Fill Out a Valid Njfamilycare Application Template

Fill Out a Valid Njfamilycare Application Template

Sample - Njfamilycare Application Form

Document Specifications

Detailed Steps for Using Njfamilycare Application

Learn More on Njfamilycare Application

Common mistakes

Documents used along the form

Similar forms

Dos and Don'ts

Misconceptions

Key takeaways

Sample - Njfamilycare Application Form

Document Specifications

Detailed Steps for Using Njfamilycare Application

Learn More on Njfamilycare Application

Common mistakes

Documents used along the form

Similar forms

Dos and Don'ts

Misconceptions

Key takeaways

Who is eligible to use the NJ FamilyCare application form?

What information do I need to apply for NJ FamilyCare?

Why is income and other personal information required on the application?

What happens after submitting the NJ FamilyCare application form?

How can I get assistance with my NJ FamilyCare application?

Does NJ FamilyCare comply with federal civil rights laws?

Who is eligible to use the NJ FamilyCare application form?

What information do I need to apply for NJ FamilyCare?

Why is income and other personal information required on the application?

What happens after submitting the NJ FamilyCare application form?

How can I get assistance with my NJ FamilyCare application?

Does NJ FamilyCare comply with federal civil rights laws?

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The NJFamilyCare Application form is a comprehensive document designed to help individuals and families in New Jersey access affordable health coverage through programs such as Medicaid or the Children's Health Insurance Program (CHIP). By filling out this application, applicants can determine their eligibility for free or low-cost insurance, as well as potential assistance with premium costs through new tax credits. The form is user-friendly, encouraging applicants to provide details about their family's income, current health insurance, and employment information, ensuring a tailored approach to health coverage based on each applicant's unique circumstances.

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Fill Out a Valid Njfamilycare Application Template

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Navigating the landscape of health coverage can seem daunting, especially when trying to find affordable options that cater to the needs of individuals and families. The NJFamilyCare Application form serves as a crucial gateway for New Jersey residents seeking access to free or low-cost health insurance through Medicaid or the Children’s Health Insurance Program (CHIP), known collectively as NJ FamilyCare. This comprehensive application is designed to simplify the enrollment process, offering a path to a range of coverage choices, including the potentially life-altering benefit of a new tax credit to assist with premium costs. Individuals and families, regardless of their immigration status, are encouraged to apply. Even those with existing health coverage may find they’re eligible for more affordable or comprehensive options through this program. The form collects vital information, such as social security numbers, income, and current insurance policies, to identify qualification for assistance. Importantly, applying does not commit one to purchase coverage but rather opens the door to discovering what aids are available. With privacy and non-discrimination at its foundation, the NJFamilyCare Application is a critical tool in ensuring that New Jersey residents have the health coverage necessary to maintain and improve their well-being. Fast-track options and assistance in various languages are readily offered, ensuring the process is as accessible as possible to all New Jersey residents, underlining the program’s commitment to public health and financial accessibility.

Application for Health Coverage & Help Paying Costs

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

	Who can use this	• Use this application to apply for anyone in your family.
	application?	• Apply even if you or your child already has health coverage. You could be
	application?	eligible for lower-cost or free coverage.
		eligible for lower-cost or free coverage.
		• If you’re single, you may be able to use a short form.
		Visit njfamilycare.org.
		• Families that include immigrants can apply. You can apply for your

			immigration status or chances of becoming a permanent resident or
			citizen.
		•	d to
			complete Appendix C.
TO KNOW	Apply faster	Apply faster online at njfamilycare.org.
	online
	What you may	• Social Security Numbers (or document numbers for any legal immigrants

THINGS			who need insurance)
	need to apply		who need insurance)
		• Employer and income information for everyone in your family (for


			example, from paystubs, W-2 forms, or wage and tax statements)
		• Policy numbers for any current health insurance
		• Information about any job-related health insurance available to your family
	Why do we ask for	We ask about income and other information to let you know what coverage
	this information?	you qualify for and if you can get any help paying for it. We’ll keep all the
	this information?	information you provide private and secure, as required by law. To view

		the Privacy Act Statement, go to njfamilycare.org.
	What happens next?	Send your complete, signed application to the address on page 7.
		If you don’t have all the information we ask for, sign and submit
		your application anyway. We’ll follow-up with you within 1–2 weeks. You’ll
		get instructions on the next steps to complete your health coverage. If you
		don’t hear from us, visit njfamilycare.org or call 1-800-701-0710. Filling out
		this application doesn’t mean you have to buy health coverage.
	Get help with this	•	Online: njfamilycare.org
	application	• Phone: Call our Help Center at 1-800-701-0710.
	application

•In person: There may be counselors in your area who can help. Visit our website or call 1-800-701-0710 for more information.

•En Español: Llame a nuestro centro de ayuda gratis al

1-800-701-0710.

	NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or	E-0919
	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).	-
		NJFC-APP
		NJFC-APP

STEP 1 Tell us about yourself.

(We need one adult in the family to be the contact person for your application.)

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

2.	Home address (Leave blank if you don’t have one.)								3. Apartment or suite number

4.	City			5. State		6. ZIP code	7. County

8.	Current mailing address (if diﬀerent from home address)								9. Apartment or suite number

10.		City		11. State		12. ZIP code	13. County

14. Phone number					15. Other phone number
(		)	–		(	)		–

16.		Do you want to get information about this application by email?			Yes	No
Email address:

17.		What is your preferred spoken or written language (if not English)?

STEP 2 Tell us about your family.

Family Planning (Plan First Program)

If any person on this application is not eligible for NJ FamilyCare, would you like them to be evaluated for family planning services (Plan First Program)?

Yes	Check here for all applicants on this application to be evaluated for family planning services.

Plan First is a program for women and men that provides only family planning and related services (such as birth control and reproductive health care). Family planning services do not provide minimum essential health care coverage (such as routine care).

Who do you need to include on this application?

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).

Page 1 of 7

NJFC-APP-E-0919

STEP 2: PERSON 1 (Start with yourself)

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you

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

4. Citizenship Status:	US Citizen	Refugee	Asylee	Not Lawfully Admitted
Legal Alien ____________ USCIS/Alien #__________________________				Immigration Card #__________________________
Date of Entry

Oﬃcial Name on Immigration Document/Card (AKA) ____________________________________________________________

6. Social Security number (SSN)						-				-

We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who’s eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.

7a. Check this box if you plan to ﬁle a federal income tax return NEXT YEAR.

(You can still apply for health insurance even if you don’t ﬁle a federal income tax return.)

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

7b. Check this box if you will be claimed as a dependent on someone’s federal tax return.

If yes, please list the name of the tax ﬁler:

How are you related to the tax ﬁler?

8. Are you pregnant? Yes

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

9.Do you need health coverage?

(Even if you have insurance, there might be a program with better coverage or lower costs.)

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.

10. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily

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

Yes

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

Yes

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

13. Are you a full-time student?

Yes

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

Yes

15.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

16.Race (OPTIONAL—check all that apply.)

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

Page 2 of 7

NJFC-APP-E-0919

STEP 2: PERSON 1

(Continue with yourself)

Current Job & Income Information

Employed

Not employed

Self-employed

If you’re currently employed, tell us

Skip to question 27.

Skip to question 26.

about your income. Start with question

17.

CURRENT JOB 1:

17. Employer name and address

18. Employer phone number

(

)

–

19. Wages/tips (before taxes)

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

20. Average hours worked each WEEK

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)

21. Employer name and address

22. Employer phone number

(

)

–

23. Wages/tips (before taxes)

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

24. Average hours worked each WEEK

25. In the past year, did you:

Change jobs Stop working

Start working fewer hours

None of these

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

a. Type of work	b. How much net income (proﬁts once business expenses are
	paid) will you get from this self-employment this month?
	$

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).

None			Net farming/ﬁshing
Unemployment	$	How often?	Net farming/ﬁshing	$	How often?
Unemployment	$	How often?	Net rental/royalty	$	How often?
Pensions	$	How often?	Net rental/royalty	$	How often?
			Other income	$	How often?

Social Security	$	How often?
Social Security	$	How often?	Type:
Retirement accounts	$	How often?	Type:
Retirement accounts	$	How often?
Alimony received	$	How often?

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).

Alimony paid

How often?

Other deductions

How often?

Student loan interest

How often?

Type:

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.

Your total income this year	Your total income next
$	$

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

Page 3 of 7

NJFC-APP-E-0919

Guamanian or Chamorro Samoan

Other

STEP 2: PERSON 2	If you have more than two people to include, make a

	copy of Step 2: Person 2 (pages 4 and 5) and complete.

Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you

with you.

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

2. Relationship to you?

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

5. Sex

Male

Female

4. Citizenship Status:	US Citizen	Refugee	Asylee	Not Lawfully Admitted
Legal Alien ____________ USCIS/Alien #__________________________				Immigration Card #__________________________
Date of Entry

Oﬃcial Name on Immigration Document/Card (AKA) ____________________________________________________________

6.	Social Security number (SSN)	-	-		We need this if you want health coverage and have an SSN.
6.	Social Security number (SSN)	-	-		We need this if you want health coverage and have an SSN.
7.	Does PERSON 2 live at the same address as you?		Yes	No
	If no, list address:

8a. Check this box if PERSON 2 plans to ﬁle a federal income tax return NEXT YEAR.

(You can still apply for health insurance even if you don’t ﬁle a federal income tax return.)

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 _______________

10.Does PERSON 2 need health coverage?

(Even if they have insurance, there might be a program with better coverage or lower costs.)

YES. If yes, answer all the questions below.	NO. If no, SKIP to the income questions on page 5.
	Leave the rest of this page blank.

11.Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? Yes No

12. Does PERSON 2 want help paying for		13. Does PERSON 2 live with at least one child under			14. Was PERSON 2 in foster care at age

medical bills from the last 3 months?		the age of 19, and are they the main person			18 or older?
Yes	No	taking care of this child?	Yes	No	Yes	No

Please answer the following questions if PERSON 2 is 22 or younger:

16.Is PERSON 2 a full-time student? Yes No

17.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

18.Race (OPTIONAL—check all that apply.)

White

Black or African American

Native American Indian or Alaska Native Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Now, tell us about any income from PERSON 2

Page 4 of 7

NJFC-APP-E-0919

STEP 2: PERSON 2

Current Job & Income Information

Employed	Not employed	Self-employed
If you’re currently employed, tell us	Skip to question 29.	Skip to question 28.
about your income. Start with question
19.

CURRENT JOB 1:

19. Employer name and address							20. Employer phone number
							(	)	–

21. Wages/tips (before taxes)	Hourly	Weekly	Every 2 weeks	Twice a month	Monthly			Yearly
$

22. Average hours worked each WEEK

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)
23. Employer name and address							24. Employer phone number
							(	)	–

25. Wages/tips (before taxes)	Hourly	Weekly	Every 2 weeks	Twice a month	Monthly			Yearly
$

26. Average hours worked each WEEK

27. In the past year, did PERSON 2:		Change jobs	Stop working	Start working fewer hours		None of these

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

a. Type of work	b. How much net income (proﬁts once business expenses are
	paid) will you get from this self-employment this month?
	$

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).

None
Unemployment	$	How often?	Net farming/ﬁshing	$	How often?
Unemployment	$	How often?	Net rental/royalty	$	How often?
Pensions	$	How often?	Net rental/royalty	$	How often?
Pensions	$	How often?	Other income	$	How often?
Social Security	$	How often?	Other income	$	How often?
Social Security	$	How often?	Type:
Retirement accounts	$	How often?	Type:
Retirement accounts	$	How often?
Alimony received	$	How often?
Alimony received	$	How often?

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).

Alimony paid

How often?

Other deductions

How often?

Student loan interest

How often?

Type:

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.

PERSON 2’s total income this year	PERSON 2’s total income next year
$	$

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

Page 5 of 7

NJFC-APP-E-0919

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?

YES. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have.

NO.

Medicaid

Employer insurance

NJ FamilyCare

Name of health insurance:

Policy number:

Medicare

Is this COBRA coverage?

Yes

TRICARE (Don’t check if you have direct care or Line of Duty)

Is this a retiree health plan?

Yes

Other

VA health care programs

Name of health insurance:

Policy number:

Peace Corps

Plan First (Family Planning)

Yes

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

Name _____________________________________________________________

Case # _________________________________________________________________

Page 6 of 7

NJFC-APP-E-0919

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

from a spouse or parent.
• Does any child on this application have a parent living outside of the home?	Yes	No

•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.

Signature	Date (mm/dd/yyyy)

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

Page 7 of 7

NJFC-APP-E-0919

APPENDIX A

Health Coverage from Jobs

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this

Tell us about the job

You need to include this page when you send in your application.

EMPLOYEE Information

1. Employee name (First, Middle, Last)

2. Employee Social Security number

EMPLOYER Information

3. Employer name

4. Employer Identiﬁcation Number (EIN)

5. Employer address

6. Employer phone number

(

)

–

7. City

8. State

9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above)

12. Email address

(

)

–

13. A

Yes (Continue)

13a. If you’re in a waiting or probationary period, when can you enroll in coverage?

List the names of anyone else who is eligible for coverage from this job.

(mm/dd/yyyy)

Name:

No (Stop here and go to Step 5 in the application)

Tell us about the health plan

d*? Yes No

15.For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

a.How much would the employee have to pay in premiums for this plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Quarterly

Yearly

16.What change will the employer make for the new plan year (if known)?

Employer

the employee that meets the minimum value standard.* (Premium should reﬂect the discount for wellness programs. See question 15.)

a. How much will the employee have to pay in premiums for that plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Quarterly

Yearly

Date of change (mm/dd/yyyy):

*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed beneﬁt costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este	-E-0919
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	-APP
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

APPENDIX B

Native American Indian or Alaska Native Family Member (AI/AN)

Complete this appendix if you or a family member are Native American Indian or Alaska Native. Submit this with your NJ FamilyCare Application for Health Coverage & Help Paying Costs.

Tell us about your Native American Indian or Alaska Native family member(s).

Native American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible.

NOTE: If you have more people to include, make a copy of this page and attach.

AI/AN PERSON 1

AI/AN PERSON 2

1. Name

First

Middle

First

Middle

(First name, Middle name, Last name)

Last

2. Member of a federally recognized tribe?

Yes

If yes, tribe name

3. Has this person ever gotten a service from

Yes

the Indian Health Service, a tribal health

program, or urban Indian health program,

or through a referral from one of these

If no, is this person eligible to get

programs?

services from the Indian Health

Service, tribal health programs, or

urban Indian health programs, or

through a referral from one of these

programs?

Yes

4. Certain money received may not be

counted for NJ FamilyCare. List any

income (amount and how often) reported

How often?

on your application that includes money

from these sources:

•Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

•Payments from natural resources, farming, ranching, ﬁshing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations)

•Money from selling things that have cultural signiﬁcance

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

➤ PDF

Fact Name	Description
Application Purpose	The form is designed to determine eligibility for free or low-cost insurance through Medicaid or the Children’s Health Insurance Program (CHIP), known collectively as NJ FamilyCare, and potentially for a new tax credit to help pay premiums.
Who Can Apply	Individuals and families, including those with immigrants, applying for anyone in their family, can use this form. Even applicants with existing health coverage are encouraged to apply to see if they qualify for lower-cost or free coverage.
Information Required	Applicants must provide Social Security Numbers (or document numbers for legal immigrants needing insurance), employer and income information, current health insurance policy numbers, and details about any job-related health insurance available.
Privacy and Security	The NJ FamilyCare program pledges to keep all provided information private and secure, in compliance with relevant laws, ensuring applicants' personal and sensitive data are protected.

Filling out the NJ FamilyCare Application is the first step towards securing health coverage for you and your family. This process might seem daunting, but it’s essentially about providing information about yourself, your family, and your financial situation to see what kind of assistance you can get. It's important to know that an incomplete application should not stop you from submitting it; the NJ FamilyCare team will reach out if they need more details. Here's how to correctly fill out your application:

Start by providing details about yourself as the main contact for this application. Include your first, middle, and last names, and suffix if applicable, along with your home address. If you don’t have one, leave it blank.
Enter your apartment or suite number, city, state, ZIP code, and county. If your current mailing address is different from your home address, provide those details as well.
Include your phone numbers and email address. Indicate if you wish to receive information about this application by email and provide your preferred spoken or written language if it's not English.
For the section about your family, indicate if anyone should be evaluated for family planning services under the Plan First Program. Include on this application: 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, and anyone else under 21 who you take care of and lives with you.
For each family member you're including, start with yourself (Person 1): Provide your name, relationship to you, date of birth, sex, citizenship status, social security number (if applying for health coverage), and information about if you’ll file a federal income tax return next year. Answer questions about your pregnancy status, need for health coverage, any health conditions, if you want help with medical bills from the last 3 months, if you live with and take care of a child under 19, your student status, and if you were in foster care at 18 or older. Optional: Include ethnicity and race.
Detail your current job and income information, including employer name, address, phone number, wages/tips before taxes and average hours worked each week. If you’re not employed, skip to the questions about other income sources, and if you’re self-employed, provide details about your work and net income.
List all other types of income this month and any deductions you might have.
If your income changes from month to month, provide your total income this year and your expected total income next year. If your income is stable, you can skip this section.
Repeat these steps for each additional person (Person 2, etc.) in your family by making copies of the pages as needed.

After completing the application, review it carefully to ensure all information is accurate and sign it. Send your complete signed application to the address provided on page 7 of the form. Remember, submitting your application is not a promise to buy coverage but a step towards understanding the health insurance options available to you and your family. Don't hesitate to seek help through the resources provided if you have questions or need assistance during this process.

The NJ FamilyCare application form is designed for anyone in a family who needs health coverage. This includes individuals, children, and even those with current health insurance who may be eligible for lower-cost or free coverage. Singles, families that include immigrants, and those applying on behalf of another family member can use this application. Even if there is concern about immigration status affecting eligibility for becoming a permanent resident or citizen, it's important to still apply.

When applying for NJ FamilyCare, it’s essential to gather the following information:

Social Security Numbers (or document numbers for legal immigrants needing insurance)
Employer and income information for everyone in the family
Policy numbers for any current health insurance
Information about any job-related health insurance available to your family

The application requests income and other personal details to determine your eligibility for coverage and if you can receive financial assistance. This might include free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP), known as NJ FamilyCare, and possibly a new tax credit to help pay premiums for health coverage. Rest assured, all provided information is kept private and secure, as mandated by law.

Once your application is fully completed and submitted, you should expect to hear back from NJ FamilyCare within 1–2 weeks with further instructions on completing the process for your health coverage. If you haven’t received communication in that timeframe, you’re encouraged to visit njfamilycare.org or call 1-800-701-0710. It’s important to note, submitting an application does not obligate you to purchase health coverage.

Assistance with your NJ FamilyCare application can be found through several channels:

Online at njfamilycare.org
By phone at 1-800-701-0710
In-person, with counselors available in some areas to help
For Spanish speakers, assistance is available by calling 1-800-701-0710

Yes, NJ FamilyCare adheres to applicable Federal civil rights laws and does not engage in discrimination based on race, color, national origin, sex, age, or disability. Assistance services, including language assistance, are available at no cost to ensure equitable access to programs and information for all individuals, regardless of the language they speak.

Applying for health coverage through NJ FamilyCare is a crucial step towards ensuring you and your family have access to affordable healthcare. However, applicants can make several common mistakes that may delay approval or affect the coverage received. Recognizing and avoiding these missteps can significantly streamline the application process and improve the chances of receiving the optimal benefits.

Not filling out the application completely: Applicants often skip sections or leave blanks instead of providing the required information, causing delays in the processing of their application.
Incorrectly listing household members: It's vital to include all household members who meet the criteria laid out in the form, including those without a need for coverage.
Failure to provide accurate income information: Underreporting or not thoroughly detailing the income for all family members can lead to incorrect eligibility determination.
Misunderstanding the eligibility criteria: Applicants sometimes misunderstand who in their household is eligible, leading to either missing out on coverage for eligible individuals or applying for individuals who are not eligible.
Omitting Social Security Numbers (SSNs) or document numbers for legal immigrants needing insurance: This information is crucial for verifying eligibility and identity.
Incorrectly reporting existing health coverage: Not properly detailing any existing health insurance coverage can complicate the benefits determination process.
Not using the correct application form: Individuals and families sometimes use outdated forms or the wrong application type, leading to processing delays.
Forgetting to sign the application: An unsigned application is incomplete and will be returned, delaying the enrollment process.
Not applying for potentially eligible programs: Many applicants overlook or are unaware they can apply for additional benefits like family planning services under the Plan First Program.
Missing the submission of required documentation: Failing to attach necessary documents such as proof of income, identity, or residence can halt the application process.

Avoiding these mistakes requires careful attention to detail and thorough reading of the application instructions. Applicants are encouraged to seek assistance if they encounter uncertainties during the application process. This proactive approach can help ensure a smoother process and enhance access to vital health coverage.

Filling out the NJFamilyCare Application Form is a crucial step towards securing health coverage for many families. However, this process often requires additional forms and documents to fully assess eligibility and provide the appropriate coverage options. Understanding these supplementary materials can streamline the application process and ensure families receive the maximum benefits available.

Proof of Income Documents: These include recent pay stubs, W-2 forms, and tax returns. They help verify the income information provided in the application, ensuring families are placed in the correct program tier.
Proof of Citizenship or Legal Residency: Applicants are often required to provide documentation such as birth certificates for U.S. citizens or green cards for permanent residents. This verifies eligibility for the program based on residency and immigration status.
Social Security Numbers: Documentation is needed for all family members applying for coverage. If a member does not have a Social Security number, documentation showing that an application for one has been submitted is required.
Current Health Insurance Policy Numbers: If an applicant or any family member currently has health insurance, policy numbers and proof of insurance must be submitted. This information helps evaluate if the applicant qualifies for NJ FamilyCare as a secondary coverage or if they’re better served with their existing plan.
Employer's Proof of Insurance Offer: If health insurance is available through an employer for any family member, a statement or document from the employer detailing the insurance offer is necessary. This determines whether the employer's coverage meets affordability and coverage standards.
Proof of New Jersey Residency: Applicants need to provide documentation proving they live in New Jersey, such as utility bills, rental agreements, or mortgage statements. This establishes state residency, which is required for NJ FamilyCare eligibility.

Gathering these documents ahead of the application can significantly speed up the process. Understanding and compiling the necessary forms and documents not only makes the application process more efficient but also helps ensure that families receive the appropriate level of health coverage without unnecessary delay. Being prepared with all the required information reflects well on the application process, facilitating a smoother path to securing health benefits.

The Affordable Care Act (ACA) Health Insurance Marketplace Application shares similarities with the NJFamilyCare Application form in its purpose and structure. Both are designed to help individuals and families assess their eligibility for health coverage and financial assistance. The forms collect detailed information on household composition, income, and current health coverage to determine eligibility for either low-cost or no-cost health insurance programs, or for new tax credits that can help cover the costs of premiums.

State Medicaid Application forms closely resemble the NJFamilyCare Application as both are gateways to Medicaid and the Children’s Health Insurance Program (CHIP), tailored for low-income individuals and families. These applications require similar information about income, household size, and insurance status to establish eligibility for state-administered health coverage programs.

The Free Application for Federal Student Aid (FAFSA) form, while serving a different primary purpose — financial aid for education — parallels the NJFamilyCare Application in its thorough assessment of financial information. Both applications probe into household income and dependents to determine eligibility for financial support, albeit for different programs.

Income Tax Returns, such as the Form 1040 used by the IRS, also align with the NJFamilyCare Application. They both necessitate comprehensive income data and information about dependents. This data is critical in the NJFamilyCare form to make eligibility and financial assistance decisions and in tax returns to calculate tax liabilities and potential refunds.

The Health Insurance Portability and Accountability Act (HIPAA) Authorization Form shares the confidentiality concern inherent in the NJFamilyCare Application. Both documents emphasize privacy and secure handling of personal and sensitive information, complying with federal laws to protect individuals’ data from unauthorized access or use.

Application for Supplementary Security Income (SSI) mirrors the NJFamilyCare Application in targeting individuals who may need financial assistance due to low income or disability. Both applications gather detailed personal information, proof of income, and family composition to assess eligibility for benefits designed to support their specific needs.

The SNAP (Supplemental Nutrition Assistance Program) application is similar to the NJFamilyCare Application form in its aim to provide assistance to low-income families and individuals. Both require applicants to provide detailed household income information and composition to determine eligibility for benefits intended to meet basic needs.

Employment Insurance (EI) applications, while focused primarily on providing temporary financial assistance to unemployed workers, share the NJFamilyCare Application's approach of collecting personal, employment, and income information to ascertain eligibility for benefits.

The CHIP (Children’s Health Insurance Program) standalone application, specific to states that use separate applications for CHIP apart from Medicaid, closely resembles the NJFamilyCare form in purpose and content. Both are designed to extend health coverage to children and in some cases, pregnant women, in low-income families who do not qualify for Medicaid but still need assistance with healthcare coverage.

General Assistance or Welfare Program applications, targeting a broad array of assistance programs for low-income individuals and families, have similar requirements to the NJFamilyCare Application. These forms assess household size, income, and other factors to qualify applicants for various forms of support, including health coverage, food assistance, and other welfare benefits.

When filling out the NJ FamilyCare Application form, it's important to follow certain guidelines to ensure your application is processed smoothly. Here are some dos and don'ts:

Do gather all necessary documentation before starting the application, including Social Security numbers, employer and income information, policy numbers for any current health insurance, and information about any job-related health insurance available.
Do apply regardless of your or your child’s current health coverage status. You could qualify for lower-cost or free coverage.
Do provide accurate and complete information about your income and other information requested to determine the coverage you qualify for and if you can get any help paying for it.
Do submit your application even if you don't have all the information asked. Follow-up with the required information as soon as possible.
Do seek assistance if you need help filling out the application. Help is available online, by phone, or in person, including support in languages other than English.
Don't include people who do not need health coverage on the application, such as an unmarried partner who doesn’t need health coverage or their children if they're not part of your tax household.
Don't forget to list all sources of income, as omitting income can affect the type of coverage for which you qualify.
Don't provide false information. All the information you provide must be accurate to the best of your knowledge.
Don't wait to send in your application. Apply as soon as you’re ready to ensure you get coverage when you need it.

Remember, filling out the NJFamilyCare Application thoroughly and truthfully is the first step toward securing health coverage for you and your family. If you encounter any issues or have questions during the application process, don't hesitate to reach out for help.

When it comes to applying for health coverage through NJ FamilyCare, there are a few common misconceptions that need clarification:

Immigrant families cannot apply: This is not true. Families that have immigrant members are encouraged to apply. The application does not require you to report your immigration status or affect your chances of becoming a permanent resident or citizen. The key focus is on providing necessary health coverage to all family members who need it.
You must fill out every section for all family members: Actually, you only need to provide detailed information about family members who are seeking coverage. If a family member does not need health coverage, you do not need to provide immigration status or Social Security Numbers for those individuals. This makes the application process more straightforward for families with varying coverage needs.
Applying automatically means you have to buy health coverage: Submitting an application does not obligate you to purchase health coverage. The purpose of the application is to see what coverage choices you qualify for, including free or low-cost insurance through Medicaid or CHIP, known as NJ FamilyCare, or a new tax credit that can help pay your premiums. After submission, you will be informed about your options and then you can make an informed decision.
Applying is a long and complicated process: NJ FamilyCare encourages applicants to apply online for a faster process, but assistance is also readily available. You can get help with your application by calling their Help Center, visiting their website for online assistance, or speaking with counselors in your area. Language assistance services are also provided at no cost, making the application process accessible to everyone regardless of primary language or Internet access.

Understanding these clarifications helps ensure that all eligible individuals and families can apply for and receive the health coverage they need without unnecessary concerns or hesitations.

Filling out the NJ FamilyCare Application form is vital for securing health coverage for you and your family. Here are some key takeaways to help guide you through the process:

The application allows individuals and families to apply for free or low-cost insurance through Medicaid or CHIP, known as NJ FamilyCare, and potentially qualify for a new tax credit to help pay premiums.
Everyone in your family can use the application, including those with current health coverage, to potentially qualify for more affordable options.
Applicants are encouraged to apply faster online at njfamilycare.org, but paper applications are also accepted and should be sent to the specified address upon completion.
Required information includes Social Security Numbers (or document numbers for legal immigrants), employer and income details, current health insurance policy numbers, and any job-related health insurance information.
This application asks for income and other personal information to determine eligibility for coverage and any financial assistance with costs; all provided information is kept private and secure, as required by law.
After submitting the application, a follow-up will occur within 1–2 weeks to provide instructions on completing the health coverage process. If no response is received, applicants should contact NJ FamilyCare directly.
Assistance with filling out the application is available online, by phone, or in person, with support in multiple languages offered to ensure all applicants can navigate the application process effectively.

Understanding these key points ensures a smoother application process for NJ FamilyCare, allowing individuals and families to access the health coverage they need.

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15. Did PERSON 2 have insurance through a job and lose it within the past 3 months?

a. If yes, end date:

b. Reason the insurance ended:

a. If yes, end date:

b. Reason the insurance ended: