10:71-2.16 Retroactive eligibility for Medicaid
(a) All applicants for Medicaid Only shall be queried as to whether or not they have
outstanding unpaid medical bills incurred within the three month period prior to the month of
application for Medicaid Only. Those indicating the existence of such bills are to be supplied
with an "Application for payment of unpaid medical bills," form FD-74, for completion. The
intake worker will be responsible for assisting the applicant, where necessary, in the
interpretation and completion of the application form (regardless of whether the individual is
eventually determined to be eligible for Medicaid). The intake worker will not be responsible
for making a financial determination of eligibility for the three-month period in question.
(b) The applicant shall attach all outstanding unpaid medical bills to the FD- 74 form and
forward it to the:
Division of Medical Assistance and Health Services
Retroactive Eligibility Unit
PO Box 712 Mail Code 10
Trenton, NJ 08625-0712
(c) For individuals who are incapable of acting on their own behalf, an authorized agent can
make application for retroactive Medicaid eligibility when there are outstanding medical bills.
Such persons, at the time of application, should be provided with a form FD-74 for
completion and submission to the retroactive eligibility unit with the unpaid medical bills
attached.
(d) In the case of an individual who is deceased, an authorized agent, as defined above,
may make application for retroactive Medicaid eligibility by obtaining an application form FD-
74 from either the county welfare board or the Medicaid District Office.