reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 2 - CASE PROCESSING › Section 10:72-2.1 - Application

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Application for
				Medicaid benefits for pregnant women and infants shall be accomplished by the
				completion and signing of Form FD-335 for pregnant women and infants as well as
				any addenda to that form as prescribed by the Division of Medical Assistance
				and Health Services. Application for Medicaid benefits for aged, blind, or
				disabled individuals shall be accomplished by the completion and signing of
				Form PA-1G as well as any addenda to that form as prescribed by the Division of
				Medical Assistance and Health Services.
1.
				The application for the program shall be executed by:
i. The pregnant woman (regardless of
				age);
ii. The parent, guardian, or
				caretaker relative of an infant or a blind or disabled child for whom Medicaid
				is sought; or
iii. The aged, blind
				or disabled individual.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 2 - CASE PROCESSING › Section 10:72-2.2 - Interview

Current through Register Vol. 56, No. 14, July 15, 2024
The county welfare agency is required to conduct a personal
				  face-to-face interview with the program applicant or the authorized agents as
				  part of the process of determining program eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 2 - CASE PROCESSING › Section 10:72-2.3 - Verification requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The county
				welfare agency is required to verify all factors related to eligibility for the
				Medicaid program. Factors subject to verification include:
1. Pregnancy: For women seeking benefits
				under the provisions of this chapter, pregnancy must be medically verified. The
				medical verification must include the estimated dates of conception and
				delivery.
2. Disability and
				blindness: For individuals seeking Medicaid benefits because of disability or
				blindness, the condition must be established in accordance with the
				definitions, verification requirements, and processes set forth at
				10:71-3.10 through 3.13.
3. Birth date: The birth date of any person
				for whom benefits are sought must be verified.
4. Alien status: The status of any alien
				seeking benefits must be verified to establish entitlement for Medicaid
				benefits.
5. Citizenship: When an
				applicant's or beneficiary's statements of U.S. citizenship are questionable,
				citizenship must be verified.
6.
				Household composition: The county welfare agency must verify the household
				composition in order to ascertain which persons will be included in the
				determination of eligibility for Medicaid benefits.
7. Social Security number: The Social
				Security number of any person seeking Medicaid benefits must be
				verified.
8. The county welfare
				agency must verify all sources of income of any person whose income must be
				counted in the determination of program eligibility. While resources are not a
				factor of eligibility for benefits for pregnant women and children under this
				chapter, resources must be identified and verified to determine if income is
				derived from the resources. For the aged, blind, and disabled, resources must
				be verified.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 2 - CASE PROCESSING › Section 10:72-2.4 - Case transfer

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When
				individuals move permanently to another county within the State, responsibility
				for the case shall be transferred in accordance with the provisions of this
				section. The case transfer shall be accomplished in a manner so as not to
				adversely affect the rights of any individual to program entitlement.
1. A temporary visit out-of-county shall not
				be considered to be a change of county residence until the visit has continued
				for longer than three calendar months.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 2 - CASE PROCESSING › Section 10:72-2.5 - Redetermination of eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Eligibility for
				Medicaid under this chapter shall be redetermined, including the completion of
				the appropriate application form, as follows:
1. For a pregnant woman, eligibility need not
				be redetermined until the birth of her child. Upon the birth of the child, the
				newborn shall remain eligible for a period of not less than 60 days from his or
				her birth and up to one year, so long as the mother remains eligible, or would
				remain eligible if pregnant, and the child resides with her, whether or not
				application has been made.
2. For
				an aged, blind, or disabled individual, including a disabled child, eligibility
				must be redetermined no later than 12 months following the month of initial
				eligibility or the last redetermination using Form PA-1G-NJR2 (Redetermination
				Form). The CBOSS may require that the form be completed during a face-to-face
				interview. However, at the option of the CBOSS, and with the approval of the
				beneficiary, the face-to-face interview may be eliminated. Form PA-1G-NJR2
				(Redetermination Form) may be mailed to and completed by the beneficiary and
				mailed to the CBOSS.
i. When a loss of
				assistance will result, the face-to-face interview shall be required, unless
				the agency documents a clear refusal by the beneficiary to have a face-to-face
				meeting. Before benefits are terminated, a beneficiary shall be offered a
				face-to-face home visit. The visit shall not be required to be in the office,
				but at the beneficiary's request, in the home.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 2 - CASE PROCESSING › Section 10:72-2.6 - Post-application client responsibilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon a
				determination of eligibility for the Medicaid program, eligible persons have
				the on-going responsibility for the reporting of changes in family
				circumstances and for the provision of information as delineated at
				10:72-2.1(c).
				Further, as requested by the county welfare agency, additional information must
				be provided. At any time that the county welfare agency lacks sufficient
				information to confirm continuing program eligibility because of the
				unwillingness of an eligible person to provide necessary information, the
				agency shall commence action to terminate the case.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 2 - CASE PROCESSING › Section 10:72-2.7 - Retroactive eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Persons may be
				eligible under the provisions of this chapter for retroactive Medicaid
				eligibility for the three months preceding the month of application.
				Retroactive Medicaid coverage is available for any of the three months prior to
				application so long as eligibility existed and there are unpaid medical bills
				for services in that month. In the case of a pregnant woman, in order to be
				eligible for a retroactive month, the medical verification of pregnancy must
				have occurred in the retroactive month or in a previous month. In the case of a
				disabled or blind individual, the disability or blindness must be confirmed to
				have begun in a retroactive month or earlier.
(b) Determination of retroactive eligibility
				is the responsibility of the Division of Medical Assistance and Health
				Services. If the applicant has unpaid medical bills from the retroactive
				eligibility period, the county welfare agency shall provide the applicant with
				an Application for Payment of Unpaid Medical Bills (FD-74) and instruct the
				applicant to forward it to the Division of Medical Assistance and Health
				Services, Retroactive Eligibility Unit, PO Box 712, Trenton, New Jersey
				08625-0712. An application for retroactive eligibility must be received by the
				Retroactive Eligibility Unit within six months of the date of application for
				Medicaid at the county welfare agency.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:72-3.1 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Eligibility for
				the Medicaid program must be established in relation to each requirement of the
				Medicaid program to provide a valid basis for the granting or denying of
				medicaid assistance.
(b) The
				applicant's statements regarding his or her eligibility, as set forth in the
				application form, are evidence. The statements must be consistent and meet
				prudent tests of credibility. Incomplete or questionable statements shall be
				supplemented and substantiated by corroborative evidence from other pertinent
				sources.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:72-3.2 - Citizenship

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to be
				eligible for the Medicaid program, an individual must be a citizen of the
				United States, an alien lawfully admitted for permanent residence, or an alien
				approved for temporary residence who can be classified as an eligible alien in
				accordance with this chapter.
1. The term
				"citizen of the United States" includes persons born in Puerto Rico, Guam, the
				Virgin Islands, Swain's Island, American Samoa, and the Northern Mariana
				Islands.
2. An individual who
				cannot be classified as an eligible alien in accordance with this subchapter
				due to changes mandated by the Personal Responsibility and Work Opportunity
				Reconciliation Act of 1996 (
				Public Law
				104-193 ) but who was residing in a
				Medicaid-certified nursing facility prior to January 29, 1997, shall continue
				to be eligible for medical assistance until the individual is no longer
				eligible for long-term care services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:72-3.3 - State residency

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to be
				eligible for the Medicaid program, an individual must be a resident of the
				State of New Jersey. The term "resident" shall be interpreted to mean a person
				who is living in the State voluntarily and not for a temporary purpose, that
				is, with no intention of presently removing therefrom.
1. If an individual leaves New Jersey with
				the intent to establish permanent residence elsewhere, or for an indefinite
				period for purposes other than a temporary visit, he or she ceases to be
				eligible to receive Medicaid from this State.
2. When an individual enters this State in
				order to receive medical care and applies for Medicaid to meet all or a portion
				of the costs of such care, the fact that the immediate purpose of the move was
				to secure medical care does not, in and of itself, have the effect of making
				the person ineligible for the Medicaid program. It is the responsibility of the
				county welfare agency to evaluate all such cases and to make an eligibility
				determination, considering carefully all the following criteria:
i. Whether the move is a temporary one, being
				solely for the purpose of receiving medical care for a limited time;
ii. Whether there is clear expression of
				intent on the part of the individual to remain permanently in this
				State;
iii. Whether there is
				objective evidence that the individual has, in fact, abandoned or not abandoned
				residence in the State from which he or she came;
iv. Whether the state in which the individual
				previously resided recognizes him or her as having continuing eligibility under
				the Medicaid program (or other program providing payment for medical care) of
				that jurisdiction.
3.
				If, after full consideration of the above factors, the county welfare agency is
				satisfied that the individual has become a resident of this State, Medicaid
				eligibility may be established.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:72-3.4 - Eligible persons

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				persons who meet all eligibility criteria of this chapter are eligible for
				Medicaid benefits:
1. Pregnant women: Women of
				any age during the term of a medically verified pregnancy.
i. A woman who is determined eligible under
				the criteria of this chapter will, for purposes of eligibility, be considered
				to be a pregnant woman until the end of the 60-day period beginning with the
				last day of her pregnancy. Her eligibility as a pregnant woman shall end on the
				last day of the month in which the 60-day period ends.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:72-3.5 - Household unit

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The term
				"household unit" means those persons whose income is counted in the
				determination of eligibility under the provisions of this chapter. The
				following persons, if they reside with the program applicant or beneficiary,
				shall be considered members of the household unit:
1. In the case of a pregnant woman:
i. The pregnant woman and the unborn child
				(or children, when it is medically verified that there is more than one
				fetus);
ii. The pregnant woman's
				spouse;
iii. The pregnant woman's
				natural or adoptive children under the age of 21;
iv. The blood-related siblings (including
				those of half-blood) of the pregnant woman's children who are under the age of
				21; and
v. The natural or adoptive
				father of any children in the household unit.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:72-3.6 - Third party liability

Current through Register Vol. 56, No. 14, July 15, 2024
Program applicants and beneficiaries are required to
				  identify to the county welfare agency any third party (individual, entity, or
				  program) that is or may be liable to pay all or part of the medical cost of
				  injury, disease, or disability of an applicant or beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:72-3.7 - Persons sanctioned under AFDC rules

Current through Register Vol. 56, No. 14, July 15, 2024
Persons who would be ineligible for AFDC using the rules in
				  existence as of July 16, 1996 or due to the imposition of a sanction of
				  ineligibility for a factor of AFDC eligibility that does not apply in Medicaid
				  (such as noncooperation with work registration or WIN requirements) shall have
				  eligibility determined under this chapter without regard to the sanction. (For
				  persons ineligible for AFDC due to a period of ineligibility imposed as a
				  result of the receipt of lump sum income, see
				  10:72-4.3(c) 
				  ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:72-3.8 - Application for other benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) As a condition
				of eligibility for the Medicaid program, applicants and beneficiaries are
				required to take all necessary steps to obtain any annuities, pensions,
				retirement and disability benefits to which they are entitled, unless they can
				show good cause for not doing so. Applicants and beneficiaries must avail
				themselves of any health insurance coverage available to the household unit at
				no cost, such as coverage provided by an employer at no cost.
1. Annuities, pensions, retirement and
				disability benefits include, but are not limited to, veterans' compensation and
				pensions, Social Security benefits, and unemployment compensation. They do not
				include AFDC, Supplemental Security Income (SSI), or General
				Assistance.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:72-3.9 - Inmates of public institutions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any person who
				is an inmate of a public institution is ineligible for the Medicaid
				program.
(b) Any person who is
				incarcerated in a Federal, State, or local correction facility (prison, jail,
				detention center, reformatory, etc.) is not eligible for the Medicaid program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:72-3.10 - Emergency services for aliens and limited prenatal care for aliens

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any
				alien who is not an eligible alien as specified in
				10:72-3.2(c) and
				(d), shall be ineligible for Medicaid
				benefits. Any such alien shall be, if a resident of New Jersey and if he or she
				meets all other Medicaid eligibility requirements, entitled to Medicaid
				coverage for the treatment of an emergency medical condition only.
1. An emergency medical condition is one of
				sudden onset that manifests itself by acute symptoms of sufficient severity
				(including severe pain) such that the absence of immediate medical attention
				could reasonably be expected to result in:
i.
				Placing the patient's health in serious jeopardy;
ii. Serious impairment to bodily functions;
				or
iii. Serious dysfunction of any
				bodily organ or part.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:72-4.2 - Prospective budgeting of income

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The county
				welfare agency shall establish the best estimate of income that will be
				available to the household unit.
1. The best
				estimate of income shall be based on an average of the household unit's income
				for the full one-month period preceding the date of application or
				redetermination. Adjustments shall be made to the estimated income to reflect
				changes in income that either have occurred or which are reasonably anticipated
				to occur which would affect the household unit's income during a period of
				eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:72-4.3 - Countable income: pregnant women and infants

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as
				specified below, countable income for pregnant women and infants under the
				provisions of this chapter shall include the income of all members of the
				household unit as determined at
				10:72-3.5(a)1 
				and 2, and shall be determined in accordance with regulations applicable to
				income in the AFDC-C program in effect as of July 16, 1996 (see N.J.A.C.
				10:69).
1. The maximum income limits as
				provided for at
				10:69-10.3 do not apply.
2. Neither the $ 30.00 nor the one-third
				disregard of earned income at
				10:69-10.13(c) 
				apply.
3. The deeming of stepparent
				income at 10:69-10.33 does not apply. (See
				10:72-3.5(a)2 
				regarding the inclusion or exclusion of the stepparent in the household
				unit.)
4. The deeming of an alien
				sponsor's income at
				10:69-10.43 does not
				apply.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:72-4.4 - Income eligibility; aged, blind and disabled individuals

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as
				specified below, countable income for aged, blind, and disabled individuals
				shall be determined in accordance with rules applicable to income in Medicaid
				Only--Aged, Blind, and Disabled (see N.J.A.C. 10:71-5 ).
1. The disregard of cost-of-living increases
				in Social Security benefits provided for in
				10:71-5.3(a)7  x
				and xi do not apply.
2. The deeming
				of the income of an alien's sponsor as provided for at
				10:71-5.7 does not
				apply.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 4 - FINANCIAL ELIGIBILITY › Section 10:72-4.5 - Resource eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pregnant women
				and infants seeking Medicaid benefits under the provisions of this chapter are
				eligible without regard to the value of the household unit's resources. The
				county welfare agency shall inquire about the household unit's resources only
				in order to establish income that may result from the household unit's
				resources.
(b) Aged, blind or
				disabled persons (including specified low-income Medicare beneficiaries) must
				meet resource eligibility criteria as specified below in order to be eligible
				for benefits under this chapter. Eligibility for benefits does not exist in any
				month in which the countable resources of an aged, blind or disabled person
				exceeds the limits of $ 4,000 for an individual and $ 6,000 for a couple.
1. The resource provisions of the Medicaid
				Only Manual apply in the determination of countable resources for aged, blind,
				or disabled individuals except that, the provisions requiring the deeming of
				the resources of an alien's sponsor (10:71-4.6(f)
				 ) do not apply in this chapter.
2. The spouse-to-spouse and parent-to-child
				deeming of resources found at
				10:71-4.6 apply to eligibility
				under this chapter. In the deeming of resources from one parent to a child, the
				countable parental resources in excess of the Medicaid Only resource limit for
				an individual shall be deemed to the blind or disabled child. When the
				resources of two parents must be deemed to a child, the countable parental
				resources in excess of the Medicaid Only resource limit for a couple shall be
				deemed to the child.
3. For aged,
				blind or disabled persons, the policy concerning transfer of resources within
				36 months of the date of application (see
				N.J.A.C.
				10:71-4.7 ), applies equally to eligibility
				under this chapter for individuals seeking eligibility for institutional
				services through long-term care (LTC) facilities or Home- and Community-Based
				Waiver (HCBW) services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 5 - ADMINISTRATIVE REQUIREMENTS › Section 10:72-5.1 - Notice of the county welfare agency decision

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The county
				welfare agency shall promptly notify any applicant for, or beneficiary of, the
				Medicaid program in writing of any agency decision affecting the applicant or
				beneficiary. When a decision relates to any adverse action which may entitle a
				beneficiary to a fair hearing, the action may not be implemented until at least
				10 days after the mailing of the notice (see (e) below for exceptions to the
				10-day notice requirement).
1. For notices of
				action adverse to a beneficiary, the date of mailing of the notice must appear
				on the notice.
2. Notices of any
				county welfare agency action must contain the name, address, and telephone
				number of the legal services agency serving that county.
3. In the case of an applicant or beneficiary
				who cannot be located, the notice shall be mailed to his or her last known
				address.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 5 - ADMINISTRATIVE REQUIREMENTS › Section 10:72-5.2 - Fair hearings

Current through Register Vol. 56, No. 14, July 15, 2024
(a) It is the right
				of every applicant for, or beneficiary of, the Medicaid program to be afforded
				the opportunity for a fair hearing in the manner set forth in N.J.A.C. 10:49,
				including, when applicable, continuation of program benefits pending the
				results of the fair hearing.
(b)
				Any request for a fair hearing shall be forwarded to the Division of Medical
				Assistance and Health Services, Office of the Legal and Regulatory Liaison, PO
				Box 712, Trenton, New Jersey 08625-0712.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 5 - ADMINISTRATIVE REQUIREMENTS › Section 10:72-5.3 - Case records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of
				the case record is to provide a complete documentary record of county welfare
				agency actions and the reasons therefor.
(b) The case record shall include:
1. A record of all county welfare agency
				actions and decisions relating to the case, as well as documentary evidence
				relating to such actions and decisions, including application forms.
2. All forms relating to financial
				eligibility.
3. All case-related
				correspondence, memorandum, and documents except those required by law or
				regulation to be maintained elsewhere.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 6 - PRESUMPTIVE ELIGIBILITY › Section 10:72-6.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The presumptive
				eligibility determination makes it possible for a pregnant woman to receive
				ambulatory prenatal care from a Medicaid participating provider for a temporary
				period prior to application for Medicaid benefits and while a Medicaid
				application is being processed by the county welfare agency. Presumptive
				eligibility continues until the county welfare agency reaches its formal
				eligibility determination as follows:
1. The
				period of presumptive eligibility begins on the date a qualified provider
				determines that, based on information provided by the pregnant woman, the woman
				meets the requirements and standards of this chapter applicable to pregnant
				women.
2. The period of presumptive
				eligibility will terminate:
i. If the woman
				has filed an application with the county welfare agency, on or before the last
				day of the month subsequent to the month in which she was determined
				presumptively eligible, or on the date a determination of eligibility or
				ineligibility for Medicaid is made by the county welfare agency; or
ii. If the pregnant woman fails to file an
				application with the county welfare agency, on the last day of the month
				subsequent to the month in which she was determined presumptively
				eligible.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 6 - PRESUMPTIVE ELIGIBILITY › Section 10:72-6.3 - Responsibility of the Division of Medical Assistance and Health Services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon receipt of
				a properly completed Certification of Presumptive Eligibility (FD-334) from the
				qualified provider, Division staff shall:
1.
				Assign a presumptive eligibility number from a log of unissued
				numbers:
2. Create an eligibility
				record on the Medicaid Eligibility File;
3. Issue a Medicaid Eligibility
				Identification (MEI) Card; and
4.
				Notify the qualified provider and the appropriate county welfare agency of the
				presumptive eligibility identification number assigned to the
				beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 6 - PRESUMPTIVE ELIGIBILITY › Section 10:72-6.4 - Responsibility of the county welfare agency

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon receipt of
				the Certification of Presumptive Eligibility (FD-334) and a properly completed
				New Jersey Care Pregnant Women and Infants Application Referral (FD-335) from
				the qualified provider, the county welfare agency shall:
1. Check the Medicaid and Medically Needy
				Eligibility File for existing Medicaid eligibility.
i. If the beneficiary is receiving Medicaid
				benefits as an AFDC child or adult, a Medicaid Special individual, or a New
				Jersey Care or Medically Needy pregnant woman, no further action shall be
				required by the county welfare agency.
ii. If the beneficiary is receiving Medicaid
				benefits as a Medically Needy child or Medically Needy disabled adult, a
				separate case shall be established which would entitle the beneficiary to
				receive additional prenatal services available to Medically Needy pregnant
				women. In such instances, the county welfare agency shall schedule a
				face-to-face interview with the beneficiary to verify all factors of
				eligibility before a final determination of eligibility or ineligibility is
				made.
iii. If the beneficiary is an
				AFDC adult or child, and there are indications of a change in circumstances,
				such as a marriage of the pregnant woman, the county welfare agency may
				schedule a face-to-face interview with the beneficiary to verify all factors of
				continued eligibility as an AFDC case before a final determination of
				eligibility or ineligibility is made. However, she cannot be found ineligible
				for Medicaid solely because she does not meet AFDC standards for cash
				assistance, but must be evaluated for eligibility for other Medicaid programs
				without regard to any changes which occurred after the determination of
				presumptive eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 6 - PRESUMPTIVE ELIGIBILITY › Section 10:72-6.5 - Responsibility of the applicant

Current through Register Vol. 56, No. 14, July 15, 2024
A presumptively eligible pregnant woman must contact the
				  county welfare agency during the presumptive eligibility period so that a
				  face-to-face interview can be scheduled. As part of the eligibility
				  determination process for Medicaid, the pregnant woman must be interviewed by
				  county welfare agency staff, complete any forms required as a part of the
				  application process, and assist the county welfare agency in securing evidence
				  that verifies her statements regarding eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 6 - PRESUMPTIVE ELIGIBILITY › Section 10:72-6.6 - Notification and fair hearing rights

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For a
				presumptively eligible pregnant woman who is subsequently determined ineligible
				for Medicaid benefits:
1. The county welfare
				agency is not required to provide either timely or adequate notice for the end
				of the presumptive eligibility. The pregnant woman has no right to a fair
				hearing based on the termination of her presumptive eligibility.
2. The county welfare agency shall provide
				the applicant notice of denial of her Medicaid application in accordance with
				10:72-5.1. The pregnant woman has
				the right to apply for a fair hearing based on the denial of her Medicaid
				application.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 7 - PRESUMPTIVE ELIGIBILITY FOR CHILDREN › Section 10:72-7.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter describes the presumptive eligibility
				  process for children, up to the age of one year, who may meet the eligibility
				  requirements for New Jersey Care ... Special Medicaid Programs. The presumptive
				  eligibility determination makes it possible for a child or the children in a
				  family to receive fee-for-services care from a Medicaid participating provider
				  for a temporary period prior to the application for New Jersey Care ... Special
				  Medicaid Programs benefits, and while an application for these benefits is
				  being processed by the eligibility determination agency.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 7 - PRESUMPTIVE ELIGIBILITY FOR CHILDREN › Section 10:72-7.2 - Period of presumptive eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The period of
				presumptive eligibility shall begin on the date an approved presumptive
				eligibility entity determines that, based on information provided by the family
				of the presumptive eligibility beneficiary, the child(ren) meets the
				requirements and standards of this chapter.
(b) The period of presumptive eligibility
				shall terminate:
1. On the date a
				determination of eligibility or ineligibility for New Jersey Care ... Special
				Medicaid Programs is made; or
2. If
				the child's parent, guardian, or caretaker relative fails to file an
				application with the applicable eligibility determination agency, on the last
				day of the month subsequent to the month in which the child(ren) was (were)
				determined presumptively eligible.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 7 - PRESUMPTIVE ELIGIBILITY FOR CHILDREN › Section 10:72-7.3 - Presumptive eligibility determination entities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A qualified
				presumptive eligibility entity shall be a New Jersey Medicaid provider and:
1. An acute care hospital;
2. A local health department; or
3. A Federally Qualified Health Center
				(FQHC).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 7 - PRESUMPTIVE ELIGIBILITY FOR CHILDREN › Section 10:72-7.4 - Policies governing the presumptive eligibility processing performed by the presumptive eligibility determination entity

Current through Register Vol. 56, No. 14, July 15, 2024
(a) From
				preliminary information provided by a parent, guardian, or caretaker relative,
				the approved presumptive eligibility entity shall determine if the child meets
				the eligibility criteria of this subchapter as it applies to children. The
				approving presumptive eligibility entity shall obtain sufficient information
				from the parent, guardian, or caretaker relative to complete the certificate of
				presumptive eligibility. For purposes of the presumptive eligibility
				determination, the approved presumptive eligibility determination entity shall
				request from the parent, guardian, or caretaker relative only that information
				necessary to determine the child's presumptive eligibility or ineligibility.
				The approved presumptive eligibility determination entity shall make the
				determination of eligibility based solely on information obtained in the
				interview and shall not require any verification or documentation of the
				presumptive eligibility beneficiary's statements.
(b) For any child determined presumptively
				eligible, the approved presumptive eligibility determination entity shall:
1. Complete and sign the certificate of
				presumptive eligibility and forward the original of the certificate of
				presumptive eligibility to the Division of Medical Assistance and Health
				Services within two working days of the date the presumptive eligibility
				determination was made;
2. Forward
				a copy of the completed certificate and the referral, if appropriate, to the
				eligibility determination agency of the applicant's choice;
3. Inform the parent, guardian, or caretaker
				relative that they must contact the eligibility determination either by mailing
				an application to the Statewide eligibility determination agency or by
				arranging for a face-to-face interview with the county board of social services
				in order to complete the application process;
4. Give the parent, guardian, or caretaker
				relative of the presumptively eligible child a copy of both the certificate and
				the referral, if completed; and
5.
				Advise the parent, guardian, or caretaker relative of the presumptively
				eligible child, in writing, of the address and telephone number of the
				eligibility determination agency that the parent, guardian, caretaker relative
				or sponsoring adult chose.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 7 - PRESUMPTIVE ELIGIBILITY FOR CHILDREN › Section 10:72-7.5 - Presumptive eligibility process performed by the Division of Medical Assistance and Health Services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon receipt of
				a properly completed certificate from the approved presumptive eligibility
				determination entity, Division staff shall:
1. Assign a presumptive eligibility
				number;
2. Create an eligibility
				record;
3. Issue a letter
				authorizing covered medical services until a permanent identification card can
				be issued; and
4. Notify the
				approved presumptive eligibility determination agency and the appropriate
				county board of social services of the presumptive eligibility identification
				number assigned to the beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 7 - PRESUMPTIVE ELIGIBILITY FOR CHILDREN › Section 10:72-7.6 - Presumptive eligibility processing performed by the eligibility determination agency

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon receipt of
				the certificate of presumptive eligibility and a referral, if completed, from
				the approved presumptive eligibility determination entity, the eligibility
				determination agency shall check the Medicaid, Medically Needy, and NJ
				FamilyCare Eligibility database for existing Medicaid or NJ FamilyCare
				eligibility. If the child is receiving Medicaid benefits, Medically Needy
				benefits or NJ FamilyCare benefits, no further action shall be required by the
				eligibility determination agency.
(b) If the child is not currently receiving
				Medicaid or NJ FamilyCare benefits, the eligibility determination entities
				shall, notwithstanding the application disposition standards in
				10:72-2.1(d),
				arrive at a case disposition within the presumptive eligibility period.
1. If the time period specified in
				10:72-7.2(b)2  is
				exceeded, the eligibility determination agency shall notify the Division of
				Medical Assistance and Health Services of any such delay. The Division shall
				continue the child's presumptive eligibility until a final determination is
				made.
2. The eligibility
				determination agency shall also provide the applicant written notification of
				the specific reason(s) for the delay, prior to the expiration of the
				presumptive eligibility period in accordance with
				10:72-7.8(b).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 7 - PRESUMPTIVE ELIGIBILITY FOR CHILDREN › Section 10:72-7.7 - Responsibility of the applicant

Current through Register Vol. 56, No. 14, July 15, 2024
The parent, guardian, or caretaker relative of a
				  presumptively eligible child shall contact the eligibility determination agency
				  during the presumptive eligibility period by mailing an application to either
				  the Statewide eligibility determination agency or arranging for a face-to-face
				  interview with the county board of social services to complete the application
				  process. As part of the eligibility determination process for Medicaid, the
				  parent, guardian, or caretaker relative of a presumptively eligible child shall
				  assist the eligibility determination agency in securing evidence that verifies
				  eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 7 - PRESUMPTIVE ELIGIBILITY FOR CHILDREN › Section 10:72-7.8 - Notification and fair hearing rights

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For a
				presumptively eligible child who is subsequently determined ineligible for
				Medicaid or NJ FamilyCare benefits:
1. The
				eligibility determination agency shall not be required to provide either timely
				or adequate notice for the end of the presumptive eligibility period. The
				presumptively eligible beneficiary shall not have any right to a fair hearing
				based on the termination of presumptive eligibility; and
2. The eligibility determination agency shall
				provide the child's parent, guardian or caretaker relative a notice of denial
				of the child's Medicaid application in accordance with
				10:72-5.1. The presumptively
				eligible beneficiary shall have the right to apply for a fair hearing in
				accordance with
				10:72-5.1 based on the denial of
				the application.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 7 - PRESUMPTIVE ELIGIBILITY FOR CHILDREN › Section 10:72-7.9 - Scope of services during the presumptive eligibility period

Current through Register Vol. 56, No. 14, July 15, 2024
All presumptively eligible New Jersey Care ... Special
				  Medicaid Programs children under the age of one year shall be eligible during
				  the presumptive eligibility period to receive on a fee-for-service basis all
				  the Medicaid services defined at
				  10:49-5.2.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 7 - PRESUMPTIVE ELIGIBILITY FOR CHILDREN › Section 10:72-7.10 - Limitation on number of presumptive eligibility periods

Current through Register Vol. 56, No. 14, July 15, 2024
All beneficiaries of presumptive eligibility for children
				  who make an application for presumptive eligibility benefits for any Medicaid
				  or NJ FamilyCare program shall be limited to one continuous presumptive
				  eligibility period during the year, which shall be counted from the first day
				  the applicant initially received presumptive eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 8 - BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT ACT SERVICES › Section 10:72-8.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this subchapter is to provide the coverage
				  stipulated in
				  P.L.
				  2001, c. 186, effective
				  July 27, 2001, for women who are New Jersey residents who are under the age of
				  65 and who have been screened for breast and cervical cancer in accordance with
				  the Breast and Cervical Cancer Prevention and Treatment Act,
				  42 U.S.C. §
										1396a(aa), and who would not
				  otherwise be eligible for the Medicaid program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 8 - BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT ACT SERVICES › Section 10:72-8.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The words and terms, when used in this subchapter, shall
				  have the following meanings, unless the context clearly indicates
				  otherwise.
"Creditable coverage" means, with respect to an individual,
				  in accordance with Public
				  Law 104-191, the Health Insurance Portability and
				  Accountability Act of 1996, coverage of that individual under any of the
				  following:
1. A group health plan;
2. Health insurance coverage;
3. Part A or Part B of Title XVIII of the Social Security
				  Act;
4. Title XIX of the Social Security Act, other than benefits
				  solely under section 1928 of the Act;
5. Title 10, Chapter 55 of the United States Code;
6. A medical care program of the Indian Health Service or of
				  a tribal organization;
7. A State health benefits risk pool;
8. A health plan offered under Title 5, chapter 89 of the
				  United States Code;
9. A public health plan;
10. A health benefit plan under
				  22 U.S.C. §
										2504(e); or
11. Coverage of excepted benefits as defined in 29 U.S.C.
				  § 1186(c).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 8 - BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT ACT SERVICES › Section 10:72-8.3 - Breast and cervical cancer-related prevention and treatment program eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An eligible
				individual shall:
1. Be a citizen or eligible
				qualified alien as defined in
				10:72-3.2;
2. Be under 65 years of age;
3. Have been screened for breast or cervical
				cancer under the Federal Centers for Disease Control (CDC) Breast and Cervical
				Cancer Early Detection program established under Title XV of the Public Health
				Service (PHS) Act, and found to need treatment for either breast or cervical
				cancer (including a precancerous condition);
4. Not have creditable coverage;
				and
5. Meet all other Medicaid
				non-financial eligibility requirements as defined in N.J.A.C. 10:49-2, unless
				otherwise specified in this subchapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 8 - BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT ACT SERVICES › Section 10:72-8.4 - Presumptive eligibility process

Current through Register Vol. 56, No. 14, July 15, 2024
In accordance with
				  Pub.L.
				  106-354 and
				  42 U.S.C. §
										1396a(aa), an individual
				  referred to the Division by a CDC funded screening center shall be determined
				  to be presumptively eligible for medical assistance in accordance with
				  10:72-7.5.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL › Subchapter 8 - BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT ACT SERVICES › Section 10:72-8.5 - Service restrictions

Current through Register Vol. 56, No. 14, July 15, 2024
In the case of an individual qualified for services in
				  accordance with this subchapter, the only medical assistance provided shall be
				  payment for services provided during the period in which the individual
				  requires treatment for breast or cervical cancer.