NEW JERSEY. PROGRAM NAME Plan: NJ FamilyCare S-CHIP 1115 Waiver: NJ FamilyCare

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1 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 (609) 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 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 ENABLING LEGISLATION Plan: NJS 2269 (December 23, 1997) Amendments: None provided S-CHIP waiver: NJA-49 (PL 2000, c.71, July 13, 2000) 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 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). 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

2 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 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.

3 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

4 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 6- month 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

5 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 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.