Current through Register Vol. 56, No. 18, September 16, 2024
(a) Application
for NJ FamilyCare benefits shall be accomplished by completing and signing the
application form as well as any addenda to that form as prescribed by the
Division of Medical Assistance and Health Services. Applicants may obtain NJ
FamilyCare applications from various social service locations, by calling the
Division or by calling the NJ FamilyCare program at 1-800-701-0710. Applicants
may also apply for the NJ FamilyCare program by completing an online
application form at http://www.njfamilycare.org or
http://www.NJHelps.org. The
eligibility determination agencies shall process all applications mailed,
forwarded or presented to them.
(b)
The eligibility determination agency shall:
1. Inform applicants of the purpose of and
the eligibility requirements for the NJ FamilyCare program, including their
rights to a grievance review;
2.
Receive applications and review them for completeness, consistency, and
reasonableness;
3. Assist program
applicants in exploring their eligibility for program benefits;
4. Make known to program applicants the
appropriate resources and services both within the agency and in the community;
and
5. Assure the prompt and
accurate submission of eligibility data to the Eligibility File for
beneficiaries and prompt notification to beneficiaries of the reason for their
eligibility or ineligibility.
(c) As part of the application process, an
applicant for NJ FamilyCare shall:
1.
Complete, with the assistance of the eligibility determination agency, as
needed, any forms required as part of the application process; and
2. Assist the eligibility determination
agency in securing evidence that verifies his or her statements regarding
eligibility.
(d) For any
application for NJ FamilyCare benefits under the provisions of this chapter,
the eligibility determination agency shall accomplish disposition of the
application as soon as all factors of eligibility are met and verified but not
later than 30 days from the date of application. Exceptions to the timeliness
standard appear in (d)2 below.
1. "Disposition
of the application" means the official determination by the eligibility
determination agency of eligibility or ineligibility of the applicant(s) for NJ
FamilyCare.
2. Disposition of the
application may exceed the applicable processing standard when substantially
reliable evidence of eligibility or entitlement for benefits is lacking at the
end of the processing period. In such circumstances, the application may be
continued in pending status. The eligibility determination agency shall fully
document in the case record the circumstances of the delayed application
processing. The processing standard may be exceeded for any of the following:
i. Circumstances wholly within the control of
the applicant;
ii. A determination
by the eligibility determination agency, when evidence of eligibility or
entitlement is incomplete or inconclusive, to afford the applicant additional
time to provide evidence of eligibility before final action on the
application;
iii. An administrative
or other emergency that could not reasonably have been avoided; or
iv. Circumstances wholly beyond the control
of both the applicant and the eligibility determination agency.
3. When disposition of the
application is delayed beyond the processing standard, the eligibility
determination agency shall provide the applicant written notification prior to
the expiration of the processing period, setting forth the specific reasons for
the delay.
4. Each eligibility
determination agency director shall establish appropriate operational controls
to expedite the processing of applications and to assure maximum compliance
with the processing standard.
i. The
eligibility determination agency shall maintain control records identifying all
pending applications which have exceeded the processing standard and the reason
therefor. The record shall be adequate to make possible the preparation of
reports of such information as may be requested by the Division of Medical
Assistance and Health Services.
(e) The following actions on an application
qualify as disposition of an application for purposes of the processing
standard:
1. Approved: The applicant has been
determined eligible for NJ FamilyCare;
2. Denied: The applicant has been determined
ineligible for NJ FamilyCare;
3.
Dismissed: A decision by the eligibility determination agency that the
application process need not be completed because:
i. The applicant has died;
ii. The applicant cannot be
located;
iii. The application was
registered in error; or
iv. The
applicant has moved out of the State during the application process;
and
4. Withdrawn: The
applicant requests that eligibility for the NJ FamilyCare program no longer be
considered.
(f) The New
Jersey FamilyCare Health Coverage Program will not process applications
postmarked on or after September 1, 2001 for single adults and couples without
dependent children who are not eligible for General Assistance.
(g) The New Jersey FamilyCare Health Coverage
Program did not process applications received after the close of business on
June 14, 2002 and prior to September 1, 2005, from those parents or caretakers
who would have qualified only under the provisions of this chapter during that
time.
