New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 1 - AFDC-RELATED MEDICAID IN NEW JERSEY › Section 10:69-1.5 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter,
				  shall have the following meanings unless the context clearly indicates
				  otherwise.
"Adequate notice" means notice to a client of the county
				  welfare agency (CWA) decision or action, which must state the nature, effective
				  date, factual and legal basis of the decision or action, and the right to a
				  fair hearing.
"Adjusted gross income" means, in self-employment, the net
				  income as determined by subtracting the cost of producing the income from total
				  gross earnings.
"AFDC" means the former Aid to Families with Dependent
				  Children program.
"AFDC-related Medicaid" means medical assistance provided to
				  families who would otherwise qualify for AFDC or deemed to qualify for AFDC if
				  the program were still in existence.
"Agency" means the CWA.
"Applicant" means parent or parent-person who applies for
				  AFDC-related Medicaid and whose application has not been officially acted upon
				  by the CWA.
"Application process" means all activity performed by the
				  eligibility staff until there is an official disposition of the
				  application.
"Approved application" means an applicant has been determined
				  to be eligible for AFDC-related Medicaid.
"Authorized representative" means an individual (or
				  organization) whom a client designates orally or in writing to act on his or
				  her behalf, or, in cases of incompetency, the person designated to act for the
				  client.
"Beneficiary" means the family unit of parent(s) or
				  parent-person(s) and child(ren) of eligible age who have been found eligible
				  for AFDC-related Medicaid including any individual who is an eligible member of
				  such family.
"Boarder, roomer, roomer-boarder" means a person, other than
				  a member of an eligible unit, whose acceptance in the household is a business
				  arrangement based upon payment in cash for board, room, or room and
				  board.
"BQC" means the Bureau of Quality Control in the Division of
				  Medical Assistance and Health Services.
"Calculated earned income" means amount of earned income
				  remaining after applicable disregards and deductions have been subtracted from
				  total gross earnings. This is the accountable amount to be used in determining
				  the eligible unit's total income.
"Capacity of a legally responsible relative (LRR) to support"
				  means the amount of contribution to be anticipated from an LRR.
"Caretaker relative" means the legally responsible adult or
				  adults residing with the children for whom the application is being
				  made.
"Carnegie unit" means the credit given for the successful
				  completion of one year's study in one subject in a secondary school. Four
				  Carnegie units per year represents full time attendance.
"Case record" means the official file of forms, chronological
				  narrative, correspondence, and other documents pertinent to the application and
				  eligibility of client case record. It constitutes a complete record which
				  supports the decisions and actions of the CWA on a case.
"Categorical program" means a program established by the
				  Federal Social Security Act for the purpose of enabling a state to furnish
				  assistance to financially eligible individuals or families who meet specific
				  eligibility requirements.
"CBOSS" means the county board of social services.
"CBOSS Director" means the county board of social services
				  Director or staff member to whom he or she has delegated specified
				  responsibility.
"Child born of unmarried parents" means a child born to a
				  mother who is not married to the father of such child.
"Child of eligible age" means a child up to the age of 18 or
				  a child up to the age of 19 if a full-time student in a secondary school, or in
				  the equivalent level of vocational or technical training and reasonably
				  expected to complete the program before reaching age 19.
"Client" means an all inclusive term including an applicant
				  or beneficiary of Medicaid.
"Collateral investigations" means contacts with individuals
				  other than members of the applicant's immediate household made with the
				  knowledge and consent of the applicant(s).
"County board of social services" means the county agency
				  designated to administer the AFDC-related Medicaid program.
"County residence" relates only to identification of the CWA
				  charged by law with responsibility for the official receipt, registration, and
				  processing of applications, and is not an eligibility requirement and does not
				  limit the opportunity for any person residing in New Jersey to qualify for
				  Medicaid.
"County welfare agency (CWA)" means that agency of county
				  government, that is charged with the responsibility for determining eligibility
				  for public assistance programs, including AFDC-related Medicaid, Temporary
				  Assistance to Needy Families (TANF), the Supplemental Nutrition Assistance
				  Program (SNAP), Medicaid and/or NJ FamilyCare. Depending on the county, the CWA
				  might be identified as the board of social services, the welfare board, the
				  division of welfare, or the division of social services.
"CSP" means Child Support and Paternity Program.
"CWA director" means the county welfare agency director or
				  staff member to whom he or she has delegated a specified responsibility.
"DCP&P" means the Division of Child Protection and
				  Permanency within DCF. This Division was formerly known as DYFS.
"DDD" means the Division of Developmental Disabilities in the
				  Department of Human Services.
"Denied application" means a determination that, for a
				  specific reason, the applicant is ineligible for AFDC-related Medicaid.
"Department of Children and Families (DCF)" means the New
				  Jersey Department of Children and Families.
"Department of Human Services (DHS)" means the New Jersey
				  Department of Human Services.
"Dependent child" means an eligible child, living in New
				  Jersey with a parent or other enumerated relative.
"Deprivation" means where death, incapacity or continued
				  absence of one or both natural or adoptive parents causes the loss of parental
				  support.
"Desertion" denotes a willful abandonment of duty in
				  violation of a legal obligation; failure to provide support and maintenance or
				  to perform other duties owed to the family members, thus depriving them of
				  care.
"DFD" means the Division of Family Development in the
				  Department of Human Services.
"Dismissed application" means recognition that eligibility
				  need not be considered further because the applicant moved to another state
				  during the application process or cannot be located, or the application was
				  registered in error.
"Disregards" means the amount discounted from income in the
				  AFDC programs according to Federal and/or State regulations. (see N.J.A.C.
				  10:69-10 )
"Division of Employment Services (DES)" means the office
				  within the State Department of Labor responsible for administration of
				  Unemployment Insurance and Temporary Disability Benefits programs.
"Division of Medical Assistance and Health Services" means
				  office within the State Department of Human Services responsible for
				  supervision of the administration of the AFDC-related Medicaid program.
"DMAHS" means Division of Medical Assistance and Health
				  Services.
"DVRS" means the Division of Vocational and Rehabilitation
				  Services in the Department of Human Services.
"DYFS" means the Division of Youth and Family Services in the
				  Department of Human Services.
"Eligible medical institution" means a facility or specified
				  section thereof certified as an approved institution for the purpose of
				  treating acute illness (private or general hospitals) or providing care for the
				  chronically ill (nursing homes or intermediate care facilities).
"Eligible unit" means those family members who apply for and
				  are eligible to receive AFDC-related Medicaid.
"Emancipated" means a child released from the duty to serve
				  and obey his or her parent(s) and having the right to his or her earnings.
				  Emancipation may be expressed or implied from the circumstances.
"Family size" means, in an LRR's household, those persons
				  identified in
				  N.J.A.C.
				  10:69-3.31 (members of the eligible unit are
				  not included).
"Financially eligible" means meeting the income standards in
				  this chapter.
"Gross earned income" means the total earnings of members of
				  the eligible unit before applicable disregards and deductions are
				  subtracted.
"Head of household" means the individual who is recognized by
				  other members of the household as having primary responsibility for financial
				  control and direction of the household.
"Health Benefits Identification (HBID) Card" means a
				  permanent, plastic identification card issued to each Medicaid beneficiary. The
				  card is for identification purposes only; providers must verify eligibility in
				  accordance with N.J.A.C. 10:49-2 before they provide services. The front of the
				  card includes the beneficiary's name and a 16-digit card control number (CCN).
				  The back of the card includes a magnetic strip that electronically stores the
				  beneficiary's name and CCN.
"Health Benefits Identification (HBID) Emergency Services
				  Letter" means a letter that contains pertinent information the provider will
				  need to confirm eligibility and submit claims for services rendered to an
				  eligible Medicaid beneficiary prior to the receipt of his or her HBID Card. The
				  letter will include an expiration date indicating when the letter will no
				  longer be acceptable as a substitute for the HBID Card.
"Incapacity" means physical or mental defect, illness or
				  impairment, supported by competent medical testimony, of such a debilitating
				  nature as to reduce substantially or eliminate the parent's ability to support
				  or care for the otherwise eligible child, which is expected to last for a least
				  30 days.
"Incompetent (certified)" means certified by a court of law
				  as incompetent.
"Inquiry" means any request for information about assistance
				  programs which is not a request for application.
"Institution in New Jersey" means a total facility, or a
				  designated part thereof, that include the following:
1. Hospital--general or special;
2. Nursing facility (NF);
3. Public psychiatric or tuberculosis hospital;
4. Certified section of State operated institution for the
				  mentally retarded; or
5. Intermediate care facility for the mentally retarded
				  (ICF/MR).
"Institution outside New Jersey" means a public or voluntary
				  medical institution which is licensed, certified or approved by the proper
				  authority of the jurisdiction in which the institution is located, so that the
				  costs of care and services provided therein may be paid. Evidence of such
				  license, certification or approval shall be obtained from the Division of
				  Medical Assistance and Health Services.
"Legally responsible relative (LRR)" means a relative held to
				  be legally responsible for the support and care of one or more relatives by the
				  laws of this State, as identified in
				  N.J.A.C.
				  10:69-3.31.
"LRR" means legally responsible relative.
"MACC" means a Medical Assistance Customer Center in the
				  Division of Medical Assistance and Health Services.
"Mandatory payroll deductions" means deductions including,
				  but not limited to, Federal, State, and city withholding taxes; Social
				  Security; Medicare; unemployment compensation taxes; and garnishments as
				  verified by legal document in possession of the employer.
"MDO" means Medicaid District Office in the Division of
				  Medical Assistance and Health Services.
"Medicaid" means a Federal/State program administered by the
				  Division of Medical Assistance and Health Services providing for payment of
				  claims for and evaluation of health services.
"Medicaid Special" means Medicaid coverage available to any
				  dependent child under 21 or an independent child under age 21, who meets the
				  qualifications at N.J.A.C. 10:69-4.
"Needy person" means a person who lacks sufficient income and
				  resources to maintain the AFDC-related Medicaid level of living.
"New application" means the filing of an application request
				  for AFDC-related Medicaid from an individual/family who has never previously
				  requested AFDC-related Medicaid in any county in the State under that
				  program.
"N.J.A.C." means New Jersey Administrative Code.
"Noneligible person" means a person ineligible for
				  AFDC-related Medicaid either due to age, relationship, or for incurring a
				  penalty of ineligibility.
"Official discharge from an institution" means legal
				  discharge of a patient from the institution in which he or she has been
				  confined.
"Ownership of real or personal property" means any and all
				  rights, title or interest, legal or equitable, to such property.
"Parent-minor" means a parent of a child or children who is
				  himself or herself under the age of 18.
"Parent-person" means certain relatives of a child who, in
				  the absence of a natural or adoptive parent, assume parental
				  responsibility.
"Penalty of ineligibility" means when a member(s) of an
				  eligible unit has incurred a penalty for not complying with program
				  requirement(s) and such member(s) is excluded from the eligible unit.
"Pending application" is a general term for application,
				  reapplication, reopened application, or transfer application prior to official
				  disposition.
"Per capita" means an amount equal to one individual's share
				  of the total (allowance, cost, income, etc.).
"Personal interview" means face-to-face discussion between
				  individuals.
"Policy" means guidelines, limited by and consistent with
				  law, which control CBOSS and DMAHS staff in carrying out AFDC-related Medicaid
				  programs.
"Primary wage earner" means principal earner and shall be
				  referred to as the principal earner in this chapter.
"Principal earner" means the parent who earned the greater
				  amount of income in the 24-month period immediately preceding the month of
				  application for AFDC-F.
"Reapplication" means a written request for AFDC-related
				  Medicaid by an individual who has previously applied for, but never received,
				  AFDC-related Medicaid under that program in any county in the State.
"Recovery" means the process whereby the CWA seeks the
				  repayment of AFDC-related Medicaid improperly or properly obtained.
"Redetermination of eligibility" means investigation of all
				  facts and circumstances relating to the beneficiary's application for
				  continuation of AFDC-related Medicaid.
"Referral" means a request from an agency, institution, or
				  individual on behalf of another individual who is interested in applying for
				  AFDC-related Medicaid; or a request from the CWA to another agency.
"Registration" means the action of the CWA in creating an
				  official record of and assigning a control number to an application.
"Rejected application" means an inclusive term covering
				  applications which have been denied, dismissed, or withdrawn.
"Relatives, legally-responsible" means relatives held to be
				  legally responsible by the laws of this State, as identified in N.J.A.C.
				  10:69-3.
"Release without discharge" means an arrangement under which
				  a patient in an institution is, for a special purpose, permitted to reside
				  outside the institution, and includes extended visit and convalescent
				  leave.
"Reopened application" means a written request for Medicaid
				  by an individual who has previously received AFDC-related Medicaid under that
				  program in any county in the State.
"Request for local administrative review" means any clear
				  expression (oral or written, by letter or otherwise) by a client or his or her
				  authorized representative that he or she wishes to present his or her case in a
				  proceeding before the CWA director or his or her delegated representative. This
				  is not to be confused with a request for a fair hearing.
"Resident" means a person who is living in the State for
				  other than a temporary purpose and who has no intention of moving from the
				  State.
"Retirement, Survivors and Disability Insurance (RSDI)" means
				  the Federal program administered by the Social Security Administration (SSA)
				  which provides protection to workers and their families against loss or
				  stoppage of earnings resulting from retirement at age 62 or older, death or
				  disability.
"Return to state of origin" designates the desire of a family
				  who has resided in New Jersey for a relatively short period to return to the
				  state from which it came.
"RSDI" means Retirement, Survivors and Disability
				  Insurance.
"Secondary school" means a traditional academic high school
				  or a vocational/technical school of corresponding grade level, up to 12th
				  grade, ranking between a primary school and a college or university.
"Social Security payment" means RSDI benefit.
"Sponsoring adult" means an individual 18 or older, including
				  the applicant or the adult with whom the applicant resides, who may assist in
				  making an application for presumptive eligibility. This definition is used for
				  the application presumptive eligibility only (see N.J.A.C. 10:69-12 ).
"Spouse" means a husband or wife of a specified
				  individual.
"SSA" means the Social Security Administration.
"SSI" means the Federal Supplemental Security Income Program,
				  including State supplemental payments administered through this program for
				  aged, blind or disabled of any age.
"State institution" means any institutional facility for the
				  mentally ill or retarded, penal institution or veteran's hospital under the
				  jurisdiction of the State of New Jersey.
"Total income" means the sum of all recognized income of the
				  eligible unit, including unearned and calculated earned income.
"Transfer application" means a request for AFDC-related
				  Medicaid for an individual who is presently receiving AFDC-related Medicaid
				  under the same program in another county within the State.
"Vendor payment" means a check drawn to the order of a person
				  or facility for providing goods or services to or for the client, representing
				  payment for such goods or services.
"Withdrawn application" means an oral or written request by
				  an applicant that the CWA terminate its activity on his or her
				  application.