10:71-3.12 Disability; definitions
(a) An individual is disabled for purposes of this part if he/she is unable to engage in any
substantial gainful activity by reason of a medically determinable physical or mental
impairment which can be expected to result in death or which has lasted or can be expected
to last for a continuous period of not less than 12 months (or, in the case of a child under
the age of 18, if he/she suffers from any medically determinable physical or mental
impairment of comparable severity).
(b) A physical or mental impairment is an impairment which results from anatomical,
physiological or psychological abnormalities which are demonstrable by medically
acceptable clinic and laboratory diagnostic techniques. Statements of the applicant
including his/her own description of his/her impairment (symptoms) are, alone, insufficient to
establish the presence of a physical or mental impairment.
(c) An individual is "blind" for purposes of this part if he/she has central visual acuity of
20/200 or less in the better eye with the use of a correcting lens. An eye which is
accompanied by limitation in the field of vision such that the widest diameter of the visual
field subtends an angle no greater than 20 degrees shall be considered as having central
visual acuity of 20/200 or less.
(d) The presence of a condition diagnosed as addiction to alcohol or drugs will not itself be
the basis for a finding that the individual is or is not under a disability.
10:71-3.13 County board of social services responsibility and procedures
(a) The CBOSS shall furnish the Medical Review Team with current, pertinent social and
medical information, and obtain any special or additional reports on request.
(b) When it appears that an applicant meets the income and resources requirements for
Medicaid Only, arrangements for obtaining medical evidence should be initiated immediately
by whichever of the following procedures is applicable to the applicant's situation.
1. When the applicant is currently (within three months) under the care of a private
physician, he or she shall be furnished with a copy of Form PA-5 (Examining Physician's
Report) to take to the physician for completion.
2. If the applicant is currently receiving treatment in a hospital clinic, public health facility (that is, tuberculosis clinic, mental health clinic or other outpatient facility) on a regular basis
for the medical condition related to his or her application for Medicaid Only, a copy or
abstract of the clinic record may be submitted in lieu of the PA-5.
3. If the applicant has been hospitalized within three months for a condition related to the
impairment for which he or she is applying for Medicaid Only, an abstract of the hospital
record may be submitted for patients in long-term care facilities.
4. In the event none of the above are applicable, the CBOSS should assist the applicant in
choosing a physician to complete the PA-5, who is competent to determine the nature and
extent or degree of disability.
5. When the applicant states that he or she is blind or that visual impairment is his or her
primary disability, the CBOSS shall, prior to submission of the record to the Medical Review
Team, obtain a Report of Eye Examination (Form PA-5A) from a qualified medical specialist
in diseases of the eye (for example, ophthalmologist), or an optometrist, or from an eye
clinic of a general hospital, whichever the individual may select. (The membership directory
of the Medical Society of New Jersey is suggested as reference for identification of, in each
municipality, physicians specializing in diseases of the eye.) Optometrists are listed in the
yellow pages of local telephone directories under the heading "Optometrists--Doctors of
Optometry." The Form PA-5A should be transmitted in duplicate to the MRT with any other
pertinent medical evidence as outlined above. When appropriate, the Certification of Need
for Patient Care in Facility Other Than Public or Private General Hospital (Form PA-4) will
be submitted to the Medical Review Team (MRT).
(c) Other evidence, such as education, training, work experience and daily living activities,
shall be submitted to the MRT by completion of the PA-6 (Medical-Social Information
Report). The PA-6 shall be carefully and completely filled out.
(d) If the applicant refuses to furnish medical or other evidence concerning his or her
disability, the application for Medicaid Only shall be referred to the Medical Review Team
(MRT) for recommendations.
(e) As soon as medical reports and the Medical Social Information Report (PA- 6) are
completed, one copy of each shall be stapled together for transmittal to the MRT. It shall be
clearly indicated on the PA-6 that this is a Medicaid Only case. Records transmitted by MRT
on a given date shall be listed by registration number and name on an inventory sheet,
prepared in duplicate, the cases being grouped by case status. One copy shall be attached
to the submittal records, the duplicate retained as CBOSS control.
(f) The CBOSS will prepare a similar inventory and attach cases returned to the CBOSS on
a given date. Attached to each will be Form PA-8 (Record of Action) containing the
determination of eligibility by the MRT and any necessary instructions.
(g) Upon receipt of records from the MRT, the CBOSS shall examine the PA-8 (Record of
Action) for the action of the Medical Review Team and for specific instructions or
recommendations, and to note the review date. (h) Recommendations will be made by the medical consultant to alert the CBOSS to the
possibilities of adequate medical care for the client, and to provide specific pertinent
questions to be raised with the attending physician. The medical social work consultant will
make recommendations to help the CBOSS staff recognize the social problems indicated in
the client's situation and the relationship between these problems and his or her physical
and mental adjustment.
(i) The following procedures shall be observed in respect to MRT actions:
1. "Approved" cases:
i. CBOSS shall complete, as necessary, determination of eligibility in respect to other
factors and, if applicant is eligible, take the necessary action to obtain Medicaid benefits.
ii. When an applicant is not eligible in respect to any other factor, although "approved" for
the disability or blindness factor, the application shall be denied.
iii. The CBOSS shall establish and maintain a control file for "approved" cases in order
that the date for determination review by the MRT will be observed and considered
according to N.J.A.C. 10:71-5.
iv. The Medical Review Team (MRT) shall also maintain a control file in order to ensure
appropriate and timely reevaluation by the MRT. The MRT will notify CBOSS one month in
advance of cases scheduled for such review. Cases also for reevaluation will be listed on
Form PA-655.
2. "Undetermined" cases:
i. If further medical and/or social information is required by the MRT for the initial
determination of eligibility, the CBOSS shall obtain the information promptly and resubmit
the case. Reports from medical specialists shall be submitted on their own letterheads.
ii. If the applicant fails or refuses to present himself/herself for required examinations or
tests, the application shall be referred to the MRT for recommendations.
3. "Disapproved" cases:
i. Any case determined as not medically eligible for "Medicaid Only" by the MRT shall be
denied Medicaid Only by the CBOSS.
ii. Appropriate notification shall be given to the applicant as well as any specific
recommendations for follow-up care and treatment.
(j) When page 5 of Form PA-5 carries the signature of the medical consultant approving the
payment of the examining physician, such payment shall be forwarded to the physician from
administrative funds, regardless of whether the action on the record of action is "approved",
"disapproved" or "undetermined". (In an "undetermined" case, if the request for additional
information relates to an incomplete report from the examining physician, approval for
payment will not appear on page 5 of the PA-5.)
(k) Payment for special diagnostic reports shall likewise be forwarded to the medical
specialist or clinic from administrative funds regardless of whether the case is "approved",
"disapproved", or "undetermined".
(l) Maximum allowances for examining physician (completion of PA-5) are as follows.
1. Examination at office or hospital: $20.00.
2. Examination at patient's home: $30.00.
3. Examination at public institution: No fee.
(m) Diagnostic examination services rules are:
1. This subsection is concerned with medical specialty consultant evaluation services and
diagnostic studies (that is, clinical laboratory, diagnostic x- ray and special diagnostic
examinations) incident thereto, authorized by a CBOSS upon recommendation of the MRT,
when deemed essential as part of the initial determination of medical eligibility.
2. These examinations and procedures are exclusively for diagnostic eligibility, are
chargeable as matchable administrative costs and a medical vendor payment should be
promptly made upon approval of the consultant's report by the reviewing physician
employed by the State agency.
3. The following schedule of fees is exclusive to laboratory, x-ray and other special
diagnostic studies which may be required.
i. Diagnostic Consultation and Report (ophthalmologic includes refraction: otological
includes audiometric screening) other than psychiatric or neurologic: $45.00.
ii. Diagnostic Consultation requiring complete psychiatric or complete neurological
examination or complete neuropsychiatric examination, with detailed report: $50.00.
iii. Electrocardiogram with interpretation and report: $25.00.
(n) Payment of the above allowance is to be approved only when the specialist has
received prior authorization to perform the diagnostic evaluation and when the examination
is performed by a qualified specialist (that is, eligible for or certified by the appropriate
American board; or recognized by hospital, community and peers as a specialist, and
practice is limited to the specialty). See current membership directory of the Medical
Society of New Jersey.
(o) The fee(s) listed in fees for professional and diagnostic services issued by the Medical-
Surgical Plan of New Jersey (Revised 6-1-73) shall be approved when diagnostic x-ray or
radioisotope studies, laboratory and/orspecial diagnostic studies are deemed essential by
the medical specialist authorized to perform the diagnostic consultant evaluation. Payment
based on the allowances listed by the Medical-Surgical Plan, Series 575, shall be limited to
medical specialists as defined in the section.