New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 10 - INCOME › Section 10:69-10.23 - Nonrecurring earned or unearned lump sum income

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When a
				beneficiary receives nonrecurring earned or unearned lump sum income, including
				retroactive RSDI payments and other monthly benefits, and payments in the
				nature of a windfall, such as inheritances and lottery winnings or personal
				injury and worker compensation awards, to the extent it is not earmarked and
				used for the purpose for which it was paid, for example, moneys for back
				medical bills resulting from accidents or injury, funeral and burial costs, or
				replacement or repair of resources, that income will be added together with all
				other income received that month by the eligible family after application of
				the disregards in this subchapter and the exemption of income in
				N.J.A.C.
				10:69-10.22. The TANF grant shall not be
				considered income. No portion of lump sum or other income may be applied toward
				the resource limit in the month of its receipt. When this total exceeds the
				standard of need for the eligible family size as set forth at
				N.J.A.C.
				10:69-10.2, the family shall be ineligible
				for AFDC-related Medicaid program for the number of full months derived by
				dividing this total income by the standard of need applicable to the eligible
				family. Any remaining income from this calculation is treated as if it is
				unearned income received in the first month following the period of
				ineligibility and is considered available for use at that time. SSI payments
				and one-time lump sum payments associated with participation in the EEI program
				shall not be subject to lump sum treatment.
1. For purposes of determining the period of
				ineligibility, the family includes the AFDC-related Medicaid program eligible
				unit and any other individual (such as a stepparent) whose lump sum income
				caused the unit's income to exceed the allowance standard.
2. The period of ineligibility shall begin in
				the first month subsequent to the month the nonrecurring income is received or,
				if there is insufficient time for a timely adverse action notice, the following
				month.
3. In the event the
				nonrecurring income is not reported timely, the period of ineligibility shall
				begin at the point the ineligibility would have occurred had the CWA had
				knowledge of its receipt. The amount of Medicaid overpayment for the period of
				ineligibility must be established and recovery made.
4. The period of ineligibility applies to
				each individual in the eligible family at the time of receipt of the lump sum
				nonrecurring income. Other family members to whom the penalty does not apply,
				may be eligible as a separate Medicaid eligibility unit.
5. Once established, the period of
				ineligibility may be reduced only in the circumstances below. It is the
				responsibility of the former eligible family to provide all necessary
				information and documentation required to make a determination to shorten the
				period of ineligibility. The basis for a determination to shorten the period of
				ineligibility shall be thoroughly documented in the case record.
i. The period of ineligibility may be
				recalculated when the AFDC standard of need is increased. Upon request of a
				former AFDC eligible family, the period of ineligibility shall be reduced as
				follows:
(1) The number of months of
				ineligibility already elapsed shall be multiplied by the standard of need used
				to compute the original period of ineligibility;
(2) The result shall be subtracted from the
				original lump sum amount; and
(3)
				The remaining amount shall be divided by the new AFDC standard of need for the
				eligible family size and the result will be the number of months of
				ineligibility remaining.
ii. The period of ineligibility may be
				recalculated if the income used to determine such period becomes unavailable to
				the eligible family for reasons beyond the control of the family members.
				Acceptable reasons are limited to those below:
(1) The former eligible family shall
				thoroughly substantiate an allegation of loss or theft of part or all of the
				lump sum income and shall provide the CWA with evidence that a police report of
				an incident of theft has been filed. Upon receipt of credible evidence of loss
				or theft of the income, the CWA shall reduce the amount of the original lump
				sum by the amount of the loss or theft. Loss of the income, for the purposes of
				this section, shall include circumstances where a member of the former eligible
				family has absconded with the funds.
(2) When the former eligible family incurs
				and pays verifiable expenses due to an emergent situation, including fire,
				flood, natural disaster or other emergent situation, for which, had the family
				been eligible, emergency assistance would have been authorized under N.J.A.C.
				10:90, those expenses shall reduce the amount of the original lump
				sum.
iii. The period of
				ineligibility may be reduced if the family incurs, becomes responsible for, and
				pays medical expenses during the period of ineligibility. In such cases, the
				original income used to compute the period of ineligibility shall be offset by
				verified medical expenditures. For this purpose, allowable medical expenses are
				as follows:
(1) Medical and dental care
				including psychotherapy and rehabilitation services provided by a licensed
				practitioner authorized by State law or other qualified health
				professional;
(2) Hospitalization
				or outpatient treatment, nursing care, and nursing home care, including
				payments by the household for an individual who was an eligible family member
				immediately prior to entering a hospital or nursing home, provided by a
				facility recognized by the State;
(3) Prescription drugs when prescribed by a
				licensed practitioner authorized under State law and other over-the-counter
				medication (including insulin) when approved by a licensed practitioner or
				other qualified health professional; in addition, costs of medical supplies,
				sick-room equipment (including rental) or other prescribed equipment;
(4) Health and hospitalization insurance
				policy premiums;
(5) Medicare
				premiums related to coverage under Title XVIII of the Social Security
				Act;
(6) Dentures, hearing aids,
				and prosthetics;
(7) Securing and
				maintaining a seeing eye or hearing dog including the cost of dog food and
				veterinarian bills;
(8) Eye glasses
				prescribed by a physician skilled in eye diseases or by an
				optometrist;
(9) The reasonable
				cost of transportation and lodging to obtain medical treatment or services;
				and
(10) Maintaining an attendant,
				homemaker, home health aid, housekeeper, or child care services, necessary
				because of age, infirmity, or illness.
6. In all instances, where the previously
				eligible family has been terminated due to receipt of lump sum income, the
				notice of adverse action shall include:
i. The
				reason for the family's termination from AFDC-related Medicaid
				program;
ii. The duration of the
				period of ineligibility;
iii. The
				earliest date the ineligible family may apply to reopen their AFDC-related
				Medicaid program case; and
iv. A
				statement concerning possible reduction of the ineligibility period (see (a)5ii
				or iii above).