New Jersey Administrative Code

(a) It is the right of every applicant for, or beneficiary of, Medicaid Only to be afforded the opportunity for a fair hearing in the manner established by the policies and procedures set forth in N.J.A.C. 10:49-10 and 10:69-6, regarding complaints and fair hearings (see N.J.A.C.…

To protect the assistance agency and the public against the commission of fraud, the policies and procedures as defined in N.J.A.C. 10:69-9.15 through 9.20 (fraudulent receipt of assistance) shall apply to the Medicaid Only program. Notes N.J. Admin. Code § 10:71-8.5 Amended by R…

Investigation of new applications or investigations for redetermination or eligibility may on occasion present indications to the CWA that a crime may have been committed. In such a situation, the procedures outlined in N.J.A.C. 10:69-9.19 through 9.20 (reporting criminal offense…

The Federal Social Security Act requires that a state must provide safeguards which restrict the use or disclosure of information concerning applicants and beneficiaries to purposes directly connected with the administration of public assistance. Therefore, the policies and proce…

Title VI of the Federal Civil Rights Act of 1964 ( Public Law 88-352) and Section 504 of the Federal Rehabilitation Act of 1973 prohibit discrimination on the ground of race, color, national origin or handicap in the administration of a program for which Federal funds are receive…

The Medical Assistance for the Aged Continuation (MAAC) provides payment for the costs of medical services for certain former beneficiaries of the program of Medical Assistance for the Aged (MAA). Eligibility is based on continued medical need and lack of eligibility for any othe…

(a) Certification begins for those persons and only for those persons who were in certified status in the MAA program at the close of business on June 30, 1982 and those persons that filed MAA applications on or before June 30, 1982 and whose eligibility was established in accord…

Once terminated for any reason, including loss of medical certifications, a case shall not be reopened under the provisions of this subchapter. Notes N.J. Admin. Code § 10:71-9.3

(a) Submittal of data to DMAHS/MRT: Thirty days prior to the end of each certification period, the CWA will forward to DMAHS/MRT photocopies of all forms and reports bearing on the individual's need for continued inpatient hospital services, skilled nursing home services or home …

(a) Review: The CWA will review each MAAC case in accordance with (a)1 below for potential eligibility for other assistance programs through which the costs of medical care may be met. Those programs will not include General Assistance but will include such programs as SSI and Me…

(a) This chapter contains the criteria for Medicaid eligibility for certain pregnant women and infants not eligible under the provisions of N.J.A.C. 10:69, as well as, certain aged, blind and disabled persons not eligible under the provisions of N.J.A.C. 10:71.1. Because the elig…

(a) The purpose of the rules contained within this chapter is to: 1. Set forth eligibility criteria for the Medicaid program; and 2. Specify the rights and responsibilities of program applicants and eligible persons. (b) Circumstances which are neither specifically nor generally …

Financial eligibility for the Medicaid program is administered by the county welfare agencies under the supervision of the Division of Medical Assistance and Health Services. Notes N.J. Admin. Code § 10:72-1.3

(a) The following principles of administration apply in the Medicaid program. 1. Opportunity to make application: Any individual who believes he or she is eligible shall be afforded an opportunity to make application (or reapplication) for the Medicaid program without delay. 2. P…

(a) No member, officer, or employee of the county welfare agency 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. Med…

(a) All materials distributed to program 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 progr…

(a) Title VI of the Federal Civil Rights Act of 1964 ( P.L. 88-352) and section 504 of the Rehabilitation Act of 1973 ( 29 U.S.C. § 70b) and the Americans with Disabilities Act, P.L. 101-336, codified as 42 U.S.C. §§ 12101 et seq., prohibits discrimination on the ground of race, …

(a) Any person who applies for Medicaid, 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 ri…

(a) Application for Medicaid benefits for pregnant women and infants shall be accomplished by the completion and signing of Form FD-335 for pregnant women and infants as well as any addenda to that form as prescribed by the Division of Medical Assistance and Health Services. Appl…

The county welfare agency is required to conduct a personal face-to-face interview with the program applicant or the authorized agents as part of the process of determining program eligibility. Notes N.J. Admin. Code § 10:72-2.2

(a) The county welfare agency is required to verify all factors related to eligibility for the Medicaid program. Factors subject to verification include: 1. Pregnancy: For women seeking benefits under the provisions of this chapter, pregnancy must be medically verified. The medic…

(a) When individuals move permanently to another county within the State, responsibility for the case shall be transferred in accordance with the provisions of this section. The case transfer shall be accomplished in a manner so as not to adversely affect the rights of any indivi…

(a) Eligibility for Medicaid under this chapter shall be redetermined, including the completion of the appropriate application form, as follows: 1. For a pregnant woman, eligibility need not be redetermined until the birth of her child. Upon the birth of the child, the newborn sh…

(a) Upon a determination of eligibility for the Medicaid program, eligible persons have the on-going responsibility for the reporting of changes in family circumstances and for the provision of information as delineated at N.J.A.C. 10:72-2.1(c). Further, as requested by the count…

(a) Persons may be eligible under the provisions of this chapter for retroactive Medicaid eligibility for the three months preceding the month of application. Retroactive Medicaid coverage is available for any of the three months prior to application so long as eligibility existe…

(a) Eligibility for the Medicaid program must be established in relation to each requirement of the Medicaid program to provide a valid basis for the granting or denying of medicaid assistance. (b) The applicant's statements regarding his or her eligibility, as set forth in the a…

(a) Any alien who is not an eligible alien as specified in N.J.A.C. 10:72-3.2(c) and (d), shall be ineligible for Medicaid benefits. Any such alien shall be, if a resident of New Jersey and if he or she meets all other Medicaid eligibility requirements, entitled to Medicaid cover…

(a) In order to be eligible for the Medicaid program, an individual must be a citizen of the United States, an alien lawfully admitted for permanent residence, or an alien approved for temporary residence who can be classified as an eligible alien in accordance with this chapter.…

(a) In order to be eligible for the Medicaid program, an individual must be a resident of the State of New Jersey. The term "resident" shall be interpreted to mean a person who is living in the State voluntarily and not for a temporary purpose, that is, with no intention of prese…

(a) The following persons who meet all eligibility criteria of this chapter are eligible for Medicaid benefits:1. Pregnant women: Women of any age during the term of a medically verified pregnancy. i. A woman who is determined eligible under the criteria of this chapter will, for…

(a) The term "household unit" means those persons whose income is counted in the determination of eligibility under the provisions of this chapter. The following persons, if they reside with the program applicant or beneficiary, shall be considered members of the household unit: …

Program applicants and beneficiaries are required to identify to the county welfare agency any third party (individual, entity, or program) that is or may be liable to pay all or part of the medical cost of injury, disease, or disability of an applicant or beneficiary. Notes N.J.…

Persons who would be ineligible for AFDC using the rules in existence as of July 16, 1996 or due to the imposition of a sanction of ineligibility for a factor of AFDC eligibility that does not apply in Medicaid (such as noncooperation with work registration or WIN requirements) s…

(a) As a condition of eligibility for the Medicaid program, applicants and beneficiaries are required to take all necessary steps to obtain any annuities, pensions, retirement and disability benefits to which they are entitled, unless they can show good cause for not doing so. Ap…

(a) Any person who is an inmate of a public institution is ineligible for the Medicaid program. (b) Any person who is incarcerated in a Federal, State, or local correction facility (prison, jail, detention center, reformatory, etc.) is not eligible for the Medicaid program. Notes…

(a) Income limits for Medicaid for aged, blind, and disabled persons (except for specified low-income Medicare beneficiaries), covered under the provisions of this chapter will be based on 100 percent of the poverty income guidelines as defined by the U.S. Department of Health an…

(a) The county welfare agency shall establish the best estimate of income that will be available to the household unit.1. The best estimate of income shall be based on an average of the household unit's income for the full one-month period preceding the date of application or red…

(a) Except as specified below, countable income for pregnant women and infants under the provisions of this chapter shall include the income of all members of the household unit as determined at N.J.A.C. 10:72-3.5(a)1 and 2, and shall be determined in accordance with regulations …

(a) Except as specified below, countable income for aged, blind, and disabled individuals shall be determined in accordance with rules applicable to income in Medicaid Only--Aged, Blind, and Disabled (see N.J.A.C. 10:71-5). 1. The disregard of cost-of-living increases in Social S…

(a) Pregnant women and infants seeking Medicaid benefits under the provisions of this chapter are eligible without regard to the value of the household unit's resources. The county welfare agency shall inquire about the household unit's resources only in order to establish income…

(a) The county welfare agency shall promptly notify any applicant for, or beneficiary of, the Medicaid program in writing of any agency decision affecting the applicant or beneficiary. When a decision relates to any adverse action which may entitle a beneficiary to a fair hearing…

(a) It is the right of every applicant for, or beneficiary of, the Medicaid program to be afforded the opportunity for a fair hearing in the manner set forth in N.J.A.C. 10:49, including, when applicable, continuation of program benefits pending the results of the fair hearing. (…

(a) The purpose of the case record is to provide a complete documentary record of county welfare agency actions and the reasons therefor. (b) The case record shall include: 1. A record of all county welfare agency actions and decisions relating to the case, as well as documentary…

(a) The presumptive eligibility determination makes it possible for a pregnant woman to receive ambulatory prenatal care from a Medicaid participating provider for a temporary period prior to application for Medicaid benefits and while a Medicaid application is being processed by…

(a) From preliminary information provided by a woman whose pregnancy has been medically verified, the qualified provider shall determine if the pregnant woman meets the eligibility criteria of this chapter as it applies to pregnant women. The qualified provider must obtain suffic…

(a) Upon receipt of a properly completed Certification of Presumptive Eligibility (FD-334) from the qualified provider, Division staff shall: 1. Assign a presumptive eligibility number from a log of unissued numbers: 2. Create an eligibility record on the Medicaid Eligibility Fil…

(a) Upon receipt of the Certification of Presumptive Eligibility (FD-334) and a properly completed New Jersey Care Pregnant Women and Infants Application Referral (FD-335) from the qualified provider, the county welfare agency shall: 1. Check the Medicaid and Medically Needy Elig…