reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 1 - INTRODUCTION › Section 10:71-1.2 - Choice of program by applicant

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An aged, blind
				or disabled person who desires Medicaid and does not wish to receive a money
				payment may apply for the Medicaid Only program. To qualify for this program,
				he/she must have financial eligibility as determined by the regulations and
				procedures set forth in this chapter.
(b) Persons who are neither aged, blind nor
				disabled qualify for Medicaid benefits when they are determined by the county
				welfare agency to be eligible for AFDC-related Medicaid program. Persons whose
				eligibility is thus established may choose to receive Medicaid Only benefits
				without accepting money payments. Regulations governing these programs are set
				forth in the AFDC-related Medicaid chapter (N.J.A.C. 10:69).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 1 - INTRODUCTION › Section 10:71-1.3 - Living arrangements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Aged, blind and
				disabled persons who are living in the community and meet the requirements of
				the SSI program may receive Medicaid Only.
(b) Aged, blind and disabled persons who are
				receiving care in an eligible medical institution and, because of income or
				resources, do not qualify for SSI may be eligible for Medicaid Only.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 1 - INTRODUCTION › Section 10:71-1.4 - Information on the chapter

Current through Register Vol. 56, No. 14, July 15, 2024
This chapter sets forth the policies and procedures
				  necessary for the orderly and equitable administration of the Medicaid Only
				  program as it relates to the aged, blind and disabled. It is a statement of
				  policy and procedures separate from all other assistance programs, and is
				  applicable to "Medicaid Only." The criteria for determination of eligibility
				  are based on SSI policy and procedure which do not necessarily coincide with
				  standards for other public assistance programs and therefore require separate
				  instructions.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 1 - INTRODUCTION › Section 10:71-1.5 - Administrative organization

Current through Register Vol. 56, No. 14, July 15, 2024
The Medicaid Only program is administered by the county
				  welfare agencies (CWAs) of the State of New Jersey through the Division of
				  Medical Assistance and Health Services in the Department of Human Services. The
				  CWAs contract with the Division of Medical Assistance and Health Services for
				  the purpose of providing Medicaid Only benefits to eligible persons.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 1 - INTRODUCTION › Section 10:71-1.6 - Basic principles of administration

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				principles of administration shall apply to the Medicaid Only program.
1. Any aged, blind or disabled person who
				believes he/she is eligible shall be assured an opportunity to make application
				(including reapplication) for Medicaid Only by completing the appropriate
				application form.
2. The applicants
				or beneficiaries are the primary source of information. However, it is the
				responsibility of the agency to make the determination of eligibility and to
				use secondary sources when necessary, with the applicant's knowledge and
				consent.
3. No duplication of
				assistance: No beneficiary of Medicaid Only shall receive, during the same
				period, any other medical assistance from the State or any political
				subdivision thereof with respect to any maintenance requirements or other need
				for which allowance is made in the Medicaid Only program (see
				10:71-3.14 regarding inmates of
				correctional institutions). The food stamp program is not considered a
				duplication of public assistance.
4. There shall be strict adherence to law and
				complete conformity with administrative policies. Requirements other than those
				established by law or regulations shall not be imposed on any person as a
				condition of receiving medical assistance.
5. The applicants or beneficiaries shall have
				the right to request appeal on the action or inaction of the agency whenever
				they believe that they have not been given full consideration under the law. A
				fair hearing shall be conducted by an impartial official of the Department of
				Human Services in accordance with prescribed procedure when:
i. An application for Medicaid Only is
				denied;
ii. An application for
				Medicaid Only is not acted upon by the county welfare board within 30 days for
				the aged and 60 for the disabled or blind; or
iii. Medicaid Only is terminated.
6. Information about applicants
				and beneficiaries and their circumstances shall not be disclosed except as
				required for the proper and efficient administration of the program and only to
				those agencies involved in the lawful administration or operation of public
				welfare functions or services.
7.
				There shall be no discrimination on grounds of race, color, religion, sex,
				national origin or marital, parental or birth status by state or local agencies
				in the administration of any public assistance program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 1 - INTRODUCTION › Section 10:71-1.7 - Examination or review of chapter

Current through Register Vol. 56, No. 14, July 15, 2024
This chapter is a public document. Copies are available in
				  the State office of the Division of Medical Assistance and Health Services and
				  in each CWA office for examination or review during regular office hours on
				  regular work days. An electronic rendition of the sections in this chapter can
				  be viewed at
http://www.lexisnexis.com/njoal/
.
				  However, it should be noted that the electronic rendition is not the official
				  version of the chapter; only the printed pages contained in the published
				  hardcopy of the New Jersey Administrative Code is the official version.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 1 - INTRODUCTION › Section 10:71-1.8 - County welfare agency responsibility; chapter

Current through Register Vol. 56, No. 14, July 15, 2024
The director of the CWA shall assign copies of this chapter
				  to staff members as appropriate and shall ensure that such persons are
				  thoroughly familiar with its contents, apply the required policy and procedures
				  correctly and keep up-to-date on all policy changes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 1 - INTRODUCTION › Section 10:71-1.9 - Providing chapter material in adverse action situations

Current through Register Vol. 56, No. 14, July 15, 2024
Specific chapter material necessary for an applicant or
				  beneficiary or his or her representative to determine whether a hearing should
				  be requested or to prepare for a hearing shall be provided to such persons
				  without charge.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 1 - INTRODUCTION › Section 10:71-1.10 - Revisions of the chapter

Current through Register Vol. 56, No. 14, July 15, 2024
The Division of Medical Assistance and Health Services shall
				  issue revisions and changes to this chapter as necessary. It is the
				  responsibility of each holder of the chapter to maintain its accuracy by
				  inserting new material and removing obsolete pages promptly.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 1 - INTRODUCTION › Section 10:71-1.11 - Availability of chapter

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A current
				up-to-date copy of the chapter or any part of it is available from the Division
				of Medical Assistance and Health Services at the cost of printing and mailing
				to anyone who requests it in writing.
(b) All public and university libraries which
				have agreed to keep the chapter up-to-date will have a copy available under
				their regulations.
(c) Each legal
				services office will be furnished with a copy of this chapter free of charge if
				they do not have access to the internet and are unable to view the electronic
				rendition of the sections of the chapter as discussed at
				10:71-1.7.
(d) Welfare, social service and other
				non-profit organizations will be furnished with a copy of the chapter at no
				cost by an official written request to the Division of Medical Assistance and
				Health Services.
(e) All
				supplementary State policy directives will routinely be sent to those who have
				been supplied with the chapter. A mailing list will be maintained by the
				Division. Supplemental directives will also be posted on the DMAHS website and
				made available for free download. See
http://www.state.nj.us/humanservices/dmahs/home/index.html
.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.2 - Responsibilities in the application process

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division of
				Medical Assistance and Health Services is the administrative unit of the
				Department of Human Services responsible for coordinating the administration of
				Medicaid Only with the Supplemental Security Income program. This Division
				provides for payment of claims for, and evaluation of health services rendered
				under, Medicaid Only; maintains administrative liaison with other departmental
				divisions; and provides professional, medical and paramedical staff that is
				advisory to this Division in all matters of health care relevant to the
				administration of Medicaid Only. This Division contracts with CWAs for
				reimbursement of costs of administering the Medicaid Only program.
(b) The Division of Medical Assistance and
				Health Services and the Commissioner of the Department of Human Services shall
				establish policy and procedures for the application process and supervise the
				operation of and compliance with the policy and procedures so
				established.
(c) The CWA exercises
				direct responsibility in the application process to:
1. Inform the applicants about the purpose
				and eligibility requirements for Medicaid Only, inform them of their rights and
				responsibilities under its provisions and inform applicants of their right to a
				fair hearing;
2. Receive
				applications;
3. Assist the
				applicants in exploring their eligibility for assistance;
4. Make known to the applicants the
				appropriate resources and services both within the agency and the community,
				and, if necessary, assist in their use; and
5. Assure the prompt and accurate submission
				of eligibility data to the Medicaid status files for eligible persons and
				prompt notification to ineligible persons of the reason(s) for their
				ineligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.3 - Policy and procedure on prompt disposition

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The maximum
				period of time normally essential to process an application for the aged is 45
				days; for the disabled or blind, 90 days.
(b) "Date of effective disposition" based
				upon either administrative or board action means:
1. In the case of an approved application,
				the effective date of the application. (Either the date of application, or the
				date of form PA-1C, whichever is earlier);
2. In the case of a denied application, the
				date on which written notification informing the applicant of his or her lack
				of eligibility and the reason therefor is sent to him or her;
3. In the case of a withdrawn application,
				the date on which written notification confirming to the client that the agency
				has taken cognizance of his or her voluntary withdrawal is sent to him or her;
				or
4. In the case of a dismissed
				application, the date on which written notification informing the applicant of
				the dismissal and the reasons therefor is sent to him or her.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.4 - Intake policy and procedure

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Intake" is a
				term applied to the CWA's activities in relation to requests for information
				pertaining to or requests for Medicaid Only.
(b) When a client or a representative of a
				client inquires, for Medicaid Only, an appointment for an interview with the
				client shall be arranged promptly. Such inquiries shall be recorded as
				inquiries unless and until there is an interview which results in a decision to
				make application for assistance.
(c) When the inquiry is by letter or
				telephone, an appointment, if requested, shall be arranged promptly. An
				application for Medicaid Only is not to be taken if applicant plans to or has
				applied for SSI.
(d) All inquiries
				and referrals shall be cleared with the State Data Exchange (SDX) and any
				previous information on file shall be made available to the worker for the
				initial interview.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.5 - Application policy and procedure

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Application for
				Medicaid Only may be taken by the CWA where the applicant resides or is
				institutionalized at the time of making application.
(b) A legally appointed guardian shall always
				be recognized as an authorized agent to initiate an application to establish
				eligibility for Medicaid Only.
(c)
				In Medicaid Only, an individual who wishes to apply may be confined at home or
				at an institution, or may be subject to a critical illness or injury which
				impedes action on his or her own behalf. Consequently, the CWA shall accept any
				one of the following, in order of priority as listed, as an authorized agent
				for the purpose of initiating an application:
1. A relative by blood or marriage;
2. A staff member of a public or private
				welfare agency of which the person is a client, who has been designated by the
				agency to so act;
3. A physician or
				attorney of whom the person is respectively a patient or client; or
4. A staff member of an institution or
				facility in which a person is receiving care, who has been designated by the
				institutional facility to so act.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.6 - Registration procedures and record of inquiries

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Official
				registration of an application consists of the following steps:
1. Entry in application register under
				appropriate classification as new, reapplication, reopened application or
				transfer;
2. Assignment of case
				control number (registration number) to a new application, or reassignment of
				previous number to a reapplication or reopened application; and
3. Preparation of appropriate form PA-9,
				registration card.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.7 - Reports to the Commission for the Blind and Visually Impaired under specified circumstances

Current through Register Vol. 56, No. 14, July 15, 2024
By law, the CWA is required to report to the Commission for
				  the Blind and Visually Impaired, every individual coming to its attention who
				  is known to be, or who is believed likely to become, permanently blind. The
				  permanent information shall be registered with the Commission in the prescribed
				  form.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.8 - Assignment of pending application for completion of eligibility determination

Current through Register Vol. 56, No. 14, July 15, 2024
Each CWA shall provide a method to assure assignment of a
				  pending application to a worker within three working days and establish a
				  follow-up tickler system.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.9 - Process of establishing eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
The process of establishing eligibility involves a review of
				  the application for completeness, consistency, and reasonableness. A personal
				  face to face interview with the applicant or his/her authorized agent is
				  required.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.10 - Collateral investigation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Collateral
				investigation" shall refer to contacts with individuals other than members of
				applicant's immediate household, made with the knowledge and consent of the
				applicant(s).
(b) The primary
				purpose of collateral contacts is to verify, supplement or clarify essential
				information.
(c) The applicants
				will usually be able to help select the most likely sources of information
				about themselves. If they are unwilling to have the necessary inquiries made
				and are unwilling to secure the required information from such sources
				themselves, then it shall be explained that the CWA will be unable to certify
				entitlement to Medicaid Only.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.12 - Recommendation for agency decision

Current through Register Vol. 56, No. 14, July 15, 2024
The eligibility worker is initially responsible for the
				  recommendation for approval or denial. The eligibility worker will complete the
				  work sheet and authorization for medical assistance PR-1 and a copy will be
				  sent to the Medicaid unit for preparation of the MAP-1. The statement of income
				  available for nursing home payment PR-1 (formerly PA-3L) will be completed in
				  appropriate cases.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.13 - Supervisory review and approval

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In most cases
				an eligibility worker will complete the investigation and processing of the
				application.
(b) All records shall
				be reviewed by a supervisory staff member prior to final disposition.
(c) Any difference of opinion between worker
				and supervisor shall be resolved by a conference, and, if necessary, the issue
				shall be referred to a higher administrative level for disposition.
(d) All records of application shall be
				approved in writing by the supervisor following review, either by signature or
				initialed transcript signature.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.14 - Disposition of application

Current through Register Vol. 56, No. 14, July 15, 2024
(a) It is the
				intent of State law and policy that the normal method for disposing of
				applications recommended for approval shall be by the authority vested in the
				director of welfare to make decisions on eligibility for Medicaid Only. The
				director of welfare has the same authority to make case decisions other than
				approvals.
(b) The director may
				delegate such authority to any staff member or members as he/she may determine.
				He/she shall exercise this right of delegation in such a way as to assure the
				available at all times of some staff member possessing the requisite authority
				to make decisions and to authorize payment by the Division of Medical
				Assistance and Health Services.
(c)
				Applications which may be held for the welfare board are:
1. Those where immediate medical need is not
				indicated; or
2. Those where the
				director believes that there is valid cause to question the available evidence
				on any point of eligibility, or where the case presents a special
				problem;
3. If so held, the
				application shall be identified in the narrative portion of the minutes, and in
				each instance shall include a brief statement of the question or special
				problem involved and the decision of the board.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 2 - THE APPLICATION PROCESS › Section 10:71-2.16 - Retroactive eligibility for Medicaid

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All applicants
				for Medicaid Only shall be queried as to whether or not they have outstanding
				unpaid medical bills incurred within the three month period prior to the month
				of application for Medicaid Only. Those indicating the existence of such bills
				are to be supplied with an "Application for payment of unpaid medical bills,"
				form FD-74, for completion. The intake worker will be responsible for assisting
				the applicant, where necessary, in the interpretation and completion of the
				application form (regardless of whether the individual is eventually determined
				to be eligible for Medicaid). The intake worker will not be responsible for
				making a financial determination of eligibility for the three-month period in
				question.
(b) The applicant shall
				attach all outstanding unpaid medical bills to the FD-74 form and forward it to
				the:
Division of Medical Assistance and Health Services
Retroactive Eligibility Unit
PO Box 712 Mail Code 10
Trenton, NJ 08625-0712
(c) For individuals who are incapable of
				acting on their own behalf, an authorized agent can make application for
				retroactive Medicaid eligibility when there are outstanding medical bills. Such
				persons, at the time of application, should be provided with a form FD-74 for
				completion and submission to the retroactive eligibility unit with the unpaid
				medical bills attached.
(d) In the
				case of an individual who is deceased, an authorized agent, as defined above,
				may make application for retroactive Medicaid eligibility by obtaining an
				application form FD-74 from either the county welfare board or a Medical
				Assistance Customer Center.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.1 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Eligibility
				must be established in relation to each legal requirement to provide a valid
				basis for granting or denying medical assistance.
(b) The applicant's statements regarding
				his/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, either documentary or
				nondocumentary:
1. Documentary sources of
				evidence present factual information recorded at some previous date by a
				disinterested party and filed as part of a record. Examples: certificates,
				legal papers, insurance policies, licenses, bills, receipts, notices of RSDI
				benefits, and so forth.
2.
				Nondocumentary sources of evidence are factual oral statements which appear to
				be reliable by individuals, based on the observation and personal knowledge of
				applicant's circumstances.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.2 - Citizenship; requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The applicant
				must be a resident of the United States who is either a citizen or an alien who
				can be classified as an eligible alien in accordance with this subchapter.
1. 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, will 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 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.3 - Citizenship; alien status-documentation requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A person born
				in the United States is, by definition, a United States citizen. The United
				States is defined as the Continental United States, Alaska, Hawaii, Puerto
				Rico, Guam and the Virgin Islands of the United States. Native-born persons of
				American Samoa, Swains Island and the Northern Mariana Islands are also
				regarded as citizens of the United States. Additionally, persons recognized as
				citizens of the United States pursuant to
				8 U.S.C. §
										1401 are also regarded as citizens of the
				United States.
(b) Naturalized
				citizens are those persons upon whom United States citizenship is conferred
				after birth. This may be accomplished through individual or collective
				naturalization or, under certain conditions, citizenship may be derived from a
				naturalized parent. Thus, a child(ren) of a naturalized parent(s) is
				automatically considered a naturalized citizen(s). Women who themselves could
				be lawfully naturalized and, prior to September 22, 1922, were married to
				citizens, or were married to aliens who became citizens before that date,
				automatically became citizens. On and after that date, standard U.S.
				Citizenship and Immigration Services conditions have to be met before any
				person can become a naturalized citizen.
1. A
				naturalized citizen, unless automatically naturalized as outlined above, should
				have his or her naturalization certificate as proof of citizenship. If the
				applicant does not have this document, the county welfare board should contact
				the nearest U.S. Citizenship and Immigration Services (USCIS) district office
				to verify that the applicant meets the requirements of a naturalized
				citizen.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.4 - Residence requirement

Current through Register Vol. 56, No. 14, July 15, 2024
An applicant for or beneficiary of Medicaid Only shall be a
				  resident of the State of New Jersey.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.5 - Resident defined

Current through Register Vol. 56, No. 14, July 15, 2024
(a) 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.
(b)
				County residence is not an eligibility requirement and relates only to
				identification of the CWA charged by law with responsibility for the official
				receipts, registration and processing of applications. The CWA is responsible
				for institutionalized (including nursing homes, intermediate care facilities
				and sheltered boarding homes) applicants and recipients within its county
				regardless of previous county of residence.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.6 - Change of county residence

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Responsibility
				for case management shall be transferred from one county to the other when a
				beneficiary moves to another county.
(b) A temporary visit by the beneficiary
				shall not be considered to be a change of county residence until that visit has
				continued for more than a three-month period.
1. Whenever it is determined that a
				beneficiary whose application has not been validated has changed or is planning
				to change his or her residence from one county to another, the CWA of origin
				shall continue medical assistance while completing validation, subject to the
				time limits set forth in the application process, then transfer the case
				without delay to the receiving county in accordance with (b)2 below. If the CWA
				of origin is in the process of obtaining medical records, it shall complete the
				process and forward the medical records to the receiving county.
2. Whenever it is determined that a
				beneficiary whose application has been validated is planning to change his or
				her residence from one county to another, it shall be the responsibility of the
				CWA directors of the two counties concerned to effect the transfer without
				interruption of medical assistance.
3. The county of origin shall initiate and
				the receiving county shall, on request, immediately cooperate in accomplishing
				a full investigation of the circumstances surrounding the move.
4. If the move is permanent and the case
				warrants continued medical assistance, transfer of the case shall be
				accomplished expeditiously by discontinuance of medical assistance in the
				county of origin and award of medical assistance in the receiving county, to
				occur simultaneously in the first month for which the CWA directors mutually so
				arranged.
5. The welfare of the
				client shall not be adversely affected and his or her right to uninterrupted
				medical assistance if in need shall not be prejudiced by disagreement or other
				administrative difficulty between the counties. Any adverse change in grant
				resulting from transfer requires timely notice.
i. Since the Medicaid Only client retains the
				same Medicaid number when he or she moves from one county to another, the
				county of origin shall not terminate the client from the Medicaid status file,
				but only from its own register.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.7 - Eligibility of beneficiaries who leave New Jersey

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Whenever a
				beneficiary wishes to leave New Jersey either to establish a permanent
				residence or for a temporary visit, he or she shall be advised of the effect of
				this plan on his or her eligibility for continued medical assistance.
				Particular care should be taken to advise the beneficiary how to present his or
				her New Jersey Medicaid validation stub and instruct the provider where to send
				the bill, should the beneficiary need medical care or hospitalization while out
				of the State on an approved temporary visit.
(b) It shall be the policy of this State that
				if a beneficiary leaves New Jersey with intent to establish a permanent
				residence elsewhere, or for an indefinite period for purposes other than a
				temporary visit, or if he or she decides to remain indefinitely in the place
				outside New Jersey to which he or she had gone for a temporary visit, he or she
				ceases to be eligible to receive Medicaid.
(c) Visits by a beneficiary for a period of
				not more than 30 days will be permitted without affecting the beneficiary's
				eligibility. Absence for longer periods of time must be approved by the
				Division of Medical Assistance and Health Services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.8 - Medicaid eligibility for individuals who enter New Jersey in order to secure medical care

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Federal and
				State statute and regulations expressly bar a duration-of-residence requirement
				as a condition of eligibility. The New Jersey Medical Assistance and Health
				Services Act authorizes a grant of medical assistance to a qualified applicant
				who is a resident of the State which " ... means a person living, other than
				temporarily, within the State."
(b)
				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 this person ineligible for the
				medical assistance program. It is the responsibility of the county welfare
				board to evaluate all such cases and to make an eligibility determination,
				considering carefully all the following criteria:
1. Whether the move is a temporary one, being
				solely for the purpose of receiving medical care for a limited time;
2. Whether the move is part of a carefully
				conceived social service plan which would serve to meet other requirements of
				the individual in addition to purely physical needs, for example, a person
				moves to a nursing home in order to be closer to relatives who are interested
				in the person's welfare;
3. Whether
				there is a clear expression of intent on the part of the individual to remain
				permanently in this State;
4.
				Whether there is objective evidence that the individual has, in fact, abandoned
				or not abandoned residence in the State from which he/she came;
5. Whether the State in which the individual
				previously resided recognizes him/her as having continuing eligibility under
				the Medicaid program (or other program providing payment for medical care) of
				that jurisdiction.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.9 - Age

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Age
				requirements are:
1. The applicant must be 65
				years of age or older to be eligible based on age alone;
2. A disabled or blind child must be under 18
				years of age, or under 22 years of age and a student regularly attending school
				and neither married nor the head of the household; or
3. A disabled or blind adult must be over 21
				years of age and under 65 years of age or between 18 years of age and 22 years
				of age if not a full-time student.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.10 - Disability and blindness factors

Current through Register Vol. 56, No. 14, July 15, 2024
For purposes of determining medical eligibility for the
				  Medicaid Only program, the disability and blindness standards shall be the same
				  as for the Supplemental Security Income program under Title XVI of the Social
				  Security Act, as amended by Public Law 92-603.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.11 - Determination of disability and blindness eligibility; a State function

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				determination of disability and blindness eligibility for the Medicaid Only
				program is a direct responsibility of the Medical Review Team in the Division
				of Medical Assistance and Health Services. Determination of all other factors
				of eligibility is the responsibility of the CWAs. The medical review team is
				composed of a medical consultant; and a medical social work consultant; it
				reviews Medicaid Only applications submitted by the CWAs.
(b) In situations where an applicant's
				disability or blindness appears to meet the definition in
				10:71-3.12, presumptive
				eligibility for either of these factors can be granted with the approval of the
				Medical Review Team.
(c) If an
				individual has been determined disabled for Social Security purposes (that is,
				he or she is currently receiving Disability Insurance Benefits), the CWA shall
				not refer the individual to the Medical Review Team for a determination of
				medical eligibility. The individual shall be considered automatically eligible,
				in this respect, for Medicaid Only benefits.
1. In the event the Social Security
				Administration determined within the 12 months prior to the application for
				Medicaid Only that the individual was not disabled, the Medical Review Team
				will not make an independent determination of the applicant's disability but
				will be bound by the determination of the Social Security Administration. If an
				individual whose Social Security or SSI disability claim was denied within the
				last 12 months presents new or additional evidence to support that claim, the
				CWA should refer the applicant to the Social Security Administration for a
				reevaluation of its determination.
2. When the denial by the Social Security
				Administration occurred more than 12 months prior to the application for
				Medicaid Only, the Medical Review Team will make an independent determination
				of disability.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.12 - Disability; definitions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An individual
				is disabled for purposes of this part if he/she is unable to engage in any
				substantial gainful activity by reason of a medically determinable physical or
				mental impairment which can be expected to result in death or which has lasted
				or can be expected to last for a continuous period of not less than 12 months
				(or, in the case of a child under the age of 18, if he/she suffers from any
				medically determinable physical or mental impairment of comparable
				severity).
(b) A physical or mental
				impairment is an impairment which results from anatomical, physiological or
				psychological abnormalities which are demonstrable by medically acceptable
				clinic and laboratory diagnostic techniques. Statements of the applicant
				including his/her own description of his/her impairment (symptoms) are, alone,
				insufficient to establish the presence of a physical or mental
				impairment.
(c) An individual is
				"blind" for purposes of this part if he/she has central visual acuity of 20/200
				or less in the better eye with the use of a correcting lens. An eye which is
				accompanied by limitation in the field of vision such that the widest diameter
				of the visual field subtends an angle no greater than 20 degrees shall be
				considered as having central visual acuity of 20/200 or less.
(d) The presence of a condition diagnosed as
				addiction to alcohol or drugs will not itself be the basis for a finding that
				the individual is or is not under a disability.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.13 - County welfare agency responsibility and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The CWA shall
				furnish the Medical Review Team with current, pertinent social and medical
				information, and obtain any special or additional reports on request.
(b) When it appears that an applicant meets
				the income and resources requirements for Medicaid Only, arrangements for
				obtaining medical evidence should be initiated immediately by whichever of the
				following procedures is applicable to the applicant's situation:
1. When the applicant is currently (within
				three months) under the care of a private physician, he or she shall be
				furnished with a copy of Form PA-5 (Examining Physician's Report) to take to
				the physician for completion;
2. If
				the applicant is currently receiving treatment in a hospital clinic, public
				health facility (that is, tuberculosis clinic, mental health clinic or other
				outpatient facility) on a regular basis for the medical condition related to
				his or her application for Medicaid Only, a copy or abstract of the clinic
				record may be submitted in lieu of the PA-5;
3. If the applicant has been hospitalized
				within three months for a condition related to the impairment for which he or
				she is applying for Medicaid Only, an abstract of the hospital record may be
				submitted for patients in long-term care facilities;
4. In the event none of the above are
				applicable, the CWA should assist the applicant in choosing a physician to
				complete the PA-5, who is competent to determine the nature and extent or
				degree of disability; or
5. When
				the applicant states that he or she is blind or that visual impairment is his
				or her primary disability, the CWA shall, prior to submission of the record to
				the Medical Review Team, obtain a Report of Eye Examination (Form PA-5A) from a
				qualified medical specialist in diseases of the eye (for example,
				ophthalmologist), or an optometrist, or from an eye clinic of a general
				hospital, whichever the individual may select. (The membership directory of the
				Medical Society of New Jersey is suggested as reference for identification of,
				in each municipality, physicians specializing in diseases of the eye.)
				Optometrists are listed in the yellow pages of local telephone directories
				under the heading "Optometrists--Doctors of Optometry." The Form PA-5A should
				be transmitted in duplicate to the Medical Review Team with any other pertinent
				medical evidence as outlined above. When appropriate, the Certification of Need
				for Patient Care in Facility Other Than Public or Private General Hospital
				(Form PA-4) will be submitted to the Medical Review Team.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.14 - Institutional eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Persons who are
				otherwise eligible for Medicaid Only receive medical coverage while receiving
				patient care in eligible medical institutions. Such coverage shall be provided
				through the appropriate payment mechanism of the Division of Medical Assistance
				and Health Services. The Medicaid Cap income standard is applied only to
				certain institutions.
(b)
				Individuals who are inmates of public institutions are not eligible for
				Medicaid coverage, unless they are receiving care in a Title XIX approved
				section of such facility.
(c)
				Individuals incarcerated in a Federal, State or local correctional facility
				(prison, jail, detention center, reformatory, etc.) are not eligible for
				Medicaid coverage. The needs of such individuals (inmates) are met through
				another agency of the Federal or State government or political subdivision
				thereof (see
				10:71-1.6(a)3 
				).
(d) An "institution" is any
				group living arrangement in which food, shelter and personal care (other than
				nursing care) are furnished on a continuous basis to four or more persons
				unrelated to the operator or in which food, shelter and personal care,
				including nursing care, are furnished on a continuous basis to four or more
				persons unrelated to the operator; or any establishment or facility licensed or
				approved by the State of New Jersey.
(e) Application of Medicaid Cap rules are:
1. General or Class A special hospitals: When
				a person is confined to such a hospital, the Medicaid Cap standard does not
				apply; eligibility will be determined according to the applicable living
				arrangement in Table B (see
				10:71-5.6(c)5 
				).
2. Long term care facilities
				(eligible private medical institutions): This may include licensed nursing
				homes, intermediate care facilities, or Class B and C special hospitals. These
				facilities must be licensed by the Department of Health and Senior Services
				licensing authority, and approved by the Department of Human Services for
				provider participation in the Title XIX Medicaid program. When a person is
				confined to a long term care facility, the Medicaid Cap standard is
				used.
3. Licensed boarding homes
				for sheltered care (including nonprofit incorporate homes for the aged): These
				homes must be licensed by the Department of Health and Senior Services in
				accordance with N.J.A.C. 8:43. When the person is in a facility of this type,
				the income standard for licensed boarding home is used.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.15 - County welfare agency responsibility and procedures; eligibility factors

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The CWA shall
				be responsible for determining income and resource eligibility, as outlined in
				N.J.A.C. 10:71-4 and 5, for Medicaid Only when the applicant is receiving care
				in institutions defined in
				10:71-3.14(d).
				This does not include residents of the State psychiatric hospitals, the State
				schools for persons with intellectual disabilities, Bergen Pines County
				Psychiatric Hospital and Essex County Hospital Center, which are the
				responsibility of the Institutional Services Section of the Division of Medical
				Assistance and Health Services.
(b)
				When eligibility depends upon the disability or blindness factor, the
				determination of medical eligibility shall be the responsibility of the Medical
				Review Team (MRT). The CWA shall furnish the MRT with current, pertinent social
				and medical information as outlined in this subchapter.
(c) When eligibility for Medicaid Only has
				been determined, the CWA will complete and process a Medicaid Status File
				Transaction, Form MAP-1, within 10 working days from the date of such
				determination. The CWA will issue and distribute Medicaid validation stubs to
				Medicaid Only beneficiaries who are not in long-term care facilities. The CWA
				will complete the statement of income available for nursing home payment (PR-1)
				(formerly PA-3L) when appropriate.
(d) A determination of continuing eligibility
				shall be made in accordance with N.J.A.C. 10:71-5.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 71 - MEDICAID ONLY › Subchapter 3 - ELIGIBILITY FACTORS › Section 10:71-3.16 - Medical assistance units

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medical
				Assistance Customer Centers: The Division of Medical Assistance and Health
				Services has local medical offices throughout the State, known as Medical
				Assistance Customer Centers (MACCs). The role of these MACCs is to: provide
				liaison with providers of health services; provide information about Medicaid
				to beneficiaries and members of the community; provide utilization review in
				determining the medical need for certain covered services requiring prior
				authorization; and provide information about Medicaid to, and cooperate with,
				appropriate agencies in order to ensure maximum utilization of the services
				available through the Medicaid program.
(b) Any questions with respect to policy,
				regulations or procedures of the Medicaid program should be directed to the
				appropriate MACC as listed at N.J.A.C. 10:49, Appendix, Form #13, or on the
				DMAHS website:
http://www.state.nj.us/humanservices/dmahs/home/index.html
.