When families have no way of paying for high medical costs for their children, New Jersey has a special program that may help them. It is called the Catastrophic Illness in Children Relief Fund. The Fund was established over 20 years ago and has since assisted nearly 5,000 families to pay for such uncovered medical needs for their children as hospital bills, prostheses, medicines, hearing aids, transportation, and many others. Although there is no maximum income level for eligibility, the Fund requires the cost of the needed care to exceed a certain percentage of the family’s total income. There are also non-financial requirements that are explained below.
How do I know if my child’s medical need is for a “catastrophic” illness?
A child’s illness or condition can be of any medical diagnosis. But the family must have no other way to pay for the uncovered cost of the medical care for the child. As examples, Medicaid or other health insurance does not cover this type of care. Or the family’s health insurance has “capped” (limited) the amount it will pay, and the total cost of the care needed is above its cap. And some families have no health insurance and cannot possibly pay out of pocket for the expensive care their child needs.
Can a family have too much annual income to qualify?
There is no maximum income level for eligibility. But the Fund considers the cost of the medical care or treatment in relation to the family’s income. The family must be applying for help for an uncovered health-related cost that is greater than 10% of the family’s first $100,000 in income, plus 15% of any income above $100,000.
Here are two examples:
- Family income = $50,000
10% of $50,000 = $5,000
Family’s income is not more than $100,000, so there is nothing else to add.
The cost of the uncovered care that the child needs must be more than $5,000 to be eligible.
- Family Income = $120,000 10% of $100,000 = $10,000
Plus 15% of $20,000 (income is $20,000 more than $100,000) = $3,000
The cost of the uncovered care that the child needs must be more than $13,000 to be eligible ($10,000 plus $3,000 = $13,000).
What counts as income to qualify?
The Fund examines the family’s income from the 12 consecutive months immediately before the time that the child’s health-related cost was incurred. Families can apply for assistance for a medical cost that was billed or paid for by the parent or guardian as far back as 1988 or as recent as the time of their application. If found eligible, the Fund usually pays the medical provider directly, but it will also reimburse a family for an uncovered cost that the family paid.
All forms of income are counted, such as gross wages, public assistance and Social Security benefits, unemployment and workers compensation, alimony and child support, pensions, dividends and interest, rental income, and more. However, not included as income are “withdrawals from a bank; sale of property, house, or car; tax refunds; gifts; one-time insurance payments; or compensation for an injury unless the injury directly relates to a child’s condition which is the basis for the application being made to the Fund. Also disregarded are non-cash income and any money raised by fundraising.” (N.J.A.C. 10:155-1.2)
What non-financial requirements are there?
Age of child. The child must have been no more than 21 years old when the medical cost was incurred.
Residency. The child and his or her parent or guardian must be residents of New Jersey for the three months immediately before applying to the program. Seasonal residents will not be eligible, but migrant workers who can document that they have a history of work in New Jersey will be considered.
What are types of eligible medical care?
The Fund will approve most types of medically authorized uncovered services for eligible children. Past awards have often paid for more traditional types of care, such as hospitalizations, home and long-term care, addiction and mental health services, durable medical equipment, prescription and over-the-counter drugs, and more. But the Fund has also helped families pay for such medically related needs as home modifications, purchase or lease of specially modified vehicles, and reviewed experimental medical treatment and drugs. The Fund will also assist with such uncovered health-related expenses as supplemental insurance premiums and family transportation costs.
Will all the uncovered costs be paid or reimbursed?
The Fund will look at all of the eligible submitted costs. But should the Fund not have sufficient money or because of certain assistance caps (limits that are explained below), the total amount of the eligible uncovered costs may not be fully paid by the Fund.
The Fund has the following caps on the assistance it will pay:
- Per child total assistance is capped at $100,000 per year.
- One-time purchase or lease of a specialized vehicle is capped at $15,000. But modifications to an already purchased vehicle can be considered separately.
- Home modifications are capped at $25,000 per year.
- Speech, language, and hearing services are capped at $3,000 per year.
The Fund also requires a “family responsibility” payment of 10% of the eligibility standard. This means that if a family’s eligible uncovered medical expense is $1,000, the family must pay $100 of the expense and the Fund will pay $900.
Are there ever exceptions made for special situations?
The Fund will consider special cases, such as when families have more than one child with eligible uncovered medical costs or in special hardship cases when funding allows.
Can a family appeal if they are denied eligibility?
A family can file an appeal if they disagree with the Fund’s decision. They must send it in writing to the Catastrophic Illness in Children Relief Fund Commission. The Commission must receive it within 30 days after the family received their decision. (The Commission can waive this time limit.)
The appeal should be sent to:
Catastrophic Illness in Children Relief Fund Commission
P.O. Box 0728
Trenton, NJ 08625-0728
Attention: Chairperson
The written appeal should contain all the reasons and all the documentation to show that the Fund’s decision was not correct. The Commission has 180 days to examine the appeal and respond to the family. Or the Commission may refer the appeal to the state’s Office of Administrative Law for an in-person hearing by an Administrative Law Judge.
An Administrative Law Judge’s opinion is considered an “Initial Decision.” The Commission has 45 days after an Initial Decision to issue a “Final Decision.”
If a family does not agree with the Final Decision, the family may appeal to Appellate Division of the Superior Court of New Jersey.
How can someone apply for help from the Fund?
For more details, please see Catastrophic Illness in Children Relief Fund or call 1-800-335-FUND (3863).
If you need legal assistance, you may contact your nearest Legal Services office or call LSNJ-LAW™, Legal Services of New Jersey’s statewide, toll-free legal hotline, at 1-888-LSNJ-LAW (1-888-576-5529) to see if you are eligible for free legal assistance. Hotline hours are Monday through Friday, 8:00 a.m. to 5:30 p.m. If you are not eligible for assistance from Legal Services, the hotline will refer you to other possible resources.
This information last reviewed 3/21/10. |
