N.J. Admin. Code § 10:78-11.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:78-11.2 - Eligibility and redetermination of eligibility

(a) Individuals who were enrolled in the New Jersey Health Access program on October 31, 2001, and who returned a plan selection form by November 13, 2001, shall be eligible to enroll in the NJ FamilyCare program.

1. An enrollee who is denied the opportunity to enroll in the New Jersey FamilyCare program because he or she did not return a plan selection form by November 13, 2001 shall have the right to file a grievance with the Health Access New Jersey Grievance Board in accordance with (a)2 below, if the grievance is filed with the Access program within 10 days of receipt of notice of discontinuation of the Access program mailed November 14, 2001. If the enrollee has not filed a grievance within 10 days of receipt of the notice mailed on November 14, 2001, no further opportunity to file a grievance shall be available.

2. If an enrollee has a grievance pertaining to the subsidy level calculated or involuntary disenrollment in the Access Program, the enrollee shall submit a description of the grievance to the Access Program in writing within 10 days of the adverse notification. The Access Program shall notify the enrollee of its decision on the matter in writing, specifying the reasons for the decision, within 30 days of receipt of the complete documentation of the grievance. The Access Program shall retain all correspondence and documentation relating to the grievance in the enrollee's file. The Access Program's decision shall be considered the final agency determination.

(b) An enrollee shall remain eligible for the NJ FamilyCare program for former Health Access enrollees if:

1. The enrollee meets the eligibility limits established by the Division at (b)2 through 5 below, and the applicant's family gross income meets the income limits established by the Division, which shall not exceed 250 percent of the Federal poverty income guidelines revised annually by the United States Department of Health and Human Services, pursuant to the provisions of 42 U.S.C.§ 9902(2), incorporated herein by reference. (For further information on the poverty income guidelines, contact the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, Washington, DC 20201; telephone: 202-690-6141);

2. The enrollee continues to reside in New Jersey;

i. All enrollees shall be required to submit a signed affidavit stating their intent to remain in New Jersey; and

ii. Documentation of residency may be required, if determined necessary by program audit staff;

3. The enrollee is not eligible for employer-based insurance;

4. The enrollee is not currently enrolled in any other government program providing health care benefits; and

5. The enrollee is not currently covered under an individual standard health benefits plan or other individual health coverage.

(c) An enrollee's eligibility shall be redetermined on at least an annual basis, and in each subsequent 12-month period an enrollee shall submit an attestation of assets in addition to submitting to a redetermination of eligibility based on gross income, in accordance with (d) and (e) below.

(d) Determination of income for former Health Access enrollees shall be as follows:

1. Gross income for the person to be insured shall include the gross income of all legally responsible adults in a family, unearned income of minor children, and with respect to dependents of persons residing in a household separate from the dependent, that portion of the legally responsible adult's income required to be available for the care and support of that dependent.

i. A family includes legally married spouses and their dependent child(ren), and a single person and his or her dependent child(ren), as child and dependent are defined by the Board in the standard health benefits plan HMO policy form in Exhibit F of the Appendix to N.J.A.C. 11:20.

ii. A family shall not include persons residing within the same residence who do not have a legal relationship or legal dependency obligation for support.

2. Income for purposes of redetermining eligibility of former Health Access enrollees for NJ FamilyCare shall be determined as follows:

i. For farm and non-farm self-employed persons, income shall be calculated using adjusted gross income reported on the family's Federal income tax form(s) from the prior year as the baseline and adding back in reported depreciation, carryover loss, and net operating loss amounts that apply to the business in which the family is currently engaged. Enrollees shall report the most recent financial situation of the family if it has changed from the period of time covered by the Federal income tax form. The report may be in the form of a percentage increase or decrease.

ii. For wage earners, income shall be calculated based on gross income reported in the four months immediately preceding, multiplied by three to reflect a 12-month period.

iii. For unemployed persons eligible for a governmental income program, income shall be determined by the amount of expected payments from the government agency plus any other gross income.

iv. For other individual circumstances, income shall be calculated based on a combination and/or variation of (d)2i, ii and/or iii above, as appropriate.

(e) Proof of income requirements for former New Jersey Health Access enrollees shall be as follows:

1. The enrollee shall provide acceptable proof of income that may include any of the following: paycheck stub, W-2 form, a letter from an employer on company letterhead stating an individual's income, or a statement of the gross benefit amount from any governmental agency providing benefit to the individual. These should be submitted in the combination appropriate for the individual or family. Enrollees shall submit a signed copy of their most recent Federal income tax form filed, if any.

2. Additional documentation may be requested of an individual, on a case-by-case basis, for verifying eligibility.

3. Changes that could impact an individual's or family's eligibility shall be reported immediately. As soon as identified, enrollees shall report, at a minimum, changes in the following:

i. Income;

ii. Employment status;

iii. Family composition (birth, death, marriage, divorce);

iv. Address; and

v. Availability of other health coverage.

4. Failure to provide factual information may result in immediate disenrollment and may result in the imposition of payback provisions available under the law.

(f) A beneficiary who was transferred to NJ FamilyCare from the NJ Health Access program shall be eligible to receive the service package appropriate for that beneficiary, based on all relevant eligibility factors other than financial eligibility factors.

N.J. Admin. Code § 10:78-11.2

Special amendment, R.2002 d.214, effective 6/10/2002.
See: 34 N.J.R. 2338(a).
Added (f).