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The NJ FamilyCare Application form is a tool designed to help families apply for health coverage and assistance in paying for medical costs. This application can determine if you qualify for free or low-cost insurance through Medicaid or the Children’s Health Insurance Program (CHIP), as well as potential tax credits to help cover premiums. Whether or not you currently have coverage, it's worth applying, as you might be eligible for better options.

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The NJ FamilyCare Application form is a crucial tool designed to help families navigate their health coverage options. This application assesses eligibility for various programs, including free or low-cost insurance through Medicaid and the Children’s Health Insurance Program (CHIP). It caters to a broad audience, allowing applications for anyone within a household, even if they currently have health insurance. This ensures that families can explore potential savings and better coverage. Completing this form is straightforward; applicants need basic personal information, income details, and any relevant insurance policy numbers. There are simplified options available for individuals who are applying on their own, and families with immigrants can also seek coverage, regardless of their immigration status. The form emphasizes privacy, assuring applicants that their information will remain confidential. Once submitted, families can expect communication within a week or two regarding their application status. Whether applying online or seeking in-person assistance, resources are readily available via the NJ FamilyCare Help Center. With a mission to make healthcare more accessible, NJ FamilyCare encourages everyone to assess their eligibility and explore their options for health coverage.

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

Get Njfamilycare Application PDF Form

Fact Title	Description
Purpose of Application	The NJ FamilyCare Application is used to determine eligibility for free or low-cost health insurance through Medicaid or CHIP.
Eligibility to Apply	Anyone in a family can be included in the application, regardless of current health coverage status. This includes families with immigrants seeking coverage.
Information Required	Applicants must provide Social Security Numbers or document numbers for eligible immigrants, as well as employment and income information.
Privacy Assurance	All information is kept private and secure in compliance with federal laws, ensuring confidentiality.
Submission Process	Completed applications should be mailed to the address specified in the form. Even incomplete applications can be submitted, and follow-up will occur within 1-2 weeks.
Non-Discrimination Policy	NJ FamilyCare adheres to federal civil rights laws, ensuring no discrimination based on race, color, national origin, sex, age, or disability.

The NJFamilyCare Application form is used to determine eligibility for health coverage and potential financial assistance. Completing the application requires gathering relevant information about yourself and your family, ensuring it is accurate and complete. Follow these steps carefully to fill out the form.

Start by providing your personal information in Step 1. This includes your first name, middle name, last name, suffix, and contact details such as your home address, phone numbers, and email address.
Indicate your preferred language for communication.
In Step 2, begin your family information with yourself. Fill in your relationship to yourself and provide your date of birth and sex.
Choose your citizenship status and, if applicable, provide your Social Security number (SSN).
Indicate your tax filing status and whether you'll be claiming any dependents.
If you are pregnant, provide details about the number of expected babies and the due date.
Answer questions related to your need for health coverage, health conditions, and your living situation.
Continue with income information: include your current employment details, wages, and average work hours. Note any other sources of income.
If self-employed, provide your net income from self-employment. List any deductions that apply to your income.
If you need to list additional family members, replicate Step 2 for each person, ensuring all relevant information is captured.

After filling out the form, review all entries for accuracy. Sign the application and send it to the address specified on page 7. If you lack some information, submit the application anyway, and expect follow-up within 1–2 weeks for further instructions.

What is the NJ FamilyCare application form used for?

The NJ FamilyCare application form is used to apply for health coverage options, including free or low-cost insurance from Medicaid and the Children's Health Insurance Program (CHIP). By completing this application, families can find out what coverage they may qualify for, which helps ensure they receive the necessary medical care.

Who is eligible to apply using this form?

Anyone in the family can be included in the application. This includes yourself, your spouse, children under 21, and any dependents listed on your tax return. Even if someone already has health insurance, they can still apply, as there may be options for lower-cost or free coverage. The application is also open to families that include immigrants.

What information must be provided when completing the application?

You will need to provide Social Security Numbers or documentation for legal immigrants, income and employer information for all family members, policy numbers for any current health insurance, and information about any job-related health insurance available to your family. This data helps determine eligibility for various coverage options and assistance programs.

What happens after I submit my application?

Once you have completed and signed your application, send it to the address listed on page 7. If you do not have all the required information, you can still submit the application. Expect a follow-up within 1–2 weeks, detailing the next steps for completing your health coverage. If you do not receive a response, visit the NJ FamilyCare website or call their assistance hotline.

How can I get help with the application process?

You can receive assistance with the NJ FamilyCare application in several ways. Online help is available at njfamilycare.org. For phone support, call the Help Center at 1-800-701-0710. In-person assistance may also be accessible through designated counselors in your area. Additional resources are available in multiple languages, ensuring that everyone can get the help they need.

When filling out the NJ FamilyCare Application form, there are several common mistakes that individuals often make which can lead to processing delays or unsuccessful applications. One significant mistake is failing to provide accurate and complete personal information. This includes the applicant's name, address, and phone numbers. Any errors in this section can cause delays in communication or follow-up from the application review team.

Another frequent error involves underreporting household income. Many applicants do not fully understand the income calculation process. It is vital to include all sources of income for every family member, as this affects eligibility for coverage options. Neglecting to list even small amounts of income can impact the assessment of eligibility and assistance.

Many applicants also overlook the requirement to include all necessary documentation along with their application. Missing documents can lead to application denial or unnecessary delays. Examples of required documentation include Social Security numbers and employer information, which must be complete and verifiable.

Users sometimes fail to indicate whether they want to receive updates about their application via email, phone, or mail. Leaving this question blank can result in missed communication regarding the status of their application. It is important to provide a preferred method of contact for efficient feedback.

Submitting an incomplete application is another common pitfall. Some applicants mistakenly believe they can complete the process later or ignore sections they find confusing. However, submitting a fully completed application, even if it requires additional information later on, helps ensure a smoother process.

People also often forget to include dependents who need coverage. Certain individuals qualify for assistance even if they do not live with the applicant. It’s essential to include all family members eligible for consideration, including children and spouses.

Some applicants do not review the application for errors before submission. Typographical mistakes, particularly in Social Security numbers or financial information, can cause significant issues. Double-checking the application can prevent these avoidable mistakes.

Another mistake is assuming that existing health coverage excludes eligibility for assistance. Many do not realize that even those with insurance might qualify for lower-cost options or additional help. Hence, including details about any current coverage is essential.

Finally, individuals may fail to seek help when they encounter difficulties during the application process. NJ FamilyCare offers various support options, including online resources and a help center. Utilizing these services can clarify uncertainties and assist applicants in providing accurate information.

The NJ FamilyCare application form serves as a gateway to obtaining health coverage and financial assistance for many households in New Jersey. When applying, it’s important to gather several additional documents and forms that may be necessary to support your application. Below is a list of other commonly used forms and documents that can help streamline the process.

Proof of Income: This includes recent pay stubs, W-2 forms, or tax returns that demonstrate your household's financial status. Providing accurate income information helps determine your eligibility for various coverage options.
Social Security Numbers: Include the Social Security numbers for each member of your family applying for coverage. This information is essential for processing your application and checking eligibility.
Immigration Status Documentation: If any family members are immigrants, documentation confirming their legal status, such as a green card or visa, must be provided. This ensures compliance with federal guidelines regarding health coverage applications.
Insurance Policy Numbers: If you or any family member currently hold health insurance, provide policy numbers. This information is critical to understanding existing coverage and determining if you qualify for additional assistance.
Employment Verification: Documenting employment through letters from employers or pay stubs can provide clarity on your job status and income. This is especially useful if your work situation has recently changed.
Proof of Residence: A utility bill, lease agreement, or any official document showing your current address can help verify your residence within New Jersey, which is a requirement for NJ FamilyCare eligibility.
Medical Documentation: If anyone in the household has ongoing medical conditions, providing medical records may help in obtaining the right level of coverage and services.
Dependent Information: Collect details about any dependents you claim on your taxes, including names, birthdates, and Social Security numbers. This helps ensure everyone who is eligible is covered.
Tax Returns: Submitting your federal tax returns may be necessary to verify household income levels and provide additional context about your financial situation.
Child Care Expenses Information: If you incur child care costs, providing documentation for these expenses can be beneficial as it might impact your income calculations and eligibility for assistance.

Gathering these documents ahead of time can facilitate a smoother application process and help ensure you receive the appropriate health coverage options for your family. Always keep original documents safe and provide only copies unless specifically instructed otherwise. If assistance is needed during this process, feel free to reach out to the NJ FamilyCare help center or local health care navigators.

The NJ FamilyCare Application form shares similarities with several other important documents that individuals may encounter when seeking health coverage or financial assistance. Here is a breakdown of seven such documents, explaining how each aligns with the NJ FamilyCare Application.

Medicaid Application Form: Like the NJ FamilyCare form, a Medicaid application aims to determine eligibility for government-funded health insurance based on income and household size. Both require detailed information about applicants' financial situations and family members.
Children’s Health Insurance Program (CHIP) Application: The CHIP application is similar because it addresses coverage options for low-income families with children. Both forms assess income and family structure to identify eligibility for health coverage.
Marketplace Health Insurance Enrollment Form: This form allows individuals to enroll in health coverage through the Health Insurance Marketplace. Like the NJ FamilyCare form, it collects personal and financial data to determine available health plans and potential subsidies.
Social Security Disability Insurance (SSDI) Application: While focused on disability benefits, the SSDI application also gathers extensive personal information, including income and family size. Both applications analyze the financial status of the applicant to determine eligibility.
Supplemental Nutrition Assistance Program (SNAP) Application: SNAP and NJ FamilyCare both require a detailed account of household income and members. Both programs provide assistance, with one focusing on food security and the other on health coverage.
Temporary Assistance for Needy Families (TANF) Application: The TANF application is designed for families in financial hardship. Similar to NJ FamilyCare, it necessitates thorough personal and financial disclosures to assess eligibility for support programs.
Individual Health Insurance Application: When applying for private health insurance, individuals must provide information regarding their income, family size, and health status. Like the NJ FamilyCare application, this form evaluates eligibility and expected premiums based on the disclosed information.

Here are five things to consider when filling out the NJ FamilyCare Application form:

Provide accurate information: Ensure all details, such as names, addresses, and income, are correct and up to date.
Include all eligible family members: List yourself, your spouse, and any children or dependents who live with you.
Use your Social Security Number: Provide your SSN if you want health coverage, as it helps speed up the application process.
Don’t skip required fields: Fill out every section that applies to you. Missing information may delay your application.
Don’t hesitate to ask for help: If you have questions, utilize the online resources or call the Help Center for assistance.

Being thorough can make the application process smoother and ensure you get the best coverage options for your family.

Misconception 1: Only uninsured individuals can apply.

Many people believe that if they currently have health insurance, they cannot apply for NJ FamilyCare. However, you can still apply even if you already have coverage. You may qualify for lower-cost or free alternatives.

Misconception 2: It's only for low-income families.

While NJ FamilyCare does serve low-income families, it's more inclusive than that. Eligibility is based on various factors, including family size and income, so some moderately income families can benefit as well.

Misconception 3: You must provide a Social Security Number.

Some applicants shy away due to concerns about Social Security Numbers. You do need this number only if you want health coverage. For family members who do not need coverage, providing a SSN is not necessary.

Misconception 4: Applications take too long to process.

Many believe that submitting the application is a long and tedious process. In reality, while the processing may vary, you can expect to hear back within 1–2 weeks. If you submit an incomplete application, that may also expedite the follow-up.

Misconception 5: The application is too complicated.

This application may initially seem daunting, but it's designed for ease of use. Clear prompts guide you through each step. Assistance is available online, over the phone, or in-person if you need help.

Misconception 6: You can't receive help if you're an immigrant.

Some individuals think immigrants are ineligible for NJ FamilyCare. In fact, families that include immigrants can apply. This program accommodates various immigration statuses and provides needed support for eligible families.

Filling out the NJ FamilyCare Application form can be an important step towards securing health coverage for you and your family. Here are some key takeaways to keep in mind as you navigate the process:

Everyone Counts: You can apply for all members of your family, whether or not they currently have health coverage. This includes children, spouses, and others you support, such as tax dependents.
Eligibility for All: Even if someone in your family is not eligible for NJ FamilyCare, you can still apply for family planning services through the Plan First Program.
Gather Information: Before starting the application, make sure to have essential documents ready. This includes Social Security numbers, income information, and current health insurance policy numbers.
Online Applications are Quicker: You may complete your application online through njfamilycare.org for a faster process.
Sign It: After filling out the application, make sure it is signed before sending it to the provided address. If information is missing, submit the application anyway.
What to Expect: You will receive follow-up instructions within 1–2 weeks after submitting your application. If you don’t hear from them, don’t hesitate to reach out via the website or call for assistance.
Help is Available: If you run into any challenges while filling out the application, you can seek help online, by phone, or even in-person with local counselors.
Privacy Matters: Know that the information you provide is kept secure and confidential, as mandated by law. Your personal details will only be used to determine your eligibility for coverage.

By keeping these takeaways in mind, you can approach the NJ FamilyCare application process with confidence. Remember, it's an opportunity to access potentially much-needed health coverage.

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:

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