From the LRRC Case Files - Week 6


Shira Booth is 24 years old and recently found out that she is pregnant with her first child. She earns $39k annually as a medical biller. Her husband is in yeshiva and does not receive a kollel check. Because she is under 26 years old, she is still covered by her parents' private insurance. Her friends are advising her to apply for NJ FamilyCare even though she already has insurance through her parents. Considering her household income, she is eligible for NJ FamilyCare for her pregnancy. However, applying to NJ FamilyCare seems like an unnecessary hassle to Shira. This is especially true because her doctor accepts her private insurance but does not accept NJ FamilyCare.

Question: Is there any reason for Shira to apply for NJ FamilyCare even though she already has insurance through her parents?

Answer: Yes! Even though Shira has private insurance, she should definitely apply to NJ FamilyCare as a secondary coverage. There are a number of reasons why this is prudent:

Coverage for her baby: By applying for NJ FamilyCare during her pregnancy, Shira guarantees that her baby will have insurance for its first year. Once a pregnant woman is approved for NJ FamilyCare, she is guaranteed coverage until two months after birth and her baby is guaranteed coverage for a full year. This coverage will continue regardless of any income changes that Shira has during this time.

Another important point is that if Shira does not apply for NJ FamilyCare when she is pregnant, she will have to fill out a new application from scratch once her baby is born. It takes time for an application to be processed, and her baby may not have insurance until the application is fully processed and approved. By applying for herself while she is pregnant, Shira ensures that her baby will have full insurance from the moment it is born.

Deductibles: Another important reason to apply for NJ FamilyCare even if you have private insurance is to help pay for deductibles. Most private insurances have a deductible of a few thousand dollars that the customer is responsible for paying before the insurer begins coverage. NJ FamilyCare fully covers all NJ hospital bills and will cover any deductible that is not paid by the private insurance as long as the provider accepts NJ FamilyCare.

Tip: If you have NJ FamilyCare as well as private insurance and deliver your baby with a doctor who only accepts your private insurance, it is very important to ask the doctor to not bill your insurance for delivering the baby until after the hospital submits its bill.

This is critically important and can make a difference of thousands of dollars. The reason is a little complicated, but the basic idea is as follows:

The difference between private insurance and NJ FamilyCare is that the private insurance plan has a deductible that must be met ' let's say of $3,000 ' before its coverage begins, while NJ FamilyCare fully covers the patient without demanding a deductible. Let's say a woman gives birth and has a hospital bill of $20,000 and a doctor bill of $5,000. Depending on the order in which the bills are submitted, the patient might end up having to pay nothing, or she could face a daunting bill of $3,000. What matters is who bills the insurance first ' the doctor or the hospital.

Scenario 1 - The doctor bills first: If the doctor bills the private insurance before the hospital does, the insurer will say that it is happy to pay its portion of the bill ' $2k out of the $5k bill. However, the patient will be responsible for her deductible, namely the remaining $3k. Because the doctor does not accept NJ FamilyCare, the patient will be stuck with a $3k bill. Only after she pays her $3k deductible will the insurer pay the remaining $2k.

Scenario 2 - The hospital bills first: If the hospital bills the insurance before the doctor does, the entire story changes. The hospital submits its $20k bill to the private insurance. As before, the insurance company says that it is happy to pay its portion of the bill ' $17k out of the $20k ' while the patient is responsible for the remaining $3k. However, here is where everything changes. Because every hospital in NJ takes Medicaid, NJ FamilyCare will pay the deductible for her. Then, because she has already fulfilled her deductible, her private insurance will pay the entire doctor bill ' leaving her with a bill of $0.

Because of this difference, it is important to respectfully ask your doctor to wait until your hospital has submitted its bill to insurance before he/she submits the doctor bill for payment.

Mrs. Nechama Heinemann - Senior Case Worker and Director of Staff Training

Number of encounters in the past month ' 433

Key Skills:

  • Comprehensive understanding of all available programs including intricate details of rules and regulations
  • Liaison between the LRRC and the local SNAP office including submitting SNAP recertifications and advocating for issues weekly

Be respectful when you are talking to a government case worker. First of all, it is basic manners. Secondly, the odds of receiving quality service are greatly enhanced if you are courteous. Thirdly, there is little point in raising your voice or getting into an argument with a case worker. If you feel your case is being mishandled or the case worker does not understand your situation, you can ask to speak with a supervisor. If you disagree with their decision, you always have the right to request a fair hearing to have an arbitrator look over your case.

It is also important to call the LRRC to discuss your situation. Our team can help you navigate your situation or, if necessary, intervene on your behalf to the government agency. We have contacts in many agencies and regularly advocate for people with pressing issues.

Also, if you plan on going down to Social Services, it is advisable to come prepared with a list of questions. Doing so allows you to stay focused and ensures that all your issues are addressed. At the LRRC, we are happy to meet with you and help you figure out your situation.'