NEW JERSEY
PROGRAM NAME
Plan: NJ FamilyCare
S-CHIP 1115 Waiver: NJ FamilyCare
CONTACT INFORMATION
Heidi J. Smith, RN, MSN
Executive Director
NJ FamilyCare
Department of Human Services
P.O. Box 712, 5 Quakerbridge Plaza
Trenton, NJ 08625
(609) 588-3526
PROGRAM START DATE
Plan: Plan A: February 1, 1998; Plans B
and C: March 1, 1998
Amendment 1: January 13, 1999
Amendment 2: September 1, 1999
Amendment 3: July 26, 1999
Amendment 4: January 1, 2000
S-CHIP waiver: January 18, 2001
Amendment 5: January 1, 2002
Amendment 6: August 24, 2001
HIFA Waiver: March 1, 2003
CMS SUBMISSION DATE
Plan: January 31, 1998
Amendment 1: January 21, 1999
Amendment 2: April 30, 1999
Amendment 3: September 16, 1999
Amendment 4: December 18, 1999
S-CHIP waiver: September 26, 2000
Amendment 5: February 4, 2002
Amendment 6: May 7, 2002
HIFA Waiver: July 15, 2002
TYPE OF PROGRAM
• NJ FamilyCare is a combination Medicaid
expansion and state-designed program.
• Under the S-CHIP 1115 waiver, NJ
FamilyCare expands coverage to uninsured
parents and pregnant women up to 200%
FPL through a Medicaid expansion, statedesigned program and employer-sponsored
insurance (ESI).
CMS APPROVAL DATE
Plan: April 27, 1998
Amendment 1: May 7, 1999
Amendment 2: August 3, 1999
Amendment 3: July 26, 1999
Amendment 4: March 16, 2000
S-CHIP waiver: January 18, 2001
Amendment 5: April 23, 2002
Amendment 6: July 22, 2002
HIFA Waiver Approval January 31, 2003
ELIGIBILITY LEVELS
• For children in families with incomes at or
below 133% of the FPL, coverage is
available under the Medicaid program (NJ
FamilyCare plan A).
• For children in families with incomes
between 133% and 200% of the FPL (NJ
FamilyCare plans B and C), a modified
benefits package is available.
• Cost-sharing is required for families with
incomes above 150% of the FPL (NJ
FamilyCare plan C and D).
• For plans B and C, children in families with
incomes greater than 133% of the FPL must
be uninsured for at least 6 months before
receiving coverage (unless they were covered
by insurance purchased in the individual
market or a COBRA plan prior to
ENABLING LEGISLATION
Plan: NJS 2269 (December 23, 1997)
Amendments: None provided
S-CHIP waiver: NJA-49 (PL 2000, c.71,
July 13, 2000)
NGA SUMMARY
STATE CHILDREN'S HEALTH INSURANCE PROGRAM
NEW JERSEY
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application for NJ FamilyCare).
Plan D extends coverage to children from
birth to age 19 in households with incomes
between 200% and 350% of the FPL.
Income disregards would be applied such
that these children’s income levels would fall
below 200% of the FPL.
Amendment 4 provides presumptive
eligibility for children under age 19 eligible
for NJ FamilyCare Plan A, B, and C, but not
children eligible for NJ FamilyCare Plan D.
A child who presents himself/herself at an
acute care hospital, a federal qualified health
center, or local health department that agrees
to be a presumptive eligibility determination
agency, is deemed presumptively eligible for
all NJ FamilyCare program services if a
preliminary determination by the staff of the
facility indicates that the child meets NJ
FamilyCare program eligibility standards for
NJ FamilyCare Plan A, B, or C and the child
is a member of a household with a gross
income not exceeding 200% of the FPL. An
application must be completed by the child
(if appropriate), child’s parent, guardian, or
caretaker-relative no later than the end of the
month following the month in which
presumptive eligibility is determined.
The S-CHIP 1115 waiver expands Medicaid
coverage to parents with earned incomes up
to 133% of the FPL. Since children below
133% of the FPL are eligible for Medicaid as
a result of an S-CHIP expansion, NJ sought
to claim Federal Financial Participation at the
enhanced S-CHIP rate of 65% for parents, up
to the limits of the S-CHIP allotments. If the
allotment amount is exceeded, the
entitlement continues and NJ would claim
the Medicaid matching rate of 50 percent.
The S-CHIP waiver also expands coverage to
parents with incomes between 134% and
200% of the FPL. NJ sought to claim the
Federal Financial Participation at the
enhanced S-CHIP rate of 65% for this
population of parents. The federal funding
would be claimed only up to the limits of the
S-CHIP allotment. If the allotment amount is
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exceeded, the families would be covered
under a state-only program, up to the limit of
the State appropriation. If the State
appropriation limit is reached, enrollment
will be capped and a waiting list established.
Under the S-CHIP waiver, while coverage is
available to qualifying families with incomes
below 200% of the FPL, the state wants to do
everything possible to leverage available
funds through employer-sponsored coverage.
As of June 15, 2002, NJ FamilyCare no
longer processes applications for new parents
wishing to apply.
Under the S-CHIP waiver, when possible,
coverage will be expanded to parents through
a Premium Support Program. Enrollment in
employer-sponsored insurance (ESI) will
only be pursued if the costs to the State and
family combined is less than what it would
cost the State to provide coverage under the
State-contracted plan. The employer will pay
50% of the cost of family coverage.
Under the S-CHIP waiver, coverage is
expanded to pregnant women with incomes
up to 200% of the FPL.
Utilizing state-only funds, NJ will provide
comparable coverage for lawfully admitted
aliens who do not meet the definition of
qualified alien. Like NJ FamilyCare, this
includes lawfully admitted children with
gross incomes up to 350% of the FPL before
application of disregards.
Utilizing state-only funds, NJ provided
comparable coverage for adults without
dependent children up to 100% of the FPL.
As of September 1, 2001, no new
applications were accepted.
Amendment 5 disregards income from the
Division of Medical Assistance and Health
Services to individuals who provide
information regarding individuals or entities
engaged in fraudulent or abusive health care
related activity.
NGA SUMMARY
STATE CHILDREN'S HEALTH INSURANCE PROGRAM
NEW JERSEY
BENEFITS
• The standard Blue Cross/Blue Shield PPO
option of the Federal Employees Health
Benefit Program is the benchmark for the NJ
FamilyCare program.
• Children in NJ FamilyCare plans B and C
purchase a subset of the Medicaid package
from the Title XIX program. Coverage
consists of Title XIX program and fee-forservice payments to existing Medicaid
participating network providers for benefits
not included in the managed care contracts.
• For plan D, the benefits package consists of a
subset of services from the Medicaid package
structured to mirror the commercial
benchmark plan, which is the HMO with the
largest non-Medicaid enrollment in the state.
• Under the S-CHIP waiver, pregnant women
with incomes under to 200% of the FPL,
have the benefits that are the same as under
Medicaid.
• Under the HIFA waiver, NJ FamilyCare
offers a benefit package equivalent to the
most widely sold HMO plan in the State,
Plan D, to parents that do not qualify for
AFDC and that have incomes up to 200% of
the FPL. Higher income parents pay a copay
and a premium.
• Under the Premium Support Program, if the
employer is a large business (more than 49
employees), families are not enrolled in the
employer-sponsored coverage unless the
benefit package meets or exceeds the NJ
FamilyCare package. If the employer is a
small business, families would not be
enrolled unless one of the standardized
insurance plans is provided. Wrap-around
services will be provided on a fee-for-service
basis for families employed by small
businesses only.
• Under the Premium Support Program, if an
employer offers a plan that has richer benefit
package than that provided under NJ
FamilyCare but the employer is not
determined to be cost-effective, families
would have the option of paying the excess
amount out-of-pocket.
SERVICE DELIVERY
• For children enrolled in NJ FamilyCare,
service delivery is the Title XIX system of
mandatory managed care using licensed
HMOs, with certain services carved out of
the managed care contracts and provided on a
fee-for-service basis.
• NJ FamilyCare plan D uses a managed care
delivery system with some services not
covered by the managed care contracts
provided on a fee-for-service basis.
• Service delivery under NJ FamilyCare is
based on mandatory managed care using
licensed HMOs, with certain services carved
out and provided on a fee-for-service basis.
For families with incomes below 133% of the
FPL, Medicaid services are provided on a
fee-for-service basis pending enrollment in a
managed care plan.
TARGETED NUMBER OF ENROLLEES
As of September 2002, 94,225 children were
enrolled in NJ FamilyCare.
SOURCE OF STATE MATCH
The match is from the state’s general fund.
COST-SHARING
• Plans A and B have neither premiums nor
copayments.
• Plan C has a $16.50 monthly premium for
families, regardless of income or family size.
• Plan C has the following copayment
schedule:
- $5 for practitioner visits (no charges for
well-child visits, lead screening,
immunizations, preventive dental,
prenatal care, family planning, and pap
smears);
- $10 for emergency room visits; and
- $1 for generic prescriptions; $5 for
brand-name prescriptions
NGA SUMMARY
STATE CHILDREN'S HEALTH INSURANCE PROGRAM
NEW JERSEY
• Plan D has the following cost-sharing
provisions of premiums: (On a sliding scale
based on household income.)
- 201% to 250% of the FPL: $33 monthly
per family;
- 251% to 300% of the FPL: $66 monthly
per family; and
- 301% to 350% of the FPL: $110 monthly
per family.
• Plan D has the following cost-sharing
provisions of copayments:
- Office visit: $5 for regular hours, $10 for
off-hours, and no copayment for
preventive services.
- Outpatient hospital: $5, except for
preventive care.
- Emergency room: $35, but no copayment
if the visit results in admission.
- Prescription drugs: $5, and $10 if for
greater than a 34-day supply.
- Outpatient mental health: $25.
- Outpatient detoxification: $5 per day.
Nurse-midwifery: $5, and $10 for home
visits or off-hours, except for preventive
services.
- No copayments are charged for wellchild visits, age-appropriate
immunizations, and preventive dental
- care for children under age 12, lead
screening and treatment, and prenatal
care beyond the first visit.
• Under the S-CHIP waiver, copayments equal
to those used under NJ FamilyCare Plan D
apply to parents with income above 150% of
the FPL.
• Under the S-CHIP waiver, premiums apply
only to parents with incomes above 150% of
the FPL. The premium is set at $27.50 for the
first adult and $11 for each additional
member of the household. Therefore, a
family of four pays $55 per month ($27.50
for first adult, $11 for second adult, $16.50
for children).
• Under the ESI plan, since copayments are not
permitted for preventive services for
children, the State would develop a voucher
program to reimburse providers for any such
copayments under an ESI plan.
• Under the S-CHIP waiver, there are no
premiums or other cost-sharing for pregnant
women.
• American Indian/Alaskan Native children of
federally recognized tribes do not have any
cost-sharing requirements under the sixth
amendment.
CROWD OUT
• To qualify for plans B and C, a child must be
uninsured for 6 months, unless insurance is
lost through no fault of the family, such as a
layoff.
• Under the third amendment, children who
were insured under an individual market
health plan and lost coverage, do not have a
6-month waiting period before being eligible
for SCHIP. This does not apply to children
covered by employer-sponsored health plans.
• If the child is covered by an individual health
insurance plan that was purchased on the
individual market or a COBRA plan prior to
applying for NJ FamilyCare, there is no 6month waiting period.
• The applicant is required to submit
supporting information that adequately
demonstrates income. For those applying for
Medicaid, this is checked by the state against
outside sources.
• Contact is made with the employer to ensure
that group coverage or other employersponsored coverage is not being provided.
• For children living with a custodial parent or
guardian, outreach is made to the child
support agency to determine if the child
support order includes health insurance.
• Under the S-CHIP waiver, for families with
incomes below 133% of the FPL, there
would be no crowd out provisions.
• Under the S-CHIP waiver, for families with
incomes between 134% and 200% of the
FPL, parents must be uninsured and there is a
6-month waiting period with some
NGA SUMMARY
STATE CHILDREN'S HEALTH INSURANCE PROGRAM
NEW JERSEY
exceptions for situations such as changes in
employment.
• Under the S-CHIP waiver, there are no
crowd-out provisions for coverage in the
individual market.
EVALUATION AND PERFORMANCE MEASURES
• Methods used to assure quality of care
include both internal and external
monitoring.
• HMOs are contractually required to provide
EPSDT screenings and preventive services
for well-baby care and immunizations.
• The New Jersey Department of Health and
Senior Services also has created a data
reporting system to collect standardized,
reliable, and comparable information about
access, availability of services, and quality
from each HMO. The results of an HMO's
performance are made public through release
of a “report card” that includes HEDIS
measures and results of the consumer
assessment of health plans (CAHPS) survey.
• Plan D has added a new strategic objective,
with its respective goal and measures to:
- provide near-universal access to health
care coverage for uninsured children in
the state;
- track enrollment into NJ FamilyCare; and
- track the number of uninsured children in
the state according to the current
population survey (CPS).
• Effective outreach is measured by the
number of enrolled children in Title XXI by
age, income, race, non-English speaking
beneficiaries, and customer satisfaction
surveys.
• Coordination with Title XIX is measured by
the number of individuals referred to Title
XXI and the increased percentage of
Medicaid-eligibles enrolled.
• Network adequacy is measured by the
percentage of providers accepting
beneficiaries, the number of specialists
limiting their practice to pediatrics, the
number of mental health providers trained to
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treat children, and the percentage of dentists
providing pediatric services.
Children's access to primary care providers is
measured by the percentage of Title XXIenrolled children by age category who visited
a primary care provider in the last year.
Use of services is measured by well-child
and adolescent well-care visits.
Health outcome is measured by
immunization status, adolescent
immunization status, and lead screening.
Under the S-CHIP waiver, the following
evaluation measures are used:
- to determine the number of newly
enrolled children under NJ FamilyCare
by age;
- determine the retention rate for children
whose parents are covered under NJ
FamilyCare compared to children whose
parents are not covered under NJ
FamilyCare;
- determine the number of well-child
examinations for children whose parents
are covered under NJ FamilyCare to
children whose parents are not covered
under NJ FamilyCare;
- determine the health status of children
born to pregnant women with incomes
between 185% and 200% of the FPL
under the waiver compared to otherwise
uninsured pregnant women; and
- determine health status of newborns born
to pregnant women covered under the
terms of this waiver compared to
newborns of similar but otherwise
uninsured pregnant women.™
NGA SUMMARY
STATE CHILDREN'S HEALTH INSURANCE PROGRAM