Njfamilycare Application – Fill Out and Use This PDF

Use this application to see what coverage choices you qualify for

•Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP), known as NJ FamilyCare

•

you stay well

•A new tax credit that can help pay your premiums for health coverage

DO Include:

•Yourself

•Your spouse

•Your children under 21 who live with you

•Your unmarried partner who needs health coverage

•Anyone you include on your tax return, even if they don’t live with you

•Anyone else under 21 who you take care of and lives with you

You DON’T have to include:

•Your unmarried partner who doesn’t need health coverage

•Your unmarried partner’s children

•

(if you’re over 21)

•

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than 2 people in your family, you’ll need to make a copy of the pages and attach them.

You don’t need to provide immigration status or a Social Security Number (SSN) for family members who don’t need health coverage. We’ll keep all the information you provide private and secure as required by law. We’ll use personal information only to check if you’re eligible for health coverage.

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

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with you.

1. First name, Middle name, Last name, & Suffix

2. Relationship to you?

SELF

3.Date of birth (mm/dd/yyyy)

5.Sex Male Female

Official Name on Immigration Document/Card (AKA) ____________________________________________________________

Will you file jointly with your spouse?

Yes No

If yes, name of spouse:

Will you claim any dependents on your tax return? If yes, list name(s) of dependents:

Yes No

8. Are you pregnant? Yes

No a.If yes, how many babies are expected during this pregnancy? _________ Due Date _______________

YES. If yes, answer all the questions below.

NO. If no, SKIP to the income questions on page 3. Leave the rest of this page blank.

chores, etc) or live in a medical facility or nursing home?

Yes

No

11. Do you want help paying for medical bills from the last 3 months?

Yes

No

12. Do you live with at least one child under the age of 19, and are you the main person taking care of this child?

Yes

No

13. Are you a full-time student?

Yes

No

14. Were you in foster care at age 18 or older?

Yes

No

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

White

Black or African American

Native American Indian or Alaska Native Asian Indian

Chinese

Filipino Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro Samoan

Other

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

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26.If self-employed, answer the following questions:

27.OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

28. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 27b).

29.YEARLY INCOME: Complete only if your income changes from month to month.

If you don’t expect changes to your monthly income, skip to the next person.

THANKS! This is all we need to know about you.

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

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with you.

1. First name, Middle name, Last name, & Suffix

2. Relationship to you?

3. Date of birth (mm/dd/yyyy)

Official Name on Immigration Document/Card (AKA) ____________________________________________________________

Will PERSON 2 file jointly with their spouse?

If yes, name of spouse:

Yes No

8b.

Will PERSON 2 claim any dependents on their tax return? Yes No

If yes, list name(s) of dependents:

Check this box if PERSON 2 plans to be claimed as a dependent on someone’s federal tax return. If yes, please list the name of the tax filer:

How is PERSON 2 related to the tax filer?

9. Is PERSON 2 pregnant?

Yes

No a. If yes, how many babies are expected during this pregnancy? _________ Due Date _______________

White

Black or African American

Native American Indian or Alaska Native Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

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STEP 2: PERSON 2

Current Job & Income Information

CURRENT JOB 1:

28.If self-employed, answer the following questions:

29.OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

30. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 29b).

31.YEARLY INCOME: Complete only if PERSON 2’s income changes from month to month.

If you don’t expect changes to PERSON 2’s monthly income, add another person or skip to the next section.

THANKS! This is all we need to know about PERSON 2.

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

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STEP 3 Native American Indian or Alaska Native (AI/AN) family member(s)

1.Are you or is anyone in your family Native American Indian or Alaska Native?

If No, skip to Step 4. Yes. If yes, go to Appendix B.

STEP 4 Your Family’s Health Coverage

Answer these questions for anyone who needs health coverage.

1.Is anyone enrolled in health coverage now from the following?

2.Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else’s job, such as a parent or spouse.

YES. If yes, you’ll need to have your employer complete Appendix A and return to address provided.

NO. If no, continue to Step 5.

STEP 5 Select your Health Plan

If you need assistance selecting your Health Plan, contact a Health Benefits Coordinator at 1-800-701-0710, TTY 1-800-701-0720.

Choose one:

Aetna Better Health® of New Jersey (Available in ALL counties)

Amerigroup New Jersey, Inc. (Available in ALL counties)

Horizon NJ Health (Available in ALL counties)

UnitedHealthcare Community Plan (Available in ALL counties)

WellCare Health Plans of New Jersey (Available in ALL counties, except Hunterdon county)

I understand that if I’m found eligible and because I have joined a Health Plan, I must follow the rules for obtaining health care from the Health Plan. I understand that I must let my Health Plan and NJ FamilyCare know if there is any change in the number of people in my family and that any newborn children will be enrolled in my Health Plan. I understand that, unless I, or a family member, have a true medical emergency, I must call my personal doctor for medical advice, medical care or for a referral to a specialist. I understand that if I, or a family member, have a true medical emergency, I must call my personal doctor or the Health Plan as soon as possible after I, or the family member, go to the hospital. I understand that I must keep any medical appointment I have scheduled with a doctor and, if I cannot, I must call the doctor’s office to cancel the appointment. I understand that if I go to a doctor other than my personal doctor I have selected, without a referral from my doctor or

approval from the Health Plan, I may have to pay for that doctor’s services because NJ FamilyCare will not pay for the unapproved service or visit. I understand that I may change to another Health Plan and that I can call the Health Benefits Coordinator to help me do that. I give permission

for the release of my medical history and health care records and those of my family members who will be enrolled to any person(s) in the Health Plan and its providers who shall provide or coordinate health care to me and my family as long as I am a member of the Health Plan.

FOR OFFICE USE ONLY

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STEP 6 Read & sign this application.

•I understand that the NJ FamilyCare program may use or disclose protected health information about me or my children if Federal privacy law requires or allows it, or if State law requires it.

•

•I understand that the outcome of this application may be shared with any Provider providing services or who provided

•I understand that I must tell NJ FamilyCare immediately about any changes in my information, such as a change in income, address, family size, if someone in my household is expecting a baby, or if anyone in my household who applied for

member(s) of my household. I know that I must call 1-800-701-0710 (TTY 1-800-701-0720) to report any changes.

•I authorize the NJ Division of Taxation to release my tax return information to NJ FamilyCare.

•I also authorize any educational institution or school district to release my medical records or those of my child(ren) to the NJ FamilyCare program for the purpose of determining eligibility and billing the Program.

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, NJ Division of Taxation, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof.

Renewal of coverage in future years

To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow NJ FamilyCare to use income data, including information from tax returns. NJ FamilyCare will send me a notice, let me make any changes, and I can opt out at any time.

If anyone on this application is eligible for NJ FamilyCare

•I am giving to the NJ FamilyCare agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I am also giving to the NJ FamilyCare agency rights to pursue and get medical support

•If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell NJ FamilyCare and I may not have to cooperate.

My right to appeal

If I think NJ FamilyCare has made a mistake, I can appeal its decision. To appeal means to tell someone at NJ FamilyCare that I

NJ FamilyCare at 1-800-701-0710. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me.

Estate Recovery

I understand that Medicaid payments for services received on or after age 55 may be reimbursable to the State of New Jersey

be limited to, capitation payments made to a managed care organization (MCO) or transportation broker for health coverage,

transportation broker. For more information about Estate Recovery, visit http://www.state.nj.us/humanservices/dmahs/ clients/The_NJ_Medicaid_Program_and_Estate_Recovery_What_You_Should_Know.pdf

Sign this application.

may sign here, as long as you have provided the information required in Appendix C.

NOTE: The submission of a Social Security number (SSN) is mandatory in accordance with 42 U.S.C. 1320b-7.

The SSNs provided (including for a husband or wife, family members, or dependents) will be used to associate records pertaining to applicants and other

to the extent it is useful in verifying eligibility or the amount of medical assistance payments under 42 CFR 435.940 through 435.960, and preventing duplicate

audits. These procedures are designed to determine eligibility and to identify persons who fraudulently or wrongfully participate in Medicaid and DMAHS

STEP 7 Mail Completed Application.

Mail your signed application to: NJ FamilyCare

PO BOX 8367

TRENTON, NJ 08650-9802

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

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AI/AN PERSON 1

AI/AN PERSON 2

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Español, llame 1-800-701-0710 . If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-701-0720.

NJFC-APP-E-0919