Current through Register Vol. 56, No. 18, September 16, 2024
(a) The Statewide
eligibility determination agency or CWA shall screen all mail-in and walk-in
applications against the existing Medicaid eligibility file. Applications that
involve family members who are already enrolled in the Medicaid program shall
be forwarded to the applicable eligibility determination agency for inclusion
in the existing case, as appropriate. The eligibility determination agencies
are required to refer any child found not eligible for Medicaid or any child
losing eligibility for Medicaid or NJ FamilyCare-Children's Program-Plan A to
the NJ FamilyCare-Children's Program-Plan B, C, and D program. The CWA should
process all applications mailed or forwarded to them or all walk-ins for NJ
FamilyCare-Children's Program-Plan A if the child's family income appears to
meet the income standards. NJ FamilyCare-Plan A cases that are enrolled in a
managed care organization (MCO) that are under the jurisdiction of the CWA and
who would qualify for NJ FamilyCare-Plan B solely due to an increase of
household income can be retained at the CWA.
(b) The eligibility determination agency is
required to verify all factors related to eligibility for the NJ
FamilyCare-Children's Program. Factors subject to verification include:
1. Birth date: The birth date of any child
for whom benefits are sought must be provided. If there is a discrepancy
between the age reported by the applicant and the age appearing on the Medicaid
record, and the discrepancy affects eligibility or categorical requirement,
then documentation shall be requested;
2. Citizenship: For applicants whose family
income appears to meet the income standards for NJ FamilyCare-Children's
Program-Plan A, the child's citizenship and identity must be verified as
required by Section 6036 of the Deficit Reduction Act of 2005 (109 P.L. 171).
For applicants whose family income appears to meet the income standards for NJ
FamilyCare-Children's Program-Plans B, C or D, verification of citizenship may
be requested if the child's U.S. citizenship is not certain;
3. Alien status: If the child is not a U.S.
citizen, the alien status must be verified;
4. Household composition: The eligibility
determination agency must verify the household composition in order to
ascertain which persons will be included in the determination of eligibility
for NJ FamilyCare-Children's Program benefits;
5. Social Security number: A Social Security
number is not required in order to apply for NJ FamilyCare-Children's Program
benefits under this chapter, which are provided under Title XXI of the Social
Security Act. In the event that a child is found to be otherwise eligible for
Medicaid coverage under Title XIX of the Social Security Act, a Social Security
number would be required in order to enroll the child in that
program;
6. Eligibility for or
coverage under other health insurance; and
7. The eligibility determination agency must
verify all sources of income of any person whose income must be counted in the
determination of program eligibility. While resources are not a factor of
eligibility for benefits for children under this chapter, resources must be
identified and verified to determine if income is derived from the
resources.
(c) The
eligibility determination agency shall use documentary evidence as the primary
source of verification. Documentary evidence is written confirmation of the
family's circumstances. It is the responsibility of the authorized agent or
applicant to obtain or to assist the eligibility determination agency in
obtaining any required documentation.
(d) In circumstances in which the documentary
evidence is questionable or is not available, the eligibility determination
agency may use appropriate databases, records and/or collateral contact to
confirm the family's circumstances. A collateral contact is a verbal
confirmation of a family's circumstances by a person outside the family. In
order to be acceptable as verification, a collateral contact must be in a
position to provide accurate information about the family and the circumstance
in question.
(e) In the absence of
credible verification of all eligibility factors, eligibility for the NJ
FamilyCare-Children's Program may not be established.
(f) For any application for NJ
FamilyCare-Children's Program benefits under the provisions of this chapter,
the eligibility determination agency must 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, or from the date of the
inquiry form PA-1C, if applicable. Exceptions to the timeliness standard appear
in (f)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-Children's Program.
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 which identify 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.
(g)
The following actions documented by the eligibility determination agency 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-Children's
Program;
2. Denied: The applicant
has been determined ineligible for NJ FamilyCare-Children's Program;
3. Dismissed: A decision by the eligibility
determination agency that the application process need not be completed
because:
i. The child has died except that:
(1) The application process must be completed
if there are unpaid medical bills for covered services in the retroactive
coverage period or subsequent to program application if applicable (Plan A
only);
ii. The child
cannot be located;
iii. The
application was registered in error;
iv. The child has moved out of the State
during the application process and there are no unpaid bills for the time
period beginning with the retroactive eligibility period up to the date of
relocation for Plan A only;
v.
Requested verifications were not provided; or
vi. Initial premiums were not paid;
and
4. Withdrawn: The
authorized agent or applicant requests in writing or by telephone that
eligibility for the NJ FamilyCare-Children's Program be no longer
considered.
