A Grievance is a formal type of appeal or challenge to a decision or action with which you do not agree. In the NJ FamilyCare program, these types of actions are called adverse actions. Unless you are eligible for NJ Medicaid (with the right to an in-person Fair Hearing), a written grievance process is the only type of formal appeal that you can use if you think you were wrongfully denied or terminated from NJ FamilyCare.

There are strict time limits for Grievances, as there are for most types of appeals, so you must not wait to respond to NJ FamilyCare if you receive a notice about an adverse action. If you want legal representation, 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.

How Do I Know if I Have the Right to a Fair Hearing or a Grievance?

If you satisfy the non-financial requirements for eligibility in NJ FamilyCare, and your family income is below 133% of the federal poverty level/fpl (examples: $24,353 for a family of three; $29,327 for a family of four), you have the right to a Fair Hearing to appeal an adverse action. (Note: Your children will have NJ FamilyCare Plan A benefits and, as a parent or caretaker, you will have Plan A or Plan D benefits, depending on your family income.)

If you satisfy the non-financial requirements for eligibility in NJ FamilyCare and your family income is more than 133% fpl, you have the right to a Grievance process to appeal an adverse action. (Note: Your children will have Plan B, C, or D benefits and you as a parent or caretaker will have Plan D benefits, depending on your family income.)

What Are Examples of Adverse Actions?

The following are examples of adverse actions that affect your eligibility for NJ FamilyCare that can be “grieved” to appeal a wrongful decision by the program:

• Determination of household composition (usually a disagreement about whose income in your family should be counted toward eligibility);
• Earned and unearned income calculations (the program must disregard some earned income); and
• Interpretation of residency, citizenship status, and age requirements.

How Do I File a Grievance with NJ FamilyCare?

NJ FamilyCare is administered by the NJ Department of Human Services through the Division of Medical Assistance and Health Services (Medicaid). This agency is required to send you a dated, written notice of a denial or termination of your eligibility for NJ FamilyCare that clearly explains the reasons for their action. The notice must include specific details about required information that may be missing with your application or the reasons why you are no longer eligible.

If you are already enrolled in NJ FamilyCare, they should mail this notice at least 10 days before the termination date of your coverage. If you respond to NJ FamilyCare before the termination date in writing that you want to have a grievance review and that you want your benefits to continue until your grievance is decided, your benefits (NJ FamilyCare coverage) must continue. However, you should be aware that you may be held financially responsible for the costs of continued benefits you requested if you lose your grievance appeal.

You have 20 days from the date that the adverse action notice was mailed to you to send them your written grievance. Your grievance should include all details and proofs to show that NJ FamilyCare’s decision was wrong. You are allowed to have legal assistance and representation for your grievance and, depending on your income, you may be eligible for free legal assistance from Legal Services. But you need to contact your nearest Legal Services office immediately 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.

Who Decides My Grievance?

NJ FamilyCare may contact you after they receive your grievance to try to resolve the matter informally. If not, your grievance will be decided by a grievance board, a panel of state staff who work for the NJ FamilyCare program. The board must notify you of their decision within 60 days of receiving your grievance. Their decision is final but can be legally appealed to the Appellate Division of the New Jersey Superior Court.

If you have not received a written notice from NJ FamilyCare but the program has not determined your eligibility more than 30 days after you submitted a complete application or you have learned that your coverage has been terminated, you need to contact NJ FamilyCare immediately (1-800-701-0710).

This information last reviewed 3/21/10.