New Jersey Administrative Code

(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 evi…

(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 Pr…

(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…

(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 N.J.A.C. 10:71-3.5, 3.7, and 3.8. Notes N.J. Admin. Code § 10:70-3.3 Amended by R.19…

(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 …

(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…

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. Notes N.J.…

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 paymen…

(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…

(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…

(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 el…

(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 prospect…

(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 …

(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 equ…

(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 N.J.A.C. 10:69-10.3(a)3 do not apply. 2. The $ …

(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 benefi…

(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…

(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…

(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 (N.J…

(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…

(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 med…

(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 …

(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 incurre…

(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 f…

(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 hea…

(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…

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 p…

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. Notes N.J. Admin.…

(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 …

(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 c…

(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 …

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 ap…

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 Serv…

(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 appropr…

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…

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. Notes N.J. Admin…

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. Notes N.J. Admin. Code § 10:71-1.9 Amended by R.2000 d…

The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise: "Application process" means all activity performed by the Income Maintenance Section relating to a request for medical assistance payments. …

(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 inf…

All pertinent information relating to the eligible applicant shall be recorded. Notes N.J. Admin. Code § 10:71-2.11

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 statemen…

(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) 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 authorit…

Designation of personnel responsible for preparation of decision notices shall be at the discretion of the agency. Notes N.J. Admin. Code § 10:71-2.15

(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 a…

(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 f…

(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 effe…

(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 arra…

(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 …

(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,…