N.J. Admin. Code § 10:78-3.4

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

Section 10:78-3.4 - Beneficiaries

(a) Except as specified in (b) through (d) below, the following persons who meet all the eligibility criteria of this chapter and are not eligible to receive Medicaid or NJ FamilyCare Children's Program coverage under current provisions shall be eligible for NJ FamilyCare benefits:

1. Parents and caretakers of dependent children under the age of 19 whose gross family income does not exceed 200 percent of the Federal Poverty level (see N.J.A.C. 10:78-4), who applied as such for NJ FamilyCare benefits prior to June 15, 2002, and continuously have received those benefits;

2. Single adults or couples without dependent children whose gross family income does not exceed 100 percent of the Federal Poverty level (see N.J.A.C. 10:78-4) who applied as such for NJ FamilyCare benefits prior to September 1, 2001, and continuously have received those benefits.

i. A couple shall be defined as a man and a woman who are legally married, or who have been determined to be a couple by the Social Security Administration, or who are living together in the same household and presenting themselves to the community in which they live as husband and wife;

3. Pregnant women of any age during the term of a medically verified pregnancy whose gross family income does not exceed 200 percent of the Federal Poverty level.

i. A pregnant woman who is determined eligible under the criteria of this chapter shall, for purposes of eligibility, be considered to be a pregnant woman until the end of the 60-day period beginning with the last day of her pregnancy. Her eligibility as a pregnant woman shall end on the last day of the month in which the 60-day period ends;

4. Individuals under the age of 21 lawfully admitted for permanent residence and who qualify under the provisions in N.J.A.C. 10:69 or 10:79 but for Federal immigration residency restrictions;

5. Any child born to a woman eligible under the provisions of this chapter (except to a presumptively eligible pregnant woman who has subsequently been found ineligible for the month the child was born) shall remain eligible for a period of not less than 60 days from his or her birth and up to one year, so long as the mother remains eligible for NJ FamilyCare, or would remain eligible if pregnant, whether or not application has been made, if the child lives with his or her mother.

i. Notwithstanding (a)5 above, any child resulting from the pregnancy shall be eligible for NJ FamilyCare, if not otherwise eligible for Medicaid or the NJ FamilyCare Children's Program, without regard to changes in the household unit's income for a period of not less than 60 days and up to a period of one year, so long as the mother remains eligible for NJ FamilyCare, or would remain eligible if pregnant, and the child remains in the mother's custody;

6. Parents, or caretakers, of dependent children under the age of 19 who meet the eligibility criteria contained in (a)6i through iv below and in this chapter, and who either were enrolled for benefits in the NJ FamilyCare Program on or after September 1, 2005, and continuously have received those benefits or have a pending application for such benefits that was received on or before February 28, 2010. The gross family income standards for eligibility of such individuals follows:

i. Effective September 1, 2005, parents, or caretakers, of dependent children under the age of 19 whose gross family income does not exceed 100 percent of the Federal Poverty Level;

ii. Effective September 1, 2006, parents, or caretakers, of dependent children under the age of 19 whose gross family income does not exceed 115 percent of the Federal Poverty Level;

iii. Effective September 1, 2007, parents, or caretakers, of dependent children under the age of 19 whose gross family income does not exceed 133 percent of the Federal Poverty Level; and

iv. Effective September 1, 2008, and applying to NJ FamilyCare existing enrollments under this paragraph and applications received by February 28, 2010, parents or caretakers of dependent children under the age of 19 whose gross family income does not exceed 200 percent of the Federal Poverty Level; and

7. Any individual receiving NJ FamilyCare under the provisions of this chapter who is receiving inpatient services covered by NJ FamilyCare shall continue to be eligible for FamilyCare until the end of the stay for which the inpatient services are furnished, notwithstanding any other provision of this chapter.

(b) For all enrollment applications received after February 28, 2010, all programs under this chapter are closed to any enrollments of, or benefits for, parents and caretakers whose benefits are not funded or payable under Title XIX of the Social Security Act, except as described in (b)1 below. Therefore, such applications for such persons will not be processed for enrollment. This exclusion from enrollment and benefits additionally applies to parents or caretakers who are applying to enroll after being terminated from enrollment in the NJ FamilyCare Program, including, but not limited to, individuals who have been terminated due to non-payment of premiums or other amounts due.

1. This exclusion from enrollment and benefits does not apply to parents or caretakers who are enrolled in NJ FamilyCare and who subsequently become enrolled in one of the State's programs for pregnant women, provided that they otherwise continue to be eligible for NJ FamilyCare benefits at the time of application and provided that they apply for re-enrollment in NJ FamilyCare at the close of their coverage under the other program.

(c) Effective June 15, 2002, applicants who are restricted alien children, as defined at 10:78-3.2, shall be uninsured and financially eligible for the NJ FamilyCare Children's Program Plans A, B, C or D, in accordance with the provisions of N.J.A.C. 10:79.

(d) On and after April 1, 2010, applicants or beneficiaries who are adult restricted aliens, as defined at 10:78-3.2, shall be ineligible for enrollment in, and benefits from, the NJ FamilyCare Program or any other program under this chapter, except as allowed pursuant to 10:78-3.2(e)2. This termination of enrollment and benefits under the program does not apply to individuals who are pregnant women or children under the age of 19.

N.J. Admin. Code § 10:78-3.4

Special amendment, R.2002 d.214, effective 6/10/2002.
See: 34 N.J.R. 2338(a).
In (a), substituted "Except as specified in (b) below, the" for "The", inserted "the" preceding "eligibility criteria" and substituted "shall be" for "are" in the introductory paragraph; added (b) and (c).
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 the section.
Special amendment, R.2010 d.133, effective 6/1/2010.
See: 42 N.J.R. 1404(a).
In the introductory paragraph of (a), inserted "through (d)"; rewrote the introductory paragraph of (a)6; in (a)6i and (a)6ii, substituted a semicolon for "shall be eligible to apply for NJ FamilyCare." at the end; in (a)6iii, deleted "shall be eligible to apply for NJ FamilyCare" following "Level"; added (a)6iv; added new (b); recodified former (b) as (c); in (c), inserted ", as defined at N.J.A.C. 10:78-3.2,", and deleted a comma following "C"; and added (d).