N.J. Admin. Code § 10:78-2.1

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

Section 10:78-2.1 - Application

(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.

N.J. Admin. Code § 10:78-2.1

Special amendment, R.2001 d.304, effective 7/31/2001 (operative September 1, 2001).
See: 33 N.J.R. 2912(a).
Added (f).
Special amendment, R.2002 d.214, effective 6/10/2002.
See: 34 N.J.R. 2338(a).
Added (g).
Amended by R.2006 d.347, effective 10/2/2006.
See: 38 N.J.R. 2602(a), 38 N.J.R. 3095(a), 38 N.J.R. 4222(a).
Rewrote (a), (c) and (g).