reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 12 - PRESUMPTIVE ELIGIBILITY FOR AFDC-RELATED MEDICAID CHILDREN › Section 10:69-12.5 - Presumptive eligibility processing 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 application from the approved presumptive eligibility
				determination entity, Division staff shall:
1. Assign a presumptive eligibility
				number;
2. Create an eligibility
				record on the Medicaid Eligibility File;
3. Issue a Health Benefits Identification
				(HBID) Card; and
4. Notify the
				approved presumptive eligibility determination agency and the appropriate CWA
				of the presumptive eligibility identification number assigned to the
				beneficiary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 12 - PRESUMPTIVE ELIGIBILITY FOR AFDC-RELATED MEDICAID CHILDREN › Section 10:69-12.6 - Presumptive eligibility processing performed by the county welfare agency (CWA)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon receipt of the presumptive
				eligibility application from the qualified presumptive eligibility
				determination entity, the CWA shall check the Medicaid, Medically Needy, and NJ
				FamilyCare -- Children's Program Eligibility database for existing eligibility.
				If the child is receiving Medicaid or NJ FamilyCare -- Children's Program
				benefits, no further action shall be required by the CWA.
(b) If the child is not currently receiving
				Medicaid or NJ FamilyCare -- Children's Program benefits, the CWA shall,
				notwithstanding the application disposition standards in
				N.J.A.C.
				10:69-2.1, arrive at a case disposition
				within the presumptive eligibility period.
1.
				If the time specified in
				N.J.A.C.
				10:69-12.2(b)2  has elapsed
				without a determination being made by the CWA, the CWA 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 by the CWA.
i. The CWA
				shall also provide the individual applying on the child's behalf with written
				notification of the delay prior to the expiration of the presumptive
				eligibility period, of the specific reasons for the delay. See
				N.J.A.C.
				10:69-12.8(b)  for the
				requirements related to the applicant's rights to a fair hearing due to the
				delay.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 12 - PRESUMPTIVE ELIGIBILITY FOR AFDC-RELATED MEDICAID CHILDREN › Section 10:69-12.7 - Responsibility of the applicant

Current through Register Vol. 56, No. 14, July 15, 2024
The child, if appropriate, parent, guardian, or caretaker of
				  a presumptively eligible child shall contact the CWA during the presumptive
				  eligibility period so that a face-to-face interview can be scheduled. As part
				  of the eligibility determination process for AFDC-related Medicaid or Medicaid
				  Special, the parent, guardian, or caretaker of a presumptively eligible child
				  shall be interviewed by the CWA staff, complete any forms required as a part of
				  the application process, and assist the CWA in securing evidence that verifies
				  eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 12 - PRESUMPTIVE ELIGIBILITY FOR AFDC-RELATED MEDICAID CHILDREN › Section 10:69-12.8 - 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
				AFDC-related Medicaid benefits, Medicaid Special benefits, or any other
				Medicaid or NJ FamilyCare -- Children's Program benefits program, the CWA:
1. Shall not be required to provide either
				timely or adequate notice to the beneficiary or applicant of 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. Shall provide
				the child (if appropriate), child's parent, guardian, or caretaker relative, as
				appropriate, a notice of denial of the child's AFDC-related Medicaid or
				Medicaid Special application in accordance with
				10:69-2.15. The denied
				AFDC-related Medicaid or Medicaid Special applicant shall have the right to
				apply for a fair hearing in accordance with
				10:69-6.2
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 12 - PRESUMPTIVE ELIGIBILITY FOR AFDC-RELATED MEDICAID CHILDREN › Section 10:69-12.9 - Scope of services during the presumptive eligibility period

Current through Register Vol. 56, No. 14, July 15, 2024
All AFDC-related Medicaid or Medicaid Special beneficiaries
				  shall be entitled to receive fee-for-service during the presumptive eligibility
				  period all the regular Medicaid services defined at
				  10:49-5.2.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 12 - PRESUMPTIVE ELIGIBILITY FOR AFDC-RELATED MEDICAID CHILDREN › Section 10:69-12.10 - 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-Children's 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 70 - MEDICALLY NEEDY PROGRAM › Subchapter 1 - INTRODUCTION › Section 10:70-1.1 - Program scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Medically
				Needy Program, enacted by P.L. 1985, Chapter 371, extends limited Medicaid
				program benefits to certain groups of medically needy persons whose income
				and/or resources exceeds the standards for the Medicaid program but are within
				the standards for the Medically Needy Program, or whose income exceeds the
				standards for the Medically Needy Program but is insufficient to meet their
				medical expenses as determined in this chapter.
(b) Eligibility for the Medically Needy
				Program is limited to the following eligibility groups within the family and
				adult eligibility categories:
1. AFDC-related:
i. Pregnant women; and
ii. Children under 21 years of age.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 1 - INTRODUCTION › Section 10:70-1.2 - Purpose of the Medically Needy Manual

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Purpose of the
				regulations contained within this chapter is to:
1. Set forth eligibility for the Medically
				Needy Program;
2. Establish policy
				for calculating spend-down liability for persons whose income exceeds the
				Medically Needy Income Level; and
3. Specify the rights and responsibilities of
				program applicants and eligible persons.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 1 - INTRODUCTION › Section 10:70-1.3 - Administrative organization

Current through Register Vol. 56, No. 14, July 15, 2024
The Medically Needy Program is administered by the county
				  welfare agencies under the supervision of the Division of Medical Assistance
				  and Health Services of the Department of Human Services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 1 - INTRODUCTION › Section 10:70-1.4 - Principles of administration

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				principles of administration apply in the Medically Needy Program.
1. Any individual who believes he or she is
				eligible shall be afforded an opportunity to make application (or
				reapplication) for the Medically Needy Program without delay.
2. Program applicants or eligible persons are
				the primary source of information concerning program eligibility and spend-down
				liability. The county board of social services shall, when necessary, in the
				process of determining eligibility and spend-down liability, use secondary
				sources of information with the knowledge and consent of the applicant or
				eligible person.
3. There shall be
				strict adherence to law and complete conformity with regulations and
				administrative policy. Requirements other than those established by law or
				regulation shall not be imposed as a condition of receiving assistance under
				the Medically Needy Program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 1 - INTRODUCTION › Section 10:70-1.5 - Confidentiality of information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No member,
				officer, or employee of a county board of social services shall produce or
				disclose any confidential information to any person, except as authorized
				below.
1. Information considered confidential
				includes, but is not limited to, the following:
i. Names and addresses;
ii. Medical services provided;
iii. Social and economic conditions or
				circumstances;
iv. County board of
				social services evaluation of personal information; and
v. Medical data, including diagnosis and past
				history of disease or disability.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 1 - INTRODUCTION › Section 10:70-1.6 - Materials distributed to program applicants or eligible persons

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All materials
				distributed to applicants or eligible persons must:
1. Directly relate to the administration of
				the Medicaid program;
2. Have no
				political implications;
3. Contain
				names only of individuals directly connected with the administration of the
				Medicaid program; and
4. Identify
				those individuals only in their official capacity with the State or the county
				board of social services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 1 - INTRODUCTION › Section 10:70-1.8 - Assignment of medical support rights

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any person who
				applies for the Medically Needy Program, by virtue of the application for
				benefits, is deemed to have assigned to the Commissioner of the Department of
				Human Services any rights to support for the purpose of medical care as
				determined by a court or administrative order and any rights to payment for
				care from any third party. It is required that program applicants and
				beneficiaries cooperate in the identification of and the obtainment of any such
				rights.
1. The county board of social services
				shall advise applicants and beneficiaries of the terms of the assignment and
				the consequences thereto.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:70-2.1 - Application

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Application for
				the Medically Needy Program shall be accomplished by the completion and signing
				of Form PA-1G for SSI-related cases and Form PA-1J for AFDC-related cases, as
				well as, any addenda to those forms as prescribed by the Division of Medical
				Assistance and Health Services.
1.
				Application for the Program shall be executed by:
i. A parent, caretaker relative, or guardian
				for cases with children under the age of 21 residing with a parent or caretaker
				relative;
ii. A child age 18 or
				older when not residing with a parent or caretaker relative;
iii. A pregnant woman age 18 or
				older;
iv. The parent or caretaker
				relative of a disabled or blind child;
v. The adult seeking benefits as aged, blind,
				or disabled.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:70-2.2 - Interview

Current through Register Vol. 56, No. 14, July 15, 2024
A personal face-to-face interview with the program
				  applicant(s) or the authorized agent is required as part of the process of
				  determining program eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:70-2.3 - Collateral verification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Collateral
				verification is the use of third-party information (both documentary and
				nondocumentary) from agencies or individuals other than members of the
				applicant's household to substantiate the accuracy of statements made on the
				application and during the interview.
1.
				Program applicants have the primary responsibility for providing verification
				of factors of eligibility. If it would be difficult or impossible for the
				applicants to provide necessary verification in a timely manner, the county
				board of social services shall provide assistance in obtaining the
				evidence.
2. In the absence of
				credible verification of all eligibility factors, eligibility for the Medically
				Needy Program may not be established.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:70-2.4 - 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 not to
				adversely affect the rights of any individual to program entitlement. In a case
				transfer, the existing eligibility period, as established by the county of
				origin, does not change.
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 70 - MEDICALLY NEEDY PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:70-2.5 - Redetermination of eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Eligibility for
				the Medically Needy Program shall be redetermined as follows:
1. When required, on the basis of information
				the county board of social services (CBOSS) has obtained previously about
				anticipated changes in the case situation, or when additional information is
				necessary to adjust the best estimate of income when such income is subject to
				significant fluctuation;
2.
				Promptly, after information is obtained by the CBOSS which indicates changes in
				the case circumstances that may affect program eligibility or the amount of
				benefits received under the Program;
3. For cases not subject to medical
				spend-down, a full redetermination of program eligibility, no later than six
				months from the date eligibility was first established or from the date of the
				last full redetermination;
4. For
				cases subject to spend-down, a full redetermination of program eligibility, by
				the completion of the current prospective six-month budget period.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:70-2.6 - Redetermination of medical factors

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except for
				persons receiving Social Security benefits as a result of disability or
				blindness, the factors of disability and blindness will be redetermined at
				intervals established by the Division of Medical Assistance and Health
				Services, Disability Review Section.
(b) Any person whose eligibility for the
				Program is based on a determination of disability or blindness is required to
				submit to examinations or tests and provide medical and other evidence
				necessary for the purpose of determining continued disability or
				blindness.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 2 - CASE PROCESSING › Section 10:70-2.7 - Post-application client responsibilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon a
				determination of eligibility for the Medically Needy Program, members of the
				eligibility group (or their authorized agent) have on-going responsibility for
				the reporting of changes in circumstances and the provision of information as
				delineated at
				10:70-2.1(c).
				Further, as requested by the county board of social services during the
				eligibility period, additional or updated information must be provided. At any
				time the county agency lacks sufficient information to confirm continuing
				program eligibility because of the unwillingness of the eligibility group to
				provide necessary information, the agency shall commence action to terminate
				the case.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:70-3.1 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Eligibility
				must be established in relation to each legal requirement of the Medically
				Needy Program to provide a valid basis for granting or denying medical
				assistance.
(b) The applicant's
				statements regarding his or her eligibility, as set forth in 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, made by individuals based on their observation and personal
				knowledge of applicant's circumstances.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:70-3.2 - Citizenship and alien status

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to be
				eligible for the Medically Needy program, an individual must be a citizen of
				the United States, an alien who has been lawfully admitted for permanent
				residence for the five years prior to the application or an alien who can be
				classified as an eligible alien in accordance with this subchapter.
1. The term "citizen of the United States"
				includes person born in Puerto Rico, Guam, the Virgin Islands, Swains 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 70 - MEDICALLY NEEDY PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:70-3.3 - Residency

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to be
				eligible for the Medically Needy Program, an individual must be a resident of
				the State of New Jersey. State residence shall be determined in accordance with
				the regulations at
				10:71-3.5, 3.7, and 3.8.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:70-3.4 - Eligibility group criteria

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Eligibility for
				the Medically Needy Program is limited to groups of persons within two
				specified eligibility categories. An individual must meet the definition of one
				of the categories below to be eligible for the Medically Needy
				Program.
(b) The following
				eligibility groups are within the AFDC-related eligibility category:
1. Pregnant women: Needy pregnant women of
				any age during the term of a medically verified pregnancy, through the end of
				the month during which the 60th day from delivery occurs.
i. A child born to a woman eligible as a
				pregnant woman under the provisions of this chapter shall remain eligible for a
				period not less than 60 days from his or her birth, and up to one year so long
				as the mother remains eligible for Medicaid, or would remain eligible if
				pregnant, whether or not application has been made, if the child lives with his
				or her mother.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:70-3.5 - Budget unit

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The term
				"budget unit" means those persons whose income and resources are counted in the
				determination of eligibility for persons applying for or eligible for the
				Medically Needy Program. Incurred medical expenses of all members of the budget
				unit are applied in meeting spend-down liability when applicable (see N.J.A.C.
				10:70-6 ). Only those members of the budget unit who are either SSI-related or
				AFDC-related (see
				10:70-3.4 ) may qualify for
				coverage under the Medically Needy Program.
(b) For AFDC-related persons (pregnant women
				and children under the age of 21), the budget unit shall be constituted as
				follows:
1. A pregnant woman shall comprise a
				budget unit of two (except in medically verified cases of multiple pregnancy,
				where the budget unit shall consist of the pregnant woman and the confirmed
				number of fetuses). If the pregnant woman is married and living with her
				husband, the budget unit shall consist of one additional person. The woman's
				natural or adoptive children under the age of 21, living in the same household,
				shall be included in the budget unit. If the pregnant woman is under the age of
				21 and resides in the same household as her natural or adoptive parents, the
				parents shall be included in the budget unit.
2. For children under the age of 21, the
				budget unit shall be composed of all blood-related or adoptive brothers and
				sisters under the age of 21 living in the same household, as well as the
				natural or adoptive parent(s) of the children when living in the same
				household.
i. In the event the children under
				the age of 21 reside with a stepparent, the stepparent may be included in the
				budget unit. If the stepparent is included in the budget unit, his or her
				income and resources will be included in the determination of Medically Needy
				eligibility and his or her medical expenses will apply in the determination of
				spend-down liability, if applicable. If the stepparent is not to be included in
				the budget unit, his or her income, resources, and medical expenses will not be
				included in the determination of Medically Needy eligibility.
ii. The option of including or not including
				the stepparent in the budget unit, and the consequences thereof, shall be fully
				explained to program applicants so that an informed decision may be
				made.
3. Any person who
				is in receipt of AFDC or SSI or who has applied for and been found eligible for
				regular Medicaid benefits related to those programs shall not be included in
				the budget unit of an AFDC-related case. Any person whose income and resources
				have been deemed to an eligible SSI beneficiary shall likewise not be included
				in the budget unit.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:70-3.6 - Third party liability

Current through Register Vol. 56, No. 14, July 15, 2024
Program applicants and beneficiaries shall identify to the
				  county board of social services 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 70 - MEDICALLY NEEDY PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:70-3.7 - Eligibility under other Medicaid categories

Current through Register Vol. 56, No. 14, July 15, 2024
Eligibility for the Medically Needy Program will not be
				  established for any individual who is eligible for Medicaid Only, Medicaid
				  Special, Medicaid for the Unborn, or extended Medicaid benefits resulting from
				  the previous receipt of AFDC. Such individuals are eligible for payment of
				  covered medical services under the categorically needy Medicaid program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:70-3.8 - Persons sanctioned under AFDC rules

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Persons who are
				ineligible for AFDC due to the imposition of a sanction of ineligibility in
				that program may be eligible for the Medically Needy Program (with the
				exception below) without regard to the sanction.
1. Any person ineligible for AFDC solely as a
				result of being on strike is likewise ineligible for the Medically Needy
				Program. Because caretaker relatives are not eligible for the Medically Needy
				Program, participation in a strike by the caretaker relative will not affect
				the eligibility of children applying for the Medically Needy Program.
2. See
				10:70-4.5(c)  for
				persons ineligible for AFDC due to a period of ineligibility imposed as a
				result of the receipt of lump sum income.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:70-3.9 - Application for other benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) As a condition
				of eligibility for the Medically Needy 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 shall avail
				themselves of any health insurance available to the budget unit at no cost,
				such as coverage provided at no cost by an employer.
1. Annuities, pensions, retirement and
				disability benefits include, but are not limited to, veterans' compensation and
				pensions, Social Security benefits, unemployment compensation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 3 - NONFINANCIAL ELIGIBILITY FACTORS › Section 10:70-3.10 - 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 Medically Needy
				Program.
(b) Any person who is
				incarcerated in a Federal, State, or local correctional facility (prison, jail,
				detention center, reformatory, etc.) is not eligible for Medically Needy
				Program benefits.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 4 - INCOME ELIGIBILITY › Section 10:70-4.1 - Medically Needy Income Levels

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Income
				eligibility for the Medically Needy Program may be established by two methods.
				If the countable income of the budget unit (as determined in this subchapter)
				is equal to or less than the Medically Needy Income Level (MNIL) appropriate
				for the budget unit size, income eligibility is established and the eligible
				persons are entitled to Medically Needy Program payment for covered services.
				For cases in which the countable income of the budget unit exceeds the
				appropriate MNIL, income eligibility may only be established through medical
				spend-down (see N.J.A.C. 10:70-6 ).
1. The
				monthly MNIL for budget units consisting of two to 10 persons shall be based on
				the AFDC allowance standards (as set forth at
				10:69-10.3 ). The allowance
				standard for the eligible unit size corresponding to the budget unit size will
				be multiplied by 1.333. The result of this computation shall be multiplied by
				12 and the result rounded up to the next nearest $ 100.00. After rounding, the
				amount shall be divided by 12. Any cents resulting from this calculation are
				dropped and the remainder is the monthly MNIL.
2. To establish the monthly MNIL for budget
				units of more than 10 persons, the calculation in (a)1 above shall be applied
				to the AFDC increment applicable for each additional person in eligible units
				of more than 10 persons (see
				10:69-10.3 ). The resulting amount
				for each additional budget unit member shall be added to the monthly MNIL for
				10 persons.
3. For budget units of
				one person, the AFDC allowance standard for two persons shall be reduced by the
				increment for each additional person applicable to eligible units of more than
				10 persons (see
				10:69-10.3 ). The result of this
				computation shall be calculated as in (a)1 above. The resulting amount is the
				monthly MNIL for one person.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 4 - INCOME ELIGIBILITY › Section 10:70-4.2 - Eligibility periods

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The retroactive
				eligibility period is the three calendar months immediately preceding the month
				in which application for benefits is made.
(b) The prospective eligibility period is the
				six calendar months beginning with the month of application. Once established,
				the prospective eligibility period will not be changed unless the case becomes
				ineligible for the Medically Needy Program during the eligibility period. Upon
				reapplication for the program, a new prospective eligibility period will be
				established.
1. Except for certain pregnant
				women, eligibility does not extend beyond the end of the eligibility period. A
				pregnant woman, who delivers her child near the end of the six-month
				eligibility period, may be eligible for a period exceeding six months if her
				post-partum extended eligibility exceeds the last day of the prospective
				eligibility period (see
				10:70-3.4(b)1  ).
				In all other cases, continuation of program benefits is contingent upon a
				redetermination of all factors of eligibility (see
				10:70-2.5 ). Any period of
				eligibility for a pregnant woman which exceeds the prospective eligibility
				period under the provisions of
				10:70-3.4(b)1 
				shall be without regard to income or resources for such additional period of
				time.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 4 - INCOME ELIGIBILITY › Section 10:70-4.3 - Computing income for six-month prospective period

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The county
				board of social services shall establish the best estimate of income that will
				be available in the six-month prospective eligibility period.
1. The best estimate of income shall be based
				on an average of the budget unit's income for the full two-month period prior
				to the date of application. Adjustments shall be made in the estimated income
				to reflect changes in income that either have occurred or are reasonably
				anticipated to occur which would affect countable income for the prospective
				budget period. Once established, the best estimate of monthly income shall be
				applied to each of the six months of the budget period. If the income for the
				full six-month period is less than or equal to the MNIL for the six-month
				period, eligibility for program benefits has been established. If the income
				for the period exceeds the six-month MNIL, eligibility for program benefits may
				be established through the medical spend-down process.
2. Income changes during the six-month
				eligibility period require an adjustment to the countable income for the month
				of the income change and a new best estimate of income must be established for
				the remaining months of the eligibility period if the change in income will
				continue.
i. For a case not subject to
				medical spend-down, an increase in countable income for the remaining months of
				the eligibility period, will result in the establishment of a spend-down
				liability if the income for those months exceeds the MNIL for the remaining
				months.
ii. For a case which has
				been determined eligible pending spend-down, changes in income during the
				eligibility period require a recomputation of spend-down liability for the
				eligibility period which may increase or decrease the liability of the budget
				unit. If a decrease in income is sufficient to reduce the budget unit's income
				below the six-month MNIL, eligibility is established without a spend-down
				liability for the remaining months of the eligibility period.
iii. For a case which has met the spend-down
				liability during the eligibility period, the recomputation of income for the
				remaining months of the eligibility period will result in the establishment of
				an additional spend-down liability if the countable income for the remaining
				months exceeds the MNIL for those months. Eligibility for the months in which
				the previously computed liability was met will not be retroactively affected by
				the new liability established for the remaining months of the eligibility
				period.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 4 - INCOME ELIGIBILITY › Section 10:70-4.4 - Computing income for retroactive period

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In determining
				income eligibility for the retroactive eligibility period, countable income
				actually received in each month of the three-month period shall be compared to
				the budget unit's monthly MNIL for the same month. If the countable income for
				a month is less than or equal to the MNIL, eligibility for program benefits for
				that month has been established. If the income for a month exceeds the MNIL for
				that month, eligibility for program benefits may be established through the
				spend-down process (see N.J.A.C. 10:70-6 ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 4 - INCOME ELIGIBILITY › Section 10:70-4.5 - Countable income: AFDC-related cases

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as
				specified below, countable income for AFDC-related cases shall be determined in
				accordance with regulations applicable to income in the AFDC program (see
				N.J.A.C. 10:69).
1. The maximum income limits
				as provided for at
				10:69-10.3(a)3 
				do not apply.
2. The $ 30.00 and
				the one-third disregard of earned income at
				10:69-10.13(c)4 
				do not apply.
3. The deeming of
				stepparent income at
				10:69-10.33(d) 
				does not apply. See
				10:70-3.5(b)2 
				regarding inclusion or exclusion of the stepparent from the budget
				unit.
4. The deeming of income of
				an alien's sponsor at
				10:69-10.43 does not
				apply.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 4 - INCOME ELIGIBILITY › Section 10:70-4.6 - Countable income: SSI-related cases

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as
				specified below, countable income for SSI-related cases shall be determined in
				accordance with regulations 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 in the Medically Needy Program.
2. The deeming of the income of an alien's
				sponsor as provided for at
				10:71-5.9 does not
				apply.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 5 - RESOURCE ELIGIBILITY › Section 10:70-5.1 - Resource eligibility limits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Eligibility for
				the Medically Needy Program shall not exist for any month in which the total
				value of a budget unit's countable resources exceeds the limits below:
Resource Limits in the Medically Needy Program
Family Size
$
						  Resources
1
4,000
2
6,000
3
6,100
4
6,200
5
6,300
6
6,400
Each additional person
100
(b)
				No portion of a cash reward provided to any individual by the Division for
				providing information about fraud and/or abuse in any program administered in
				whole or in part by the Division shall be included in the computation of income
				for financial eligibility purposes.
1. In
				order for the cash reward to continue to be excluded, the funds shall be
				separately identifiable (that is, not commingled with other funds or assets),
				but held in a separate account. Any increase in the value of the excluded cash
				reward shall also be excluded.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 5 - RESOURCE ELIGIBILITY › Section 10:70-5.2 - AFDC-related cases; resources

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The resource
				provisions contained in this section shall apply to AFDC-related applicants and
				beneficiaries under this chapter.
(b) Available resources shall include cash
				and other forms of assets that can produce income immediately obtainable to
				meet the needs of the eligible unit, including:
1. Real or personal property that is within
				the control of one or more members of the eligible unit, or to which such
				members may have a valid property interest; and
2. Benefits and other contributions of
				support which are available to one or more of the members of the eligible
				unit.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 5 - RESOURCE ELIGIBILITY › Section 10:70-5.3 - SSI-related cases

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For SSI-related
				cases, the resource provisions of the Medicaid Only (Aged, Blind, and Disabled)
				program shall apply in determining countable resources for the Medically Needy
				Program.
1. Medicaid Only provisions requiring
				the deeming of the resources of an alien's sponsor (10:71-4.6(f)
				 ) do not apply in the Medically Needy
				Program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 5 - RESOURCE ELIGIBILITY › Section 10:70-5.4 - Transfer of resources; pursuit of resources

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For
				AFDC-related cases, the provisions of this subsection shall apply to all
				members of the budget unit.
1. Applicants
				shall disclose promptly any transfer of property made within 24 months prior to
				the time of application. Beneficiaries shall promptly disclose any transfer of
				property made during the entire time the case is in active status.
2. The circumstances surrounding the transfer
				of property shall be evaluated and a determination will be made regarding
				whether the transfer was for adequate consideration.
3. If the transfer of the property was
				determined to have been made for adequate consideration, any proceeds remaining
				shall be evaluated as resources.
4.
				If the transfer of the property was determined to have been made without
				receipt of adequate consideration, the applicant or beneficiary may have legal
				rights to secure the return of the property or the payment of adequate
				consideration. The county board of social services shall assist the applicant
				or beneficiary in reclaiming the property or in obtaining adequate
				consideration for the property. Any proceeds resulting from such effort shall
				be evaluated as resources.
5.
				Applicants under this chapter shall pursue all legal rights to child support,
				including medical support, unless good cause exists, as specified at
				10:90-16.5.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 6 - MEDICAL SPEND-DOWN › Section 10:70-6.1 - Eligibility under medical spend-down

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Persons who are
				eligible in all respects for the Medically Needy Program, except that the
				countable income of the budget unit as determined in subchapter 4 exceeds the
				medically needy income level, may establish eligibility for payment of covered
				services benefits through medical spend-down.
1. Medical spend-down is a process whereby
				the excess countable income of a budget unit is offset by the allowable
				incurred medical expenses of the budget unit.
2. Spend-down liability is the amount by
				which the countable income of the budget unit exceeds the medically needy
				income level as determined under the provisions of this subchapter.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 6 - MEDICAL SPEND-DOWN › Section 10:70-6.2 - Allowable incurred medical expenses

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Allowable
				incurred medical expenses which may be applied against spend-down liability are
				those which are:
1. Incurred by a member of
				the budget unit and for which a member of the budget unit has an express
				obligation for payment;
2. For
				necessary medical or remedial services recognized under state law, provided,
				prescribed, or recommended by a qualified and appropriately licensed medical
				practitioner; and
3. Submitted with
				sufficiently detailed information and documentation to determine the
				allowableness of the expense. Minimum necessary information includes: the date
				of the service, name of the provider, the nature of the service, the name of
				the individual to whom the service was provided, and the total amount of the
				bill, as well as the remaining balance outstanding.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 6 - MEDICAL SPEND-DOWN › Section 10:70-6.3 - Application of medical expenses toward spend-down

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In determining
				eligibility under medical spend-down, expenses are applied in the following
				order against the spend-down liability:
1.
				Medicare and other health insurance premiums, deductibles, or coinsurance
				charges incurred by a member of the budget unit;
2. Expenses incurred by the members of the
				budget unit for allowable medical expenses for services not covered under the
				Medically Needy Program (including covered services provided to members of the
				budget unit who are not members of a medically needy eligibility
				category);
3. Expenses incurred by
				budget unit members, who are also members of a medically needy eligibility
				category, for services covered by the Medically Needy Program; and
4. Costs paid in whole or in part by a public
				program of the State or a political subdivision of the State, which involves no
				Federal funds may be counted as an incurred medical expense to establish
				eligibility under a Medicaid spend-down. If such costs are covered under
				Medicaid, the costs are not allowable under spend-down.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 7 - OTHER ADMINISTRATIVE REQUIREMENTS › Section 10:70-7.1 - Notice of county board of social services decision

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The county
				board of social services shall promptly notify any applicant for, or recipient
				of, the Medically Needy Program in writing of any agency decision affecting the
				applicant or recipient. When a decision relates to any adverse action which may
				entitle a recipient to a fair hearing, the action may not be implemented until
				at least 10 days after the mailing of the notice (see (f) below for exceptions
				to the 10-day notice).
1. For notices of
				action adverse to a recipient, the date of mailing of the notice must appear on
				the notice.
2. Notices of any
				county board of social services 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 recipient
				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 70 - MEDICALLY NEEDY PROGRAM › Subchapter 7 - OTHER ADMINISTRATIVE REQUIREMENTS › Section 10:70-7.2 - 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 Medically Needy Program to be
				afforded the opportunity for a fair hearing in the manner set forth in N.J.A.C.
				10:49-10, 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, P.O. Box
				712, Trenton, New Jersey 08625.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 70 - MEDICALLY NEEDY PROGRAM › Subchapter 7 - OTHER ADMINISTRATIVE REQUIREMENTS › Section 10:70-7.3 - 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 board of
				social services decisions and actions and the reasons thereto.
(b) The case record shall include:
1. A record of all county board of social
				services actions and decisions relating to the case, as well as, documentary
				evidence relating to such actions and decisions, including application
				forms;
2. All medical reports and a
				record of action of the Disability Review Section as appropriate;
3. All forms relating to financial
				eligibility including, when appropriate, spend-down liability; and
4. 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 71 - MEDICAID ONLY › Subchapter 1 - INTRODUCTION › Section 10:71-1.1 - General introduction

Current through Register Vol. 56, No. 14, July 15, 2024
On January 1, 1974, Title XVI of the Social Security Act
				  replaced previous Titles I (Old Age Assistance), X (Aid to the Blind) and XIV
				  (Aid to the Disabled), which were repealed. The Social Security Administration
				  administers Title XVI, Supplemental Security Income (SSI), which provides cash
				  payments to the aged, blind and disabled. Individuals who desire medical care
				  only apply through the county welfare agency for the Medicaid Only program
				  under Title XIX.