10:71-3.14 Institutional eligibility
(a) Persons who are otherwise eligible for Medicaid Only receive medical coverage while
receiving patient care in eligible medical institutions. Such coverage shall be provided
through the appropriate payment mechanism of the Division of Medical Assistance and
Health Services. The Medicaid Cap income standard is applied only to certain institutions.
(b) Individuals who are inmates of public institutions are not eligible for Medicaid coverage,
unless they are receiving care in a Title XIX approved section of such facility.
(c) Individuals incarcerated in a Federal, State or local correctional facility (prison, jail, detention center, reformatory, etc.) are not eligible for Medicaid coverage. The needs of
such individuals (inmates) are met through another agency of the Federal or State
government or political subdivision thereof (see N.J.A.C. 10:71-1.6(a)3).
(d) An "institution" is any group living arrangement in which food, shelter and personal care
(other than nursing care) are furnished on a continuous basis to four or more persons
unrelated to the operator or in which food, shelter and personal care, including nursing care,
are furnished on a continuous basis to four or more persons unrelated to the operator; or
any establishment or facility licensed or approved by the State of New Jersey.
(e) Application of Medicaid Cap rules are:
1. General or Class A special hospitals: When a person is confined to such a hospital, the
Medicaid Cap standard does not apply; eligibility will be determined according to the
applicable living arrangement in Table B (see N.J.A.C. 10:71-5.6(c)5).
2. Long term care facilities (eligible private medical institutions): This may include licensed
nursing homes, intermediate care facilities, or Class B and C special hospitals. These
facilities must be licensed by the Department of Health and Senior Services licensing
authority, and approved by the Department of Human Services for provider participation in
the Title XIX Medicaid program. When a person is confined to a long term care facility, the
Medicaid Cap standard is used.
3. Licensed boarding homes for sheltered care (including nonprofit incorporate homes for
the aged): These homes must be licensed by the Department of Health and Senior Services
in accordance with N.J.A.C. 8:43. When the person is in a facility of this type, the income
standard for licensed boarding home is used.
(f) An "eligible medical institution" outside New Jersey is 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
Department of Welfare or similar authority of the jurisdiction in which the institution is
located.
1. Use of out-of-state facilities shall be restricted to temporary emergency situations where
it is established that there is no eligibility for coverage under a welfare or nonwelfare
program in the other state.