statute/Regulation Citation 42 CFR 431.10

Federal Budget Impact

Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00

Subject of Amendment state plan administration-delegation and authority (A1-A3)

Governor's Office Review Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

@ Other, as specified Describe: Not required pursuant to section 7.4 of the state plan.

Signature of State Agency Official

Submitted By: Julie Hubbs Last Revision Date: Aug 7, 2014 Submit Date: Dec 20, 2013

https://wms-mmdlI.cdsvde.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 08/26/2014

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: NJ- 13-0025 New Jersey PAGE NUMBER OF THE PLAN SECTION OR COMPLETE PAGES PARTIAL PAGES ATTACHMENT: SUPERSEDED: SUPERSEDED:

Section 1, pages 1-9 Al-A3 Attachment 1.2A Attachment 1.2 B Attachment 1.2C Attachment 1.2D

A2 Notwithstanding any other provisions of the Medicaid State Plan, the agencies designated in A2 will determine eligibility for coverage to the extent specified in A2.

Notwithstanding the checked assurances on A3, the single state agency has not entered into: 1) an agreement with the Federally-facilitated Marketplace to determine eligibility for Medicaid; nor 2) an agreement with the Office of Marketplace Eligibility Appeals to conduct Medicaid fair hearings to date, but will enter into CMS-approved agreements with the Federally-facilitated Marketplace and the Office of Marketplace Eligibility Appeals as soon as possible and no later than January 1, 2014.

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014

| Al

42 CFR 431.10

Designation and Authority

State Name: New Jersey

As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of] this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the| Department.

Name of single state agency: Department of Human Services

Type of Agency: @ Title IV-A Agency C Health C Human Resources

C Other

Type of Agency

The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.) .

The state statutory citation for the legal authority under which the single state agency administers the state plan is:

NJ Laws of 1968 (P.L. 1968 c4 13); N.J.S.A. 30:4D-5

The single state agency supervises the administration of the state plan by local political subdivisions.

C Yes @No

The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided.

An attachment is submitted.

The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies.

The single state agency administers the entire state plan under title XIX (ie., no other agency or organization administers any portion of

it).

@ Yes CNo TN: 13-0025-MM4 Approval Date: 08/25/2014 Effective Date: 10/01/2013 . New Jersey Al

Page 1 of 8

Medicaid Administration

The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are:

[KX] The Medicaid agency

oO Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

[X] An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are:

KX] The Medicaid agency

oO Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

[J An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act [X] The Federal agency administering the SSI program Indicate which agency determines eligibility for any groups whose eligibility is not determined by the Federal agency: Medicaid agency (1 Title IV-A agency (J An Exchange

The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are:

IX] Medicaid agency (7) An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act

[X] An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act

Name of entity: |Office of Marketplace Eligibility Appeals (OMEA)

The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies.

@ Yes C No

42 CFR 431.10 42 CFR 431.11

Organization and Administration

Provide a description of the organization and functions of the Medicaid agency.

The Department of Human Services administers most of the State's Social Services programs, institutions and agencies, including

the administration of federal funds appropriated to all of these services. Under its jurisdiction are the Division of Medical

Assistance and Health Services (DMAHS), Division of Aging Services (DoAS), Division of Family Development (DFD), Division TN: 13-0025-MM4 Approval Date: 08/25/2014 Effective Date: 10/01/2013 New Jersey A1-A2

Page 2 of 8

Medicaid Administration

of Mental Health and Addiction Services (DMHAS), Division of Disability Services (DDS), the Commission for the Blind and Visually Impaired (CBV1), the Division of the Deaf and Hard Hearing (DDHH), and the Division of Developmental Disabilities (DDD).

DMAHS is responsible for the training, monitoring and oversight of AFDC-related Medicaid, NJ FamilyCare, Aged, Blind, Disabled programs, and institutional/waivered programs eligibility process for the 21 County Welfare Agencies (CWAs). This division is the focal point for development, interpretation and communication of Medicaid eligibility policy to CWAs, Division staff, and outside agencies and parties. This division is responsible for the analysis of existing and proposed Federal and State laws and regulations relating to eligibility to determine the impact on Medicaid programs, clients, and county operations. It provides technical assistance and administrative oversight for Medicaid programs and serves as a liaison to the Division of Family ‘Development for functions related to their programs. Also, this division works with the Division of Disability Services in administering the NJ Workability Program as well as the Division of Children’s Behavioral Health Services in processing Medicaid applications for out of home placements for their participants.

CWA means an agency of county government that is charged with the responsibility for determining eligibility for public assistance programs, including AFDC-Related Medicaid, Temporary Assistance to Needy Families (TANF), the Food Stamp program and Medicaid (Title XIX). Depending on the county, the CWA might be identified as the Board of Social Services, the Welfare Board, the Division of Welfare, or the Division of Social Services. CWAs are overseen by the office of Eligibility Policy within DMAHS and have Memoranda of Understandings (MOUs) with DMAHS. They conduct all Title XIX Medicaid eligibility determinations including all Modified Adjusted Gross Income (MAGI) related eligibility groups and those aged and disabled groups not determined eligible by the Social Security Administration (SSA), DMAHS' Institutional Support Services (ISS), and the Health Benefits Coordinator. ISS, a subdivision of DMAHS within the Office of Eligibility Policy, makes eligibility determinations for clients placed in State developmental centers, or county or State psychiatric hospitals, who are under age 21 or over 65, and for clients enrolled in the Division of Developmental Disabilities/Community Care Waiver program. Financial eligibility for the Waiver is determined by ISS and clinical eligibility is determined by DDD. The Health Benefits Coordinator is a State Vendor overseen by the Office of the Chief of Operations within DMAHS, and makes initial eligibility determinations for both Medicaid and CHIP. All initial Medicaid determinations made by the Health Benefits Coordinator are forwarded to appropriate State staff for review and final eligibility determination. The statutory authority for the delegation of eligibility determinations to the counties is found in N.J.S. 30:4D-7.r; 30:4D-3.i(8)(f); 30:4D-7a; 26:2H-18.32; and annually in language in the N.J. Appropriations Act. N.J.S. 30:4D-7 also authorizes the Commissioner to issue rules and regulations to administer the program which include: N.J.A.C. 10:49-14.4; 10:49-14.6; 10:71-1.1; 10:71-1.2; 10:71-1.5; 10:71-2.1; 10:71-3.13; 10:71-3.15.

DMAHS determines eligibility for the Community Care Waiver (CCW) program which is an 1115 waiver, reviews vendor Medicaid cases, and performs an independent review of someone seeking disability determination following SSA rules.

Major Units and Staff-

IDMAHS Director-

The Director's Office is responsible for the overall management, administration and development of the programs administered by the DMAHS. Areas of responsibility of this office involve interpretation of program policy and related program activity, study of federal and State legislation and federal regulations as they pertain to program functioning, policy formulation, issuance of Final Agency Decisions in contested cases, provider suspensions and debarments, and program planning and evaluation. The responsibilities of this office also include responding to legislative and constituent concerns, and serving as a link with provider organizations and client advocates. The Director’s Office is also responsible for review, analysis and preparation of comments for all aspects of State and Federal legislation that may impact DMAHS. The Office ensures that its duties are carried out in accordance with Departmental directives, policies and timelines. Additionally, the Office is involved in special studies and investigations, and oversight of special projects.

Medical Assistance Advisory Council-

The primary objective of the Advisory Council is to advise the Division about health care issues and to foster communication between the larger, pluralistic community. the establishment of the Council is in accordance with federal regulation. The Council's membership is comprised of providers, consumers, Division staff and staff from other State and federal agencies.

Chief of Staff-

The Chief of Staff is responsible for supporting the Director and for the overall management of the Office of Research, Office of TN: _13-0025-1IVIIMI4- Approvat Date: 08/25/2014 Effective Date: 1070172013 New Jersey A2

Page 3 of 8

Medicaid Administration

Internal Affairs, Bureau of Quality Control and the Human Resources, General Services, Auditing and Communication Units.

Chief Financial Officer- This Office oversees the operations of the Office of Budget & Finance, the Divisions Reimbursement Offices, and the Hospital Services, In Patient Rate Setting and Data Analysis Units.

Chief of Operations-

This Chief of Operations has oversight and management responsibilities for the overall planning, organization, development and administration of all NJ FamilyCare/ Medicaid client units. Additionally the Chief of Operations evaluates program operations for improvements to increase the organization’s efficiency and effectiveness. This office also has oversight of the Office of Eligibility Policy, Premium Support, Policy, State Monitoring Unit, Waiver Operations, NJ FamilyCare Outreach, and Office of Customer Service.

Chief Information Officer-

The Chief Information Officer is responsible for all information technology and administrative support services. The Chief Information Officer plans, designs, recommends and implements major automated systems in order to fulfill the statistical, administrative, and general data processing needs of the Division. This office also oversees the Medicaid Management Information System (MMIS) Fiscal Agent contract.

Human Resources- This office is responsible for the personnel, payroll, and Public Employees Occupational Safety and Health (PEOSH) units for the Division of Medical Assistance and Health Services and the Division of Family Development.

Office of Eligibility Policy-

This office is responsible for the management of County Operations, Eligibility Policy, HMO Account Coordinators, Office of Eligibility Operations, Special Projects and the Buy-in unit. Supports the design, development and implementation of new policies, procedures and programs as determined by the Division Director.

Office of the Medical Director- This office oversees the operations of the Utilization Management, Preventive Health Care Services, Quality Assurance, Provider Relations and Dental Services Offices.

Office of Managed Health Care-

The Office of Managed Health Care (OMHC) is responsible for the overall administration of the Managed Care Program. It is the ongoing responsibility of the OMHC to interface with Managed Care Organizations (MCOs), and CMS on contractual issues, contract/policy interpretation, and the provision of contract technical assistance to MCOs, Division staff, providers, and other agencies. Within the Office of Managed Care is Managed Behavioral Health, Delivery System Innovation, and the Office of Quality Assurance.

Office of Legal and Regulatory Affairs-

The Office of Legal and Regulatory Affairs (OLRA) is the in-house legal and regulatory office within DMAHS, and performs the following functions: providing informal legal advice and assistance to. DMAHS and other State staff; drafting, reviewing and commenting on legislation and budget language; drafting and promulgating regulations; drafting state plan amendments, submitting them to CMS, and responding to CMS questions about those amendments, drafting and reviewing contracts and agreements; processing fair hearing requests and drafting final agency decisions for the Director; handling HIPAA issues and open public records requests; handling recovery cases involving torts, casualty insurance, estates, special needs trusts, and incorrect payments; and restricting to a single pharmacy or other provider beneficiaries who have engaged in overutilization or other abuse.

|The OLRA Fair Hearing Unit processes hearing requests from applicants who have been denied eligibility or whose application has not been acted upon with reasonable promptness as well any recipient whose services or eligibility have been terminated, suspended, or reduced. The Fair Hearing Unit also processes hearing requests from Medicaid providers seeking to appeal the denial of a request for prior authorization and denial of claims submitted for payment. Fair hearing requests are transmitted to the Office of Administrative Law (OAL) for a hearing before an Administrative Law Judge (ALJ). The OAL is an independent agency that conducts fair hearings for a number of agencies within the State of New Jersey, including DMAHS. The ALJ issues an Initial Decision (i.e. recommended decision) for de novo review by DMAHS’ Director. Thereafter DMAHS’ Director issues a Final

TN: 13-0025-MM4 Approval Date: 08/25/2014 Effective Date: 10/01/2013

New Jersey A2 Page 4 of 8

Ss Medicaid Administration

CORTE toe MERC ASE & aaONrAID ERECT

Agency Decision, which is appealable to the Appellate Division of the New Jersey Superior Court.

Other divisions within the Department of Human Services the Division of Aging Services (DoAS), the Division of Family Development (DFD), the Division of Mental Health and Addiction Services (DMHAS), the Division of Disability Services (DDS), the Commission for the Blind and Visually Impaired (CBVI), the Division of the Deaf and Hard of Hearing (DDHH), and the Division of Developmental Disabilities (DDD).

Division of Family Development (DFD), also within the New Jersey Department of Human Services, administers programs of financial and administrative support for certain qualified individuals and families.

Division of Aging Services (DoAS), is a Division within the New Jersey Department of Human Services created through SFY2013 budget language that transferred senior supports and services from the Department of Health to the Department of Human Services. The DoAS administers federal and State-funded services and supports for the elderly and adult disabled population. The agency receives federal funds under the Older Americans Act whereby it serves over 500,000 individuals and is the focal point for planning services for the aging, developing comprehensive information about New Jersey’s older adult population and its needs, and maintaining information about services available to older adults throughout the state.

Division of Developmental Disabilities (DDD), a division within the New Jersey Department of Human Services, provides evaluation, functional and guardianship services to eligible persons. Services include residential services, family support, contracted day programs, work opportunities, social supervision, guardianship, and referral services.

Division of Disability Services (DDS), a division within the New Jersey Department of Human Services, promotes the maximum independence and participation of people with disabilities in community life.

Division of Mental Health and Addiction Services (DMHAS), is also a Division within the New Jersey Department of Human Services.

Upload an organizational chart of the Medicaid agency.

An attachment is submitted.

Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies.

The Department of Human Services is part of the Executive Branch, led by the Commissioner of Human Services who is a cabinet official appointed by the Governor. The Department of Human Services is the single state agency which administers the Medicaid program through the Division of Medical Assistance and Health Services (DMAHS). DMAHS works with the divisions within Human Services and other departments in the Executive Branch to administer most of the State’s social services programs, institutions and agencies, including the administration of federal funds received for all of these services.

The Department of Health (DOH), which is in the Executive Branch of New Jersey State government is responsible for the oversight and licensure of certain medical providers, among other functions.

The Department of Children and Families (DCF), is in the Executive Branch of New Jersey State government. It includes the Division of Child Protection and Permanency (DCP&P), the Division of Children’s System of Care (CSOC), the Division of Prevention and Community Partnerships (DPCP), the Child Welfare Training Academy, Central Operations, the Office of Communications and Legislation, the Office of Education, and the Office of Licensing. DCP&P, formerly known as the Division of Youth and Family Services (DYFS), within the New Jersey Department of Children and Families, is responsible for ensuring the safety of children and providing social services to children and their families. DCP&P enrolls into Medicaid financially eligible children under its supervision who reside in DCP&P-supported substitute living arrangements, such as foster care and certain

dea

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‘S Medicaid Administration

KERR FOE MDAC ARE 8 can AID NORTE

| |

i | | i | | | | |

Lo

Type of entity that determines eligibility:

single state agency.

subsidized adoption placements.

The Department of Banking and Insurance (DOBI), also in the Executive Branch of New Jersey State government, is responsible for regulation of health insurers.

The Medicaid Fraud Division (MFD) is a Division of the Office of the State Comptroller, and was created by statute to preserve the integrity of the Medicaid and NJ FamilyCare programs by conducting and coordinating fraud, waste, and abuse control activities for all State agencies responsible for services funded by those programs.

“Remove

Type of entity that determines eligibility:

Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, | Puerto Rico, or the Virgin Islands

C An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act @ The Federal agency administering the SSI program

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

Pursuant to a 1634 agreement, the Social Security Administration determines Medicaid eligibility for Supplemental Income

recipients. | Remove

Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

@ An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act | C The Federal agency administering the SSI program

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

The Federally-Facilitated Marketplace (FFM) will be determining eligibility for Medicaid for groups of individuals whose income eligibility is determined based on MAGI income methodology and who apply through the FFM. The FFM will not be assigning an individual who is determined eligible for Medicaid whose income eligibility is determined using MAGI methodology to a specific eligibility group, determining cost-sharing (if applicable), or assigning a benefit package — functions that will be performed by the

Remove

Type of entity that conducts fair hearings: C An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act @ An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

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Medicaid Administration

|OMEA will conduct Medicaid fair hearings for individuals whose Medicaid eligibility has been denied by the Federally-facilitated Marketplace (FFM). These will be individuals whose income eligibility is determined based on MAGI income methodology and who applied for health coverage through the FFM.

Add

Supervision of state plan administration by local political subdivisions (if described under Designation and Authority)

Is the supervision of the administration done through a state-wide agency which uses local political subdivisions?

C Yes C No

42 CFR 431.10 42 CFR 431.12 42 CFR 431.50

Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50.

All requirements of 42 CFR 431.10 are met.

There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12.

The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters.

Assurance for states that have delegated authority to determine eligibility:

There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d).

Assurances for states that have delegated authority to conduct fair hearings:

There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d).

When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency.

Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings:

The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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“CMS Medicaid Administration

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New Jersey A1-A3 Page 8 of 8

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TN: 13-0025-MM4 Approval Date: 08/25/2014 Effective Date: 10/01/2013 New Jersey A1-A3

Effective Date: 10/01/2013

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8/6/2013

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New Jersey

A1-A3

NJ DEPARTMENT OF HUMAN SERVICES

Commissioner Secretary to the Commissioner ] [ I [ I [ I [ ] . oe Assistant Commissioner . Director Deputy Commissioner Deputy Commissioner Chief of Staff Assistant Commissioner Budget, Finance, fran Commissioner Medical Assistance & Office of Legistative Affairs perations JAdministration, Capital & IT] _OMice of airs Health Services . Division of Office of Division of Office of 1} Developmental L} Human Resources LH] Legal & Regulatory H . Public information Aging Services Disabilities Affairs Budget Planning Division of Office of i Division of Human Services Office of 7 , H Mental Health& 8 Emergency Hi H i, Publications Family Development Addition Services Management Police Finance & Accounting Division of Office of Research, Office of Office of Property " - LY LJ Evaluation & 1 Program int H Management & Community Outreach Disability Services Deaf & Hard of Hearing Special Projects & Accoun Construction L|commision for the Blind Office of peal ee and 1] Office of & Visually Impaired “| Recovery I Facilities Management Administration L Bureau of l Office of Guardianship Services information Technology| Office of Workforce ‘; Oevelopment and Training

Produced by DHS Office of Publications 1/2014

Effective Date: 10/01/2013

Approval Date: 08/25/2014 A1-A3

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New Jersey

Table of Contents

State/Territory Name:

NEW JERSEY State Plan Amendment (SPA) #: 13-26-MA This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Jacob K. Javits Federal Building 26 Federal Plaza Room 37-100 New York, New York 10278-0063

November 19, 2013

Valerie Harr, Director State of New Jersey Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712 Trenton, New Jersey 08625-0712

Dear Ms. Harr:

We have completed our review of New Jersey State Plan Amendment submittal 13-26-MA, “Eligibility Standards” (Supplement 8a to Attachment 2.6-A, page 5) and find it acceptable for incorporation into New Jersey’s Medicaid Plan, effective December 31, 2013. Enclosed please find copies of State Plan Amendment 13-26-MA and Form CMS-179.

If you have any questions or wish to discuss this further, please contact Patricia Ryan of my staff at 212-616-2436.

Sincerely,

/s/

Michael Melendez Associate Regional Administrator Division of Medicaid and Children’s Health

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND. MEDICAID SERVICES. OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL .13-26-MA New Jersey

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE December 31, 2013

5. TYPE OF PLAN MATERIAL (Check One):

(1 NEW STATE PLAN

(1) AMENDMENT TO BE CONSIDERED AS NEW PLAN

&] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: Social Security Act Section 1902(a)(10)(A)(i)(VI)

7. FEDERAL BUDGET IMPACT a. FFY 2014 $0 b. FFY 2015 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: SUPPLEMENT 8a to ATTACHMENT 2.6 A, Page 5

**SEE REMARKS BELOW

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT ({f Applicable): New .

10. SUBJECT OF AMENDMENT: Eligibility Standards

11. GOVERNOR’S REVIEW (Check One): (1 GOVERNOR’S OFFICE REPORTED NO COMMENT [.] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED (INO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

XJ OTHER, AS SPECIFIED: Not required, pursuant to 7.4 of the Plan

12. SIGNATURE OF STATE AGENCY OFFICIAL:

13. TYPED NAM: a i Velez

14. TITLE: — { issioner

16. RETURN TO:

Valerie Harr, Director

Division of Medical Assistance and Health Services ° P.O. Box 712, #26

Trenton, NJ 08625-0712

DRE it]1J12

"_ FORM CMS-179

ac rit

SUPPLEMENT 8a to ATTACHMENT 2.6-A Page 5

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: New Jersey

MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902(r) (2) OF THE ACT*

Section 1902(f) State X Non-Section 1902(f) State

For all mandatory poverty-level related children aged 6-18 as specified under section 1902(a)(10)(A)(i)(VII) who would qualify but for income, New Jersey will disregard income between their net income standard of 100% FPL and a gross income limit of 142% FPL.

*More liberal methods may not result in exceeding gross income limitations under section 1903(f).

13-26-MA(NJ)

TN No. 13-26-MA (NJ) Approval Date: NOV 1 9 2013 Supersedes : New Effective Date : DEC 3 1 2013

New

Table of Contents State/Territory Name: State Plan Amendment (SPA)#: NEW JERSEY 14-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services New York Regional Office 26 Federal Plaza, Room 37-100 New York, NY 10278 DIVISION OF MEDICAID AND CHILDREN'S HEALTH OPERATIONS June 6, 2014 Valarie Harr, Director State ofNew Jersey Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712 Trenton, New Jersey 08625-0712 Dear Ms. Harr: Enclosed is an approved copy ofNew Jersey's state plan amendment (SPA) 14-0002, which was submitted to CMS on March 11,2014. SPA 14-0002 incorporates Presumptive Eligibility by Hospitals (S21), into New Jersey's Medicaid state plan in accordance with the Affordable Care Act. The effective date ofthis SPA is January 1, 2014. We are approving this SPA with the understanding that New Jersey is currently incorporating the following system changes, to be completed by July 30, 2014: • Correcting language on page 2 of provided screenshots stating that non-citizen child applicants who qualify under the state's CHIPRA 214 option only need to be lawfully residing in the U.S., not necessarily permanently • The following questions will be non-required questions: Social Security Number, race/ethnicity, and questions regarding full-time student status, place of birth, and current health insurance coverage. • The state will add a question regarding the former foster care eligibility group to qualifying questions on page 6 of the provided screenshots, and build logic into their system to ensure that there is no income test for former foster care youth. Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the end ofNew Jersey's approved state plan: • S21, pages S21-1, S21-2 and S21-3 • Attachment 1- Presumptive Eligibility Client Letter • Attachment 2 - Presumptive Eligibility Training for Providers/Determining Entities

Page 2 CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Patricia Ryan at (212) 616-2436 or at Patricia.Ryan@cms.hhs.gov. Sincerely, Is/ Michael Melendez Associate Regional Administrator Division of Medicaid and Children Health Enclosure

NJ.0798.ROO.OO- Jan 01, 2014 Page 1 of2 State/Territory name: New Jersey Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY =the last two digits of th~ submission year~ (lnd 0000 = a four digit number with leading zeros. The dashes must also be entered. NJ-14-0002 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statuti:{J!f!gulation Citation 42 CFR435.1110 Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment Presumptive Eligibility by Hospitals (S21) Governor's Office Review $0.00 $0.00 Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Not required pursuant to Section 7.4 of the plan. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Julie Hubbs Jun 2, 2014 Mar 11,2014 Amount https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 06/09/2014

Medicaid Eligibility OMB Control Number 0938-1148 OMB date: 10/31/2014 Sll or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid for individuals determined presumptively eligible under this provision. (i' Yes ('No [Z] The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: ~ A qualified hospital is a hospital that: Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of ~ its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance ~ with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. Assists individuals in completing and submitting the full application and understanding any documentation requirements. l-Yes ('No ~ The eligibility groups or populations for which hospitals determine eligibility presumptively are: ~Pregnant Women ~ Infants and Children under Age 19 ~ Parents and Other Caretaker Relatives ~ Adult Group, if covered by the state ~ Individuals above 133% FPL under Age 65, if covered by the state ~ Individuals Eligible for Family Planning Services, if covered by the state ~ Former Foster Care Children ~ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state 0 Other Family/ Adult groups: 0 Eligibility groups for individuals age 65 and over 0 Eligibility groups for individuals who are blind 0 Eligibility groups for individuals with disabilities 0 Other Medicaid state plan eligibility groups 0 Demonstration populations covered under section 1115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. New Jersey 521 Page 1 of3

Medicaid Eligibility (i' Yes ('No Select one or both: IZJ The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. Although not required for Presumptive Eligibility, 80 percent of the Presumptive Eligibility . . f d d applications must result in a full Medicaid application. Participating entities are required to do a Descnpt10n o stan ar s: d. .d 1. ·b·l· h k., 100o/ fP · El. ·b·1· 1· A PE., Me ICai e 1g1 1 Ity c ec .or /o o resumptlve 1g1 1 1ty app 1cants. ny .orms designed by the hospital must be approved by DMAHS. D The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end ofthe presumptive eligibility period. ~ The presumptive period begins on the date the determination is made. ~ The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. ~ Periods of presumptive eligibility are limited as follows: (' No more than one period within a calendar year. (' No more than one period within two calendar years. (i' No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. (' Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. (' Yes (i' No ~ The presumptive eligibility determination is based on the following factors: The individual's categorical or non-financial eligibility for the group for which the individual's presumptive eligibility is ~ being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) Household income must not exceed the applicable income standard for the group for which the individual's presumptive ~ eligibility is being determined, if an income standard is applicable for this group. IZJ State residency IZJ Citizenship, status as a national, or satisfactory immigration status [Z] The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the ./ hospitals. A copy of the training materials has been included. TN: 14-0002 New Jersey I Approval Date: 06/06/2014 521 I Effective Date: 01/01/2014 Page 2 of3

Medicaid Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: 14-0002 New Jersey Approval Date: 06/06/2014 521 Effective Date: 01/01/2014 Page 3 of3

GOVERNORNAME ~tate Of jl}e\u 3JerSep COMMISSIONERNAME Governor DEPARTMENT OF HUMAN SERVICES Commissioner DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES LT.GOVERNORNAME P.O.Box 712, Trenton, NJ 08625-0712 DIRECTORNAME Lt. Governor Telephone: 1-800-356-1561 Director Date: Dear Provider: Health Benefits Identification Card Presumptive Eligibility Letter Slate of '-le~ .lerw}· llt1•lth n,ntflh ldf'Atiftt••Uibft c·~rd NEW APPLICANT: The NJFamilyCare (NJFC) client listed below has been found presumptively eligible, and will receive a plastic Health Benefits Identification (HBID) card in the mail shortly. In the meantime, please accept this letter in place of the client's new HBID card. For new applicants only this letter serves as temporary verification of NJFC presumptive eligibility for the period listed below. If you want to register to vote, you can complete a voter registration form at http://www.state.nj.us/state/elections/voting-information-voter-registration-forms.html. PE Confinnation Number Client Name Date ofBirth Client Address Office N arne Name ofStaffContact Phone Number PRESUMPTIVE EUGIDILITYLETIER VALID FROM ____ UNTIL ___ _ TN: 14-0002 New Jersey Approval Date: 06/06/2014 821 Effective Date: 01/01/2014

TN: 14-0002 New Jersey Presumptive Eligibility train ina fc)r - . ., '} . · , ··. • c · ·•· ·d··· · · : , .. .. ····o· ·· · · · · ··. ·· • · · ·· " · · · ... · · . P·rc>Vt · .. ers .. ·.•· . eterrnt.ntnl Enttttes Moving Forward ~ Approval Date: 06/06/2014 521 1 Effective Date: 01/01/2014

Presumptive Eligibility Who is Eligible for PE? • Uninsured children (CHIP} up to age 19 up to 350% FPL {355%}* • Children up to age 1 up to 194% FPL {199%}* • Children (Medicaid PE} up to age 19 up to 142% FPL (147%}* • Pregnant Women up to 194% {199%}* • Childless Adults 19-64 years old up to 133%FPL (138%)* • Parents/Caretakers up to 133% FPL (138%)* • Former Foster Care Children (Hospital PE, No Income Limit) • Breast and Cervical Cancer (Hospital PE) * 5% disregard allowed on highest thresholds TN: 14-0002 New Jersey Approval Date: 06/06/2014 521 2 Effective Date: 01/01/2014

TN: 14-0002 Ne~ Jersey· ! I Presumptive Eligibility Must be: • New Jersey Residents • U.S. citizens • Noncitizen PE applicants must be lawfully residing in the U.S. Note: PE is self attestation-driven No documents are required 3 Approval Date: 06/06/2014 .• 521 Effective Date: 01/01/2014 ., .

'"· TN: 14-0002 New Jersey Presumptive Eligibility • Individuals are eligible for PE only once in a 12 month period • Pregnant women are eligible for PE once per pregnancy 4 Approval Date: 06/06/2014 521 Effective Date: 01/01/2014 .· . . ---- .------- ~ -.-- --· ------· ..

TN: 14-0002 New Jersey ~ ;q;.~~- '-·~·· PE Determination Entity Requirements Qualified entity means an entity that is determined by the State to be capable of making determinations of presumptive eligibility and that: • furnishes health care items and services covered under the Medicaid State Plan and is eligible to receive payments under the approved plan; • is authorized to determine eligibility of a child for medical assistance under the Medicaid State plan, or eligibility of a child health assistance under the State Children's Health Insurance Program. Each entity must: • Notify DMAHS of its decision to make presumptive eligibility determinations • Participate in PE training • Agree to make determinations consistent with state policies and procedures 5 Approval Date: 06/06/2014 521 Effective Date: 01/01/2014 ~- _:~ ... ~..;

PE Determination Entity Requirements • 100% of PE applications must be looked up on MEVS/REVS • Although not required for Presumptive Eligibility, 80% of the PE applications should result in a full Medicaid application (Hospitals only) • Indivi-duals are not required to apply for full Medicaid • Third party vendors may assist hospitals/applicants with the HPE application process, however vendors cannot make determinations. 6 TN: 14-0002 New Jersey Approval Date: 06/06/2014 521 Effective Date: 01/01/2014 ,._ ..

TN: 14-0002 New Jersey Application Process - Providers • Do not complete a PE application if the applicant already has PE or full Medicaid eligi bi I ity • PE application must be completed online by a PE provider during a face-to-face interview • If applicant does not have a phone number, the Determining Agency (DA) may use their phone number on the PE application 7 Approval Date: 06/06/2014 521 Effective Date: 01/01/2014

TN: 14-0002 New Jersey Application Process (cont.) • PE on-line application must be completed the day of service. • Must include a dollar amount for income. Cannot enter "$0", unless explanation of survival without any income • If "$0" income, select living situation from drop down menu and/or provide explanation in income comment text box • The drop menu has the following options: Room & Board Homeless Living off Savings/Checking and Amount. __ _ Living with Family or Friends Lives in shelter Unemployed #months 8 Approval Date: 06/06/2014 521 Effective Date: 01/01/2014

TN: 14-0002 New Jersey Application Process - Providers • To ensure their income is within income guidelines, the PE worker must manually compare the DMAHS income standard chart to the PE online application when entering the applicant's household income • Simultaneously, the on-line PE application is received by the PE Unit and the appropriate County Welfare Agency/Vendor who will use the PE application to begin the process to determine full eligibility, if the applicant wishes to apply Approval Date: 06/06/2014 521 9 Effective Date: 01/01/2014

TN: 14-0002 New Jersey Application Process (cont.) The PE application fields that must be completed are: NJFC Pregnant Women >Name >Name > Address >Address > County >county > Modified Adjusted Gross >SSN (optional) Income (MAGI) >Marital Status > Household size >Citizenship Status > SSN (optional) >Date of entry > Citizenship Status >Race > Date of entry >Due Date > Date of Birth >Date of Birth >Race > Insurance Information (optional) > Marital Status >Household size >Modified Adjusted Gross Income (MAGI) 10 Approval Date: 06/06/2014 521 Effective Date: 01/01/2014

TN: 14-0002 New Jersey Application Process (cont.) • Provider should save or print a copy of the application for patient's file • Copy of the application and a HBID PE letter shall be given to the patient • State PE Unit assigns a PE number and an HBID Card is generated and mailed to the applicant • PE Unit sends an acknowledgement letter to the PE provider advising of PE Medicaid number. .. .. Approval Date: 06/06/2014 521 11 Effective Date: 01/01/2014

TN: 14-0002 New Jersey PE Coordinators • PE Coordinators and staff must be trained and knowledgeable in the determination of Presumptive Eligibility • PE Coordinators are required to be an employee of the Medicaid entity and monitor, onsite, the Presumptive Eligibility determination at all times • PE Coordinators can monitor a maximum of two sites, however a back-up person should be at each site to oversee the PE process • Multiple sites will require additional PE Coordinators, in order to adhere to this guideline 12 Approval Date: 06/06/2014 521 Effective Date: 01/01/2014

TN: 14-0002 New:Jersey PE Coordinators (cont.) • PE Coordinators may be urged to try to follow- up with a Medicaid application from the individual within 5 days as a best practice, but a Medicaid application cannot be required • PE Coordinators must communicate with the DMAHS regarding any changes in staff or location 13 Approval Date: 06/06/2014 521' Effective Date: 01/01/2014 . ·•

TN: 14-0002 New Jersey Certification & Training • CEO or representative completes MOLINA application for both PEPW and PEFC at www.njmmis.com and sends to DMAHS • Memorandum of Understanding is signed by Entity's CEO or representative and returned • DMAHS sends an email notification to Provider/Entity regarding mandatory training Approval Date: 06/06/2014 . 521 14 Effective Date: 01/01/2014

-·-------------------------- Certification & Training (cont.) • HealthStart certification (Pregnant Women only) • All PE staff are mandated to complete PE training in order to determine PE !;~:;~ IhmRnn:Nr or IhrMAN SuwJcl:S .,-: ... ·:~··, StAn OF Nt.w Jnst:v \~/ DIVISION OF MEDlCAL AssiSTANCE & HEALTH SeRVICES 15 TN: 14-0002 New Jersey Approval Date: .06/06/2014 521 .. ,. Effective Date: 01/01/2014

TN: 14-0002 New Jersey HBID Card The client will get their Health Benefits ldentifi.cation Card (HBID) in the mail within two weeks. Information/Assistance Hotline 1-877-414-9251 16 Approval Date: 06/06/2014 521 Effective Date: 01/01/2014 ~~;. ------

What happens next? • Once full Medicaid is determined, individuals receive a Health Plan packet • Applicants will be notified in writing of the full eligibility determination • Beneficiaries will be required to renew their insurance yearly • The PE staff should check MEVS/REVS system for full eligibility when the client returns for follow-up visit or for billing purposes {100%) 17 TN: 14-0002 New Jersey • Approval Date: 06/06/2014 521 Effective Date: 01/01/2014 .

TN: 14-0002 New Jersey Applicant Responsibilities • Must provide true and accurate statements at the PE interview Approval Date: 06/06/2014 S21 18 Effective Date: 01/01/2014 --------~-- ------------'-'--------, _______ ____:___, __

The State PE Unit's Responsibilities • Train PE providers and determining • agenc1es • Monitor PE determination for accuracy and ongoing training needs • Offer retraining if provider or entity does not meet the performance standards 19 TN: 14-0002 New Jersey Approval Date: 06/06/2914 521 Effective Date: 01/01/2014 , ..

The State PE Unit's Responsibilities • Establish PE eligibility record for the limited TN: 14-0002 New Jersey "----~- PE time period - PE is determined by the entity -Starts the day of the PE determination -Ends the last day of the month following the month PE was determined -Problem solve and distribute information to all PE Providers 20 Approval Date: 06/06/2014 521 Effective Date: 01/01/2014 ,:. ..

TN: 14-0002 New Jersey -------·-----~------------------------------------------- Breast and Cervical Cancer Program The intent of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 is to provide full Medicaid benefits to uninsured women under the age of 65 who have been diagnosed with breast and/or cervical cancer, and are in need of treatment. As part of the eligibility requirement for this program, women must be screened through the New Jersey Cancer Education and Early Detection Program (NJCEED) administered by the Dept. of Health and Senior Services. 21 Approval Date: 06/06/2014 Effective Date: 01/01/2014 •. 521 ·.·

TN: 14-0002 New Jersey Breast and Cervical Cancer Program Eligibility Requirements • Uninsured women under age 65 • Financially eligible for the NJCEED screening (income at or below 250% FPL, no asset test required) • Screened for breast and/or cervical cancer through one of NJCEED sites and requires cancer treatment • Do not qualify for any other Medicaid program • New Jersey resident • U.S. Citizens or qualified aliens (5 year bar applies) • Eligibility continues, regardless of any changes in financial circumstances, until she no longer requires cancer treatment 22 Approval Date: 06/06/2014 521 Effective Date: 01/01/2014

TN: 14-0002 New Jersey Presumptive Eligibility for the Breast and Cervical Cancer Program • NJCEED site sends documentation to state PE unit • PE unit establishes PE record • PE period begins the date the woman is screened for breast and/or cervical cancer by the NJCEED program site • PE period ends at the end of the following month • Health Benefits Identification (HBID) card is issued • PE unit sends acknowledgement letters to NJCEED program site and the County Welfare Agency (CWA) 23 Approval Date: 06/06/2014 521 Effective Date: 01/01/2014

Table of Contents

State/Territory Name: NEW JERSEY State Plan Amendment (SPA) #: 14-03-MA This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form 3) Approved SPA Page(s)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

New York Regional Office

26 Federal Plaza, Room 37-100

New York, NY 10278

CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID AND CHILDREN’S HEALTH OPERATIONS

September 12, 2014

Valarie Harr, Director

State of New Jersey

Department of Human Services

Division of Medical Assistance and Health Services P.O. Box 712

Trenton, New Jersey 08625-0712

Dear Ms. Harr:

Enclosed is an approved copy of New Jersey’s state plan amendment (SPA) 14-03-MA “Temporary Presumptive Eligibility”, which was submitted to CMS on March 21, 2014. SPA 14-03-MA designates the State Medicaid Agency the qualified entity authorized to determine presumptive eligibility for coverage effective on or after 1/1/14 and prior to 7/31/14. The effective date of this SPA is January 1, 2014.

Enclosed is a copy of the new state plan page T1, and Form CMS-179.

Please note that as agreed, we have substituted the originally submitted state plan page with the page forwarded in the states September 10, 2014 e-mail.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan- amendment. If you have any questions concerning this SPA, please contact Patricia Ryan at (212) 616-2436 or at Patricia.Ryan@cms.hhs.gov.

Sincerely, /s/ Michael Melendez Associate Regional Administrator

Division of Medicaid and Children Health

Enclosure

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES

ETT... eee

FORM APPROVED OMB NO, 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES

1, TRANSMITTAL NUMBER: 2. STATE

14-03-MA(NJ) New Jersey

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE January 1, 2014

5. TYPE OF PLAN MATERIAL (Check One):

(J) NEW STATE PLAN

[1] AMENDMENT TO BE CONSIDERED AS NEW PLAN

{k] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

42 CFR 435.1102 and 1103

7, FEDERAL BUDGET IMPACT FFY 2014: 0 FFY 2015: 0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Tl

9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable): NEW

10, SUBJECT OF AMENDMENT: Temporary Presumptive Eligibility

11, GOVERNOR’S REVIEW (Check One): (1 GOVERNOR’S OFFICE REPORTED NO COMMENT

(1 COMMENTS OF GOVERNOR’S OFFICE ENCLOSED [[] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[1 OTHER, AS SPECIFIED: Not required, pursuant to 7.4 of the Plan

12, SIGNATURE OF STATE AGENCY OFFICIAL:

16. RETURN TO:

Valerie Harr, Director

13. TYPED NAME: Jannifer Velez

14. ame, _ _ Commissioner

Division of Medical Assistance and Health Services P.O. Box 712, #26 Trenton, NJ 08625-0712

15. DATE SUBMITTED: 4 21 [14

FORM CMS-179

gh Medicaid Eligibility

State: New Jersey Transmittal Number: 14-03

The state provides Medicaid coverage to the following groups when determined presumptively eligible consistent with 42 CFR 435.1102 and 1103:

{1 Children under age 19

[I Parents and other caretaker relatives described in 42 CFR 435.110

2 Individuals who meet the categorical requirements of 42 CFR 435.119 1 Former foster care children described in 42 CFR 435.150

Pregnant women described in 42 CFR 435.116 (coverage for pregnant women is limited to ambulatory prenatal care as described in 42 CFR 435.1103)

The Health Benefits Coordinator is the qualified entity authorized to determine eligibility presumptively for these groups.

@ This state plan amendment is for presumptive eligibility determinations for coverage effective on or after January 1, 2014 and prior to July 31, 2014.

m The presumptive period begins on the date the presumptive eligibility determination is made.

@ The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of

presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

H The presumptive eligibility determination is based on the following factors:

H The individual must meet the categorical requirements of 42 CFR 435.110, 435.116, 435.118, 435.119 or 435.150

®@ Gross income or a reasonable estimate of household income must not exceed the applicable income standard for the categorical group

[] Attested state residency

Attested citizenship, status as a national, or satisfactory immigration status

TN No.: 14-03 Approval Date: SEPTEMBER 12, 2014

Supersedes: New Effective Date: JANUARY 01, 2014

new

Table of Contents State/Territory Name: NEW JERSEY State Plan Amendment (SPA) #: 16-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SP A Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services New York Regional Office 26 Federal Plaza, Room 37-100 New York, NY I 0278 DIVISION OF MEDICAID AND CHILDREN'S HEAL TH OPERATIONS DMCHO: JM May 12, 2016 Meghan Davey Director Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712 Trenton, NJ 08625-0712 RE: NJ SPA #16-0002 Dear Director Davey: C"'1S CENTI:RS FOR MEDICARE & MEOICAIO SERVICES The Centers for Medicare & Medicaid Services (CMS), New York Regional Office, has completed its review of New Jersey State Plan Amendment (SPA) Transmittal Number 16-0002. This SPA implements Health Homes as authorized under Section 2703 of the Patient Protection and Affordable Care Act. Children with SEO (Serious Emotional Disturbance) will qualify for health home services whereas SEO will be defined to include serious emotional disturbance, co-occurring developmental disability and mental illness, co-occurring mental health and substance abuse, or DD (Developmental Disability) eligible (per NJ Statute I 0: 196) with symptomology of SEO. The SPA was submitted to add Behavioral Health Home Services to children (under the age of 21) in Atlantic, Cape May and Monmouth counties to the previously approved counties, Mercer and Bergen, by enhancing the current care management teams within the Care Management Organizations. This SP A is approved May 12, 2016, with an effective date of January I, 2016. Enclosed is a copy of the approved pages for incorporation into the New Jersey State plan. In accordance with the statutory provisions at Section 1945( c )(I) of the Social Security Act, for payments made to health home providers under this amendment, during the first eight fiscal quarters that the SPA is in effect, January I, 2016 through December 31, 2017, the federal medical assistance percentage (FMAP) rate applicable to such payments shall be equal to 90 percent. The FMAP rate for payments made to health home providers will return to the state's published FMAP rate on January I, 2018. The Form CMS-64 has a designated category of service Line 43 for States to report health home services expenditures for enrollees with chronic conditions. Please share with your staff my appreciation for their time and effort throughout this process. If you have any questions regarding this State Plan Amendment, please contact John Montalto at John.Montalto@cms.hhs.gov or (212) 616-2326. Sincerely, Michael J. Melendez Associate Regional Administrator Division of Medicaid and Children's Health Operations

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Health Home State Plan Amendment OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Submission Summary

Transmittal Number:

Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

Supersedes Transmittal Number:

Please enter the Supersedes Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

The State elects to implement the Health Homes State Plan option under Section 1945 of the Social Security Act.

Name of Health Homes Program: State Information

State/Territory name: New Jersey

Medicaid agency: Authorized Submitter and Key Contacts The authorized submitter contact for this submission package.

Name:

Title:

Telephone number:

Email: The primary contact for this submission package. TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 NJ-16-0002 NJ-14-0015  NJ BHH (Children) Atlantic,Bergen,Cape May,Mercer, Monmouth Division of Medical Assistance and Health Services Julie Hubbs Regulatory Officer (609) 588-3001 Julie.hubbs@dhs.state.nj.us

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Name:

Title:

Telephone number:

Email: The secondary contact for this submission package.

Name:

Title:

Telephone number:

Email: The tertiary contact for this submission package.

Name:

Title:

Telephone number:

Email: Proposed Effective Date (mm/dd/yyyy) Executive Summary

Summary description including goals and objectives: Federal Budget Impact Federal Fiscal Year Amount First Year $ TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Ruby Goyal-Carkeek Deputy Director, Department of Children and Families, Division of Childrens System of Care (609) 888-7227 Ruby.Goyal-Carkeek@dcf.state.nj.us Meghan Davey Director, DMAHS (609) 588-2601 meghan.davey@dhs.state.nj.us Vicki Fresolone Research Scientist, Division of Mental Health and Addiction Services (609) 777-0750 Vicki.Fresolone@dhs.state.nj.us 01/01/2016 NJ plans to provide behavioral health home(BHH)services to children (under the age of 21)in Atlantic,Bergen,Cape May,Mercer,or Monmouth Co,by enhancing the current care management teams within Care Management Organization(CMO),the designated BHH provider.CMOs are agencies that provide direct,face to face care coordination&wraparound care planning for children&their families with the most complex needs&are responsible for facilitating access to a range of treatment&support services.Children must meet defined medical necessity criteria for BHH eligibility.Children in CMO are either SED,co-occurringDD/MI,Co-Occurring MH/SA,or are determined DD eligible(per NJ Statute10:196)with symptomology of SED.In anticipation of Statewide rollout of BHH,the CMO agencies in the counties will be the designated BHH to provide services to eligible children.NJs Children’s System of Care(CSOC)services are managed by a Contracted System Administrator(CSA),the single point of access for screening,referral&prior authorization for services,which includes;behavioral health,substance use&services for individuals with intellectual/developmental disabilities.The CSA makes referrals directly to CMOs.The care management teams will be enhanced to include medical&wellness expertise for purpose of providing fully integrated &coordinated care for children who meet criteria A transitional plan is actively pursued between the ages of 18 to 21 CSOC works to identify any resources needed for post children’s system involvement If further involvement with public system is warranted then applicable eligibility/assessment is pursued 2016 1728000.00

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM] Second Year $

Federal Statute/Regulation Citation

Governor's Office Review No comment. Comments received.

Describe: No response within 45 days. Other.

Describe: Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Submission - Public Notice

Indicate whether public notice was solicited with respect to this submission. Public notice was not required and comment was not solicited Public notice was not required, but comment was solicited Public notice was required, and comment was solicited Indicate how public notice was solicited:

Newspaper Announcement Newspaper

Name:

Date of Publication: (mm/dd/yyyy)

Locations Covered:

Name:

Date of Publication: (mm/dd/yyyy)

Locations Covered: TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 2017 4147200.00 Social Security Section 1945; 42 USC 1396w-4 Governor review is not required pursuant to 7.4 of the NJ State Plan.  Atlantic City Press 12/31/2015 Atlantic County NJ and surrounding area Bergen Record 12/31/2015

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Name:

Date of Publication: (mm/dd/yyyy)

Locations Covered:

Name:

Date of Publication: (mm/dd/yyyy)

Locations Covered:

Name:

Date of Publication: (mm/dd/yyyy)

Locations Covered:

Publication in State's administrative record, in accordance with the administrative procedures requirements.

Date of Publication: (mm/dd/yyyy)

Email to Electronic Mailing List or Similar Mechanism.

Date of Email or other electronic notification: (mm/dd/yyyy)

Description:

Website Notice

Select the type of website:

Website of the State Medicaid Agency or Responsible Agency

Date of Posting: (mm/dd/yyyy)

Website URL:

Website for State Regulations

Date of Posting: (mm/dd/yyyy)

Website URL:

Other

Public Hearing or Meeting

Other method TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Bergen County NJ and surrounding area Courier Post 12/31/2015 Camden County NJ and surrounding area Newark Star Ledger 12/31/2015 Newark NJ and surrounding area Trenton Times 12/31/2015 Trenton NJ and surrounding area  12/23/2015 Email sent to all County Welfare Agencies (CWAs) for posting as well as other stakeholders.   12/23/2015 http://www.state.nj.us/humanservices/providers/grants/public/index.html

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM] Indicate the key issues raised during the public notice period:(This information is optional)

Access Summarize Comments Summarize Response

Quality Summarize Comments Summarize Response

Cost Summarize Comments Summarize Response

Payment methodology Summarize Comments Summarize Response

Eligibility Summarize Comments Summarize Response

Benefits Summarize Comments Summarize Response

Service Delivery Summarize Comments Summarize Response TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Other Issue Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Submission - Tribal Input

One or more Indian health programs or Urban Indian Organizations furnish health care services in this State.

This State Plan Amendment is likely to have a direct effect on Indians, Indian health programs or Urban Indian Organizations.

The State has solicited advice from Tribal governments prior to submission of this State Plan Amendment. Complete the following information regarding any tribal consultation conducted with respect to this submission: Tribal consultation was conducted in the following manner:

Indian Tribes

Indian Health Programs

Urban Indian Organization Indicate the key issues raised in Indian consultative activities:

Access Summarize Comments Summarize Response

Quality Summarize Comments Summarize Response

Cost Summarize Comments Summarize Response

Payment methodology Summarize Comments Summarize Response

Eligibility Summarize Comments TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM] Summarize Response

Benefits Summarize Comments Summarize Response

Service delivery Summarize Comments Summarize Response

Other Issue

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Submission - SAMHSA Consultation

The State provides assurance that it has consulted and coordinated with the Substance Abuse and Mental Health Services Administration (SAMHSA) in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions. Date of Consultation

Date of consultation:

(mm/dd/yyyy)

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Health Homes Population Criteria and Enrollment

Population Criteria

The State elects to offer Health Homes services to individuals with:

Two or more chronic conditions

Specify the conditions included: TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016  12/19/2013

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Mental Health Condition

Substance Abuse Disorder

Asthma

Diabetes

Heart Disease

BMI over 25 Other Chronic Conditions

One chronic condition and the risk of developing another

Specify the conditions included:

Mental Health Condition

Substance Abuse Disorder

Asthma

Diabetes

Heart Disease

BMI over 25 Other Chronic Conditions

Specify the criteria for at risk of developing another chronic condition:

One or more serious and persistent mental health condition

Specify the criteria for a serious and persistent mental health condition:

Geographic Limitations

Health Homes services will be available statewide

Describe statewide geographical phase in/expansion. This should include dates and corresponding geographical areas that bring the program statewide.

If no, specify the geographic limitations: By county TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Certain developmental disorders (organic) Cystic Fibrosis Eating Disorder Hypertension Kidney Disease Obesity (BMI >= 85%) Seizure Disorder Sickle Cell  Children with SED will qualify. For purposes of this SPA, SED will be defined to include serious emotional disturbance, co-occurring developmental disability and mental illness, co-occurring mental health and substance abuse, or DD eligible (per NJ Statute 10:196) with symptomology of SED.

Among children meeting the above criteria, NJ will target behavioral health home services to those individuals who could benefit from the enhanced model of integrated behavioral/medical coordination that the behavioral health home model provides. This targeting will be based on a set of defined medical necessity criteria which will enumerate eligible medical comorbidities that must be present alongside the targeted conditions listed above. Medical necessity criteria will be determined and reviewed on an ongoing basis by the state and consistently applied by its qualified behavioral health home providers.

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Specify which counties: By region

Specify which regions and the make-up of each region: By city/municipality

Specify which cities/municipalities: Other geographic area

Describe the area(s):

Enrollment of Participants

Participation in a Health Homes is voluntary. Indicate the method the State will use to enroll eligible Medicaid individuals into a Health Home: Opt-In to Health Homes provider

Describe the process used: Automatic Assignment with Opt-Out of Health Homes provider

Describe the process used:

The State provides assurance that it will clearly communicate the opt-out option to all individuals assigned to a Health Home under an opt-out process and submit to CMS a copy of any letter or other communication used to inform such individuals of their right to choose. Other

Describe:

The State provides assurance that eligible individuals will be given a free choice of Health Homes providers.

The State provides assurance that it will not prevent individuals who are dually eligible for Medicare and Medicaid from receiving Health Homes services.

The State provides assurance that hospitals participating under the State Plan or a waiver of such plan will be instructed to establish procedures for referring eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated Health Homes providers.

The State provides assurance that it will have the systems in place so that only one 8-quarter period of enhanced FMAP for each Health Homes enrollee will be claimed. Enhanced FMAP may only be claimed for the first eight quarters after the effective date TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 NJ BHH will be available in Bergen and Mercer County located in the northern and central region of NJ, respectively. As of 2011 US Census, Mercer's population was 367, 063. Children represent 22% of the population in Mercer County (82, 122) and 17% of those children live below poverty line. Mercer experienced a 24% increase in children receiving NJFamilyCare (Medicaid) from 2008 to 2012. Mercer's current census is 600 youth. Bergen County is the most populous county of the state of New Jersey. As of the 2011 US Census, its population was 911,004. Children represent 22% of the population (202,352). Bergen has 4.5% of NJ children living below poverty line and the unemployment rate in Bergen is 7.7%. Bergen experienced a 37% increase in children receiving NJFamilyCare/Medicaid from 2008 to 2012 (third highest among all counties). Bergen's average monthly census in 2013 has been 540. Recent estimates indicate one third of Medicaid enrolled children who use behavioral healthcare also have serious medical conditions (Pires, March 2013) New Jersey estimates up to 200 youth will be enrolled in each of the BHH per year New Jerseys CSOC services are managed by a CSA. The CSA is the single point of access for screening, referral and prior authorization for childrens service, which includes behavioral health, substance use and intellectual/developmental disabilities. Single access to care is through the DCF/CSOC’s Contracted System Administrator, who will provide the authorization to eligible children for BHH services. An authorization is made to the CMO, the designated BHH entity who obtains consent from the parent/guardian or from youth (ages 18-20) for enrollment and participation in BHH. The CSA will continue to screen and prior authorize Atlantic, Cape May, Bergen, Monmouth and Mercer County youth for CMO service eligibility. Children and youth who are referred to the CMO will then be screened for Health Home services at the CMO and if eligible, the CMO will request prior authorization for the Health Home service from the CSA. This allows the CMO staff to work directly with the children and their families to explain and discuss the BHH services. Enrollees can opt in or opt out of the Health Home services at the CMO. If an individual opts out of the BHH services they will continue to receive the CMO services that they need If they opt in to BHH service individual will receive all of the services of the CMO plus the additional BHH services In addition if the family indicates to the lead care manager that they no longer wish to be involved with the BHH the need for continuing authorization would not be pursued BHH    

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM] of a Health Homes State Plan Amendment that makes Health Home Services available to a new population, such as people in a particular geographic area or people with a particular chronic condition.

The State assures that there will be no duplication of services and payment for similar services provided under other Medicaid authorities.

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Health Homes Providers

Types of Health Homes Providers

Designated Providers Indicate the Health Homes Designated Providers the State includes in its program and the provider qualifications and standards:

Physicians Describe the Provider Qualifications and Standards:

Clinical Practices or Clinical Group Practices Describe the Provider Qualifications and Standards:

Rural Health Clinics Describe the Provider Qualifications and Standards:

Community Health Centers Describe the Provider Qualifications and Standards:

Community Mental Health Centers Describe the Provider Qualifications and Standards:

Home Health Agencies Describe the Provider Qualifications and Standards:

Other providers that have been determined by the State and approved by the Secretary to be qualified as a health home provider:

Case Management Agencies Describe the Provider Qualifications and Standards:

Community/Behavioral Health Agencies Describe the Provider Qualifications and Standards: TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016     The BHH providers will be current CMOs. CMOs are agencies that provide care coordination and wraparound care planning for children and their families with the most complex needs and are responsible for facilitating access to a full range of treatment and support services. They facilitate and work through child-family teams to develop individualized plans of care. The CMOs goals are to keep children in their homes, their schools, and their communities. CMOs are designated by the NJ Department of Children and Families CSOC and regulated by the NJ Division of Medical Assistance and Health Services. Each BHH will be a designated CMO and will be initially certified by the State of NJ as a BHH and will be required to become accredited by a nationally accredited body within two years of certification. To become a certified behavioral health home in the State of NJ a provider must: 1) be a designated CMO provider, 2) complete approved Learning Community curriculum, 3) meet DCF’s certification requirements (inclusive of implementing a system of care approach, training on motivational interviewing, appropriate level of staffing assuring collaboration with pediatric and specialty providers is planned for policies have been developed) 4) be accredited by a national recognized accrediting organization CMO’s can provide behavioral health home services on a provisional basis if

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Federally Qualified Health Centers (FQHC) Describe the Provider Qualifications and Standards:

Other (Specify)

Teams of Health Care Professionals Indicate the composition of the Health Homes Teams of Health Care Professionals the State includes in its program. For each type of provider indicate the required qualifications and standards:

Physicians Describe the Provider Qualifications and Standards:

Nurse Care Coordinators Describe the Provider Qualifications and Standards:

Nutritionists Describe the Provider Qualifications and Standards:

Social Workers Describe the Provider Qualifications and Standards:

Behavioral Health Professionals Describe the Provider Qualifications and Standards:

Other (Specify)

Health Teams Indicate the composition of the Health Homes Health Team providers the State includes in its program, pursuant to Section 3502 of the Affordable Care Act, and provider qualifications and standards:

Medical Specialists Describe the Provider Qualifications and Standards:

Nurses Describe the Provider Qualifications and Standards:

Pharmacists Describe the Provider Qualifications and Standards:

Nutritionists Describe the Provider Qualifications and Standards:

Dieticians Describe the Provider Qualifications and Standards: TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Social Workers Describe the Provider Qualifications and Standards:

Behavioral Health Specialists Describe the Provider Qualifications and Standards:

Doctors of Chiropractic Describe the Provider Qualifications and Standards:

Licensed Complementary and Alternative Medicine Practitioners Describe the Provider Qualifications and Standards:

Physicians' Assistants Describe the Provider Qualifications and Standards:

Supports for Health Homes Providers

Describe the methods by which the State will support providers of Health Homes services in addressing the following components: 1. Provide quality-driven, cost-effective, culturally appropriate, and person- and family-centered Health Homes services, 2. Coordinate and provide access to high-quality health care services informed by evidence-based clinical practice guidelines, 3. Coordinate and provide access to preventive and health promotion services, including prevention of mental illness and substance use disorders, 4. Coordinate and provide access to mental health and substance abuse services, 5. Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care, 6. Coordinate and provide access to chronic disease management, including self-management support to individuals and their families, 7. Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services, 8. Coordinate and provide access to long-term care supports and services, 9. Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services: 10. Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate: 11. Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level. Description:

Provider Infrastructure Describe the infrastructure of provider arrangements for Health Homes Services.

Provider Standards The State's minimum requirements and expectations for Health Homes providers are as follows: TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 As described in NJs 1115 Comprehensive Medicaid Waiver, NJ has committed to providing quality driven and cost effective treatment throughout the service delivery system. NJ's CSOC will support the Behavioral Health Home (BHH) in these endeavors through a commitment to providing data, technical assistance, training and support. The CSA will have staff designated to monitor and assist the BHH in enrolling eligible children, coordinating with other systems, and providing any other real time assistance to the BHH provider to meet quality, cost and efficiency goals. NJ DMAHS will work with the NJ Managed Care Organizations to ensure that they coordinate with the BHH in the area of data, and the facilitation of patient referrals. All BHH providers must be designated as a CMO by the NJ CSOC and therefore be well versed in behavioral health issues. NJ has implemented the Behavioral Health Home Learning Community (LC) for potential BHH providers. The Learning Community assists providers in developing a full implementation and readiness plan. Through the LC, providers will have an opportunity to develop the capacity to implement the BHH services, and the opportunity to share problems and develop solutions for connecting with other systems with which they will be coordinating The work of the CMO is also supported by the CSA who authorizes tracks and coordinates care and service outcomes (reporting IT and coordination of QM function) Family Support Organizations (FSOs) are also an integral partner to a CMO involved child and their family The FSOs are All BHH providers must be designated CMOs. They provide enhanced care coordination (i.e. face-to-face care management and comprehensive service planning for youth and their families with complex needs). CMOs facilitate the development of the child and family team (CFT) and coordinate the CFT meetings and implement individual service plans (ISP). As part of care coordination they identify, and link children and their families to required services and supports that address the needs that are identified on the plan of care. The CMO is well positioned to serve as the bridge for coordinating comprehensive and holistic care for children who also have a chronic medical condition. CMOs work is supported through the CFT which is comprised of minimally the following individuals: 1. A CMO care manager; 2 The child youth or young adult and the parent or other caregiver;

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Health Homes Service Delivery Systems

Identify the service delivery system(s) that will be used for individuals receiving Health Homes services:

Fee for Service

PCCM PCCMs will not be a designated provider or part of a team of health care professionals. The State provides assurance that it will not duplicate payment between its Health Homes payments and PCCM payments. The PCCMs will be a designated provider or part of a team of health care professionals.

The PCCM/Health Homes providers will be paid based on the following payment methodology outlined in the payment methods section:

Fee for Service

Alternative Model of Payment (describe in Payment Methodology section)

Other

Description:

Requirements for the PCCM participating in a Health Homes as a designated provider or part of a team of health care professionals will be different from those of a regular PCCM.

If yes, describe how requirements will be different:

Risk Based Managed Care The Health Plans will not be a Designated Provider or part of a Team of Health Care Professionals. Indicate how duplication of payment for care coordination in the Health Plans' current capitation rate will be affected:

The current capitation rate will be reduced.

The State will impose additional contract requirements on the plans for Health Homes enrollees.

Provide a summary of the contract language for the additional requirements:

Other TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 An eligible BHH provider must meet the following:

1.Designated CMO 2.Medicaid approved provider 3.Certified as a BHH by the NJ CSOC. 4.Accredited as a specialty Behavioral Health Home by a nationally recognized and state approved accrediting body within two years of receiving state certification 5.Participation in a BHH Learning Community or other learning activity approved by the state   

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Describe: The Health Plans will be a Designated Provider or part of a Team of Health Care Professionals.

Provide a summary of the contract language that you intend to impose on the Health Plans in order to deliver the Health Homes services.

The State provides assurance that any contract requirements specified in this section will be included in any new or the next contract amendment submitted to CMS for review.

The State intends to include the Health Homes payments in the Health Plan capitation rate. Yes

The State provides an assurance that at least annually, it will submit to the regional office as part of their capitated rate Actuarial certification a separate Health Homes section which outlines the following: Any program changes based on the inclusion of Health Homes services in the health plan benefits Estimates of, or actual (base) costs to provide Health Homes services (including detailed a description of the data used for the cost estimates) Assumptions on the expected utilization of Health Homes services and number of eligible beneficiaries (including detailed description of the data used for utilization estimates) Any risk adjustments made by plan that may be different than overall risk adjustments How the final capitation amount is determined in either a percent of the total capitation or an actual PMPM

The State provides assurance that it will design a reporting system/mechanism to monitor the use of Health Homes services by the plan ensuring appropriate documentation of use of services.

The State provides assurance that it will complete an annual assessment to determine if the payments delivered were sufficient to cover the costs to deliver the Health Homes services and provide for adjustments in the rates to compensate for any differences found. No

Indicate which payment methodology the State will use to pay its plans:

Fee for Service

Alternative Model of Payment (describe in Payment Methodology section)

Other

Description:

Other Service Delivery System:

Describe if the providers in this other delivery system will be a designated provider or part of the team of health care professionals and how payment will be delivered to these providers: TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 New Jersey has in place Statewide Managed Care Organizations (MCOs) that manage the physical health services of NJ FamilyCare enrolled individuals. The current MCO contracts support coordination and non-duplication with BHH services. The contracts require that MCOs refer or coordinate referrals of enrollees with mental illness to mental health/substance abuse providers. Currently, any member of an MCO identified as having a potential care management need receives a detailed comprehensive needs assessment and ongoing care coordination from the MCO. The MCO contract will be amended 1/1/15 to reflect that, for MCO enrollees active with a BHH provider, the MCO will utilize the care management provided at the BHH and not duplicate services. The BHH team members are expected to outreach to the MCO for each enrollee The BHH Care Manager would be the point of contact for the MCO

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

The State provides assurance that any contract requirements specified in this section will be included in any new or the next contract amendment submitted to CMS for review.

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Health Homes Payment Methodologies

The State's Health Homes payment methodology will contain the following features:

Fee for Service

Fee for Service Rates based on:

Severity of each individual's chronic conditions

Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the services provided:

Capabilities of the team of health care professionals, designated provider, or health team.

Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the services provided:

Other: Describe below.

Provide a comprehensive description of the rate-setting policies the State will use to establish Health Homes provider reimbursement fee-for-service rates. Explain how the methodology is consistent with the goals of efficiency, economy and quality of care. Within your description, please explain: the reimbursable unit(s) of service, the cost assumptions and other relevant factors used to determine the payment amounts, the minimum level of activities that the State agency requires for providers to receive payment per the defined unit, and the State's standards and process required for service documentation.

Per Member, Per Month Rates

Provide a comprehensive description of the rate-setting policies the State will use to establish Health Homes provider reimbursement fee for service or PMPM rates. Explain how the methodology is consistent with the goals of efficiency, economy and quality of care. Within your description, please explain: the reimbursable unit(s) of service, the cost assumptions and other relevant factors used to determine the payment amounts, the minimum level of activities that the State agency requires for providers to receive payment per the defined unit, and the State's standards and process required for service documentation.

Incentive payment reimbursement

Provide a comprehensive description of incentive payment policies that the State will use to reimburse in addition to the unit base rates. Explain how the methodology is consistent with the goals of efficiency, economy and quality of care. Within your description, please explain: the incentives that will be reimbursed through the methodology, how the TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016   Children, Adolescents, and Young Adults will receive BHH services through the CSOC. CSOC has an existing network of CMOs that provide a variety of care management and support services reimbursed through a monthly per member per month case rate. The BHH will be an enhancement to the existing CMO services for youth that meet BHH eligibility criteria. CMOs will become Childrens BHHs through a state BHH certification process and national accreditation. The BHH rate will be an enhancement to the current CMO rate to support the functions that are specific to the Behavioral Health Home. The rate is inclusive of the CMO base rate and the add-on of the nurse manager and wellness coach.The BHH is a natural fit into the current CMO structure, which leverages the child/family team process to engage and promote better outcomes, so the nurse and wellness coach will become an integral part of delivering the core health homes services. The rate is a fee for service reimbursement structure. All applicable procedure codes listings and/or rates are published on the Department's fiscal agent's website at www.njmmis.com under the link for "rate code and information".

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

supplemental incentive payments are tied to the base rate activities, the criteria used to determine a provider's eligibility to receive the payment, the methodology used to determine the incentive payment amounts, and the frequency and timing through which the Medicaid agency will distribute the payments to providers.

PCCM Managed Care (description included in Service Delivery section)

Risk Based Managed Care (description included in Service Delivery section)

Alternative models of payment, other than Fee for Service or PM/PM payments (describe below)

Tiered Rates based on:

Severity of each individual's chronic conditions

Capabilities of the team of health care professionals, designated provider, or health team.

Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the services provided:

Rate only reimbursement

Provide a comprehensive description of the policies the State will use to establish Health Homes alternative models of payment. Explain how the methodology is consistent with the goals of efficiency, economy and quality of care. Within your description, please explain the nature of the payment, the activities and associated costs or other relevant factors used to determine the payment amount, any limiting criteria used to determine if a provider is eligible to receive the payment, and the frequency and timing through which the Medicaid agency will distribute the payments to providers.

Explain how the State will ensure non-duplication of payment for similar services that are offered through another method, such as 1915(c) waivers or targeted case management.

The State provides assurance that all governmental and private providers are reimbursed according to the same rate schedule

The State provides assurance that it shall reimburse Health Homes providers directly, except when there are employment or contractual arrangements.

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Transmittal Number: NJ-16-0002 Supersedes Transmittal Number: NJ-14-0015 Proposed Effective Date: Jan 1, 2016 Approval Date:

Attachment 3.1-H Page Number: Submission - Categories of Individuals and Populations Provided Health Homes Services

The State will make Health Homes services available to the following categories of Medicaid participants:

Categorically Needy eligibility groups Health Homes Services (1 of 2)

Category of Individuals CN individuals TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 New Jersey had four 1915(c) waivers that have been subsumed under NJ 1115(a) Comprehensive Waiver with the implementation of Managed Long Term Services and Supports (MLTSS). Those waivers were: Traumatic Brain Injury, Global Options, Community Resource for People with Disabilities, and the AIDS Community Care Alternatives Program. These programs have been consolidated into the Managed Long Term Services and Supports program and are being managed through the states MCOs. The state will pay for MLTSS services through capitated payment to the MCOs. The BHH service is excluded from the MLTSS covered services. However, the MCOs are required to coordinate referrals to the BHH for MLTSS members who meet the eligibility criteria for the BHH and the BHH service is part of the member’s plan of care (POC). The only program under 1915(c) waiver currently in place in NJ is the Community Care Waiver (CCW) that serves individuals with developmental disabilities. Individuals receiving services through the CCW waiver will not be eligible for the BHH services. NJ has instituted an edit in the MMIS system which rejects more than one bill, per individual per month, for duplicative services. This will disallow billing for services duplicative of the BHH, these include TCM 1915(c) CCW and PACT services The providers have been educated on these billing rules   

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Service Definitions

Provide the State's definitions of the following Health Homes services and the specific activities performed under each service:

Comprehensive Care Management Definition: Describe how health information technology will be used to link this service in a comprehensive approach across the care continuum:

Scope of benefit/service

The benefit/service can only be provided by certain provider types.

Behavioral Health Professionals or Specialists Description

Nurse Care Coordinators Description

Nurses Description

Medical Specialists Description

Physicians Description

Physicians' Assistants Description

Pharmacists Description

Social Workers Description

Doctors of Chiropractic TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 Care Management is the primary coordinating function in a Behavioral Health Home (BHH). The goal of Care Management is the assessment of child’s needs, development of the care plan, coordination of the services identified in the care plan, and the ongoing assessment and revisions to the plan based on evaluation of the child’s needs. The Care Manager is the Team Leader. The BHH team enhances the existing care management team by providing the medical expertise and support needed to help the child and family manage the chronic condition. The provider standards set by NJDCF require that BHH providers are able to interface with primary care, specialty care, hospitals, and support services. Every provider is required to utilize the State's EHR(CSA). Providers are also expected to use other available means to exchange protected health information safely and securely, to include but not be limited to direct messaging, facsimile, and telephonic services. 

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM] Description

Licensed Complementary and Alternative Medicine Practitioners Description

Dieticians Description

Nutritionists Description

Other (specify): Name Description

Care Coordination Definition: Describe how health information technology will be used to link this service in a comprehensive approach across the care continuum:

Scope of benefit/service

The benefit/service can only be provided by certain provider types.

Behavioral Health Professionals or Specialists Description

Nurse Care Coordinators Description

Nurses Description

Medical Specialists Description TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016  Care Managers Comprehensive care management services will be provided by care managers and involve: 1. Assessment and documentation of eligibility for BHH Services. 2. Development and periodic revision of service plans based on information collected through the assessments, review of youth's records and input from child and family. 3. Ensuring that implementation of the plan will coordinate access to high quality behavioral health care and facilitate access to health care services that are informed by evidence-based practices, facilitate access to preventative services, specialty medical care and dental care and social services Child with chronic conditions who require the expertise and additional medical support will be delegated to the Nurse Manager Plan will include child/family’s goals and preferences targeted outcomes identified service provider Care Coordination services are provided by Care Manager with support from the Nurse Manager, with the primary goal of implementing the individualized service plan/plan of care, with active involvement by the child/family, to ensure the plan reflects child/family needs and preferences. Care coordination emphasizes access to a wide variety of services required to improve overall health and wellness. Care Managers can be social workers and/or other trained health care professionals. A license in the health care professions is not required. Nurse Manager must be properly licensed and credentialed (minimum RN). The provider standards set by NJDCF require that BHH providers are able to interface with primary care, specialty care, hospitals, and support services. Every provider is required to utilize the State's EHR(CSA). Providers are also expected to use other available means to exchange protected health information safely and securely, to include but not be limited to direct messaging, facsimile, and telephonic services. 

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Physicians Description

Physicians' Assistants Description

Pharmacists Description

Social Workers Description

Doctors of Chiropractic Description

Licensed Complementary and Alternative Medicine Practitioners Description

Dieticians Description

Nutritionists Description

Other (specify): Name Description

Health Promotion Definition: Describe how health information technology will be used to link this service in a comprehensive approach across the care continuum: TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016  Care coordination can be provided by any team member including social workers and nurse managers Care Coordination services include: 1. Engaging and retaining child/family as active participants in their care. 2. Providing linkages, referrals, and coordination through face-to-face, telephone and or electronic means as necessary to implement the service plan. 3. Monitoring and conducting follow-up activities to ensure the service plan is effectively implemented and adequately addresses child/family needs. 4 Reviewing service plans with child and family Health promotion activities are conducted with an emphasis on empowering the child/family to improve health and wellness. Whenever possible these activities are accomplished using evidence based practices and/or curriculum.

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM]

Scope of benefit/service

The benefit/service can only be provided by certain provider types.

Behavioral Health Professionals or Specialists Description

Nurse Care Coordinators Description

Nurses Description

Medical Specialists Description

Physicians Description

Physicians' Assistants Description

Pharmacists Description

Social Workers Description

Doctors of Chiropractic Description

Licensed Complementary and Alternative Medicine Practitioners Description

Dieticians Description

Nutritionists TN: 16-0002 NEW JERSEY APPROVAL DATE: MAY 12, 2016 EFFECTIVE DATE: JANUARY 01, 2016 The provider standards set by NJDCF require that BHH providers are able to interface with primary care, specialty care, hospitals, and support services. Every provider is required to utilize the State's EHR(CSA). Providers are also expected to use other available means to exchange protected health information safely and securely, to include but not be limited to direct messaging, facsimile, and telephonic services. 

Application print HHS NJ.1480.R00.01 - Jan 01, 2016 file:///C/Users/Gbb9/Desktop/NJ-16-0002%205%203%2016%20(2).htm[05/16/2016 10:37:31 AM] Description

Other (specify): Name Description Health Homes Services (2 of 2)

Category of Individuals CN individuals

Service Definitions

Provide the State's definitions of the following Health Homes services and the specific activities performed under each service:

Comprehensive transitional care from inpatient to other settings, including appropriate follow-up

Definition:

Describe how health information technology will be used to link this service in a comprehensive approach across the care continuum:

Scope of benefit/service

The benefit/service can only be provided by certain provider types.

Behavioral Health Professionals or Specialists

Description

Nurse Care Coordinators

Description