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NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective

Date:

Volume:

X

Forms

Chapter:

A

Forms

2-14-2005

Subchapter:

1

Forms

Issuance:

11.42

CP&P Form 11-42, Title IV-E Medicaid Out-of-State Response Form

 

Click here to view CP&P Form 11-42.

 

PURPOSE

 

This form was developed so an out-of-state Medicaid agency may:

      notify CP&P that an adoptive parent has applied for Medicaid on behalf of a New Jersey child, and

      advise CP&P of the effective date of the child's Medicaid coverage in that state.

USE

 

The CP&P LO Subsidy Liaison gives or sends this form to an adoptive parent, along with the CP&P Form 11-41, whenever the child is eligible for IV-E Medicaid and the child is moving out-of-state with adoptive parents who are receiving subsidy.

The CP&P Subsidy Liaison fills in his or her own address in the "TO" section of the form, so the receiving state Medicaid office can return the completed document to the sending CP&P Subsidy Liaison.

The adoptive parent gives the form to the out-of-state agency to which they have applied for Medicaid. The out-of-state Medicaid agency completes the form and forwards it to the CP&P Subsidy Liaison.

 

DISTRIBUTION

 

Original          -     

Adoptive parent

Copy             - 

Child's case record