10:71-4.4 Excludable resources
(a) A resource which is classified as excludable shall not be considered either in the
deeming of resources or in the determination of eligibility for participation in the Medicaid
Only Program.
(b) The following resources shall be classified as excludable:
1. A house occupied by the individual as his/her place of principal residence, and the land
appertaining thereto, shall be excluded:
i. Short temporary absences from home such as trips, visits, and hospitalizations do not
affect this exclusion so long as the individual intends, and may reasonably be expected, to
return home. An absence of more than six months is assumed to indicate that the home no
longer serves as a principal residence. However, if the home is used by a spouse or there
is evidence that the absence from the house is temporary, the home may continue to be
excluded. With that exception, the CWA shall extend the period only with approval from the
Division of Medical Assistance and Health Services.
2. In the determination of resources of an individual (and spouse, if any), an automobile
shall be excluded or counted as follows:
i. One automobile is totally excluded regardless of value if, for the individual or a member
of the individual's household:
(1) It is necessary for employment; or
(2) It is necessary as a means of transportation for the medical treatment of a specific or
regular medical problem; or
(3) It is modified for operation by, or transportation of, a handicapped person.
ii. If no automobile is excluded under (b)2i above, one automobile is excluded as a
resource to the extent that its current market value (CMV) does not exceed $4,500. The
CMV in excess of $4,500 is counted against the resource limit. Where more than one
automobile is involved, the car of highest value may be excluded for use if it is to the
advantage of the applicant/beneficiary.
(1) The CMB of an automobile is the value of the vehicle as indicated by the "Average
Wholesale Value" in the most recent April or October edition of the Red Book; Official Used
Car Valuations.
iii. Other automobiles: Any other automobiles are treated as non-liquid resources and
counted to the extent of their equity value.
3. Personal effects and household goods, to the extent that the total equity value of such
resources does not exceed $2,000:
i. The amount by which the equity value of such resources exceeds $2,000 shall be
countable toward the appropriate resource maximum.
ii. In determining the value of household goods and personal effects of an individual (and
spouse), there shall be excluded a wedding ring and an engagement ring.
iii. Prosthetic devices, dialysis machines, hospital beds, wheel chairs, and similar
equipment shall not be considered in the evaluation of personal effects, unless such items
are used extensively and primarily by other members of the household, as well as by the
person whose physical condition requires them.
4. The cash surrender value of all life insurance policies owned and in the control of the
individual, if the total face value of such policies does not exceed $1,500 (see also (b)9
below):
i. If the total face value of such policies exceeds $1,500, the total cash surrender value of
all policies shall be included as a resource, countable toward the appropriate resource
maximum.
5. Nonhome property that is used in a business or nonbusiness self-support activity is
excluded from resources when the equity does not exceed $6,000 and the activity produces
a net annual return of at least six percent of the excludable equity value. If a net return of
six percent on $6,000 equity is shown, but the equity value of the property exceeds $6,000,
the excess equity (property value less $6,000) is a countable resource and applied to the
resource standards in N.J.A.C. 10:71-4.5. If such property is not excludable because the
net annual return is less than 6 percent of the equity value (with exceptions below), the total
equity value is an includable resource.
i. A rate of return of less than six percent is considered acceptable when all the following
conditions are met:
(1) The property is used in a business income-producing operation; and
(2) Unusual or untoward circumstances cause a temporary reduction in the net rate of
return; and
(3) The usual net rate of return is six percent of equity value; and
(4) The individual expects the property to again produce a return of six percent of equity
value within 18 months of the end of the taxable year in which the unusual incident which
caused the reduction in the rate of return occurred.
ii. Tools and equipment required for employment are assumed to be of a reasonable
value and producing a reasonable rate of return and are, therefore, excluded from
resources.
6. The value of resources which are not accessible to an individual through no fault of his
or her own.
i. Such resources include, but are not limited to, irrevocable trust funds, property in
probate, and real property which cannot be sold because of the refusal of a co-owner to
liquidate.
ii. Inaccessible resources shall be reevaluated (regarding their accessibility) at every
redetermination.
7. In the case of a blind or otherwise disabled person, resources which have been
accumulated in connection with a plan to achieve self-support.
i. To qualify for this exclusion, an individual's plan to achieve self-support shall have been
approved by the Division of Vocational Rehabilitation Services or the Commission for the
Blind and Visually Impaired, and must be current as of the date of the exemption.
8. The replacement value of excludable resources shall be considered as follows:
i. For insurance proceeds, the amount received from an insurance company for the
purpose of replacing or repairing an originally excludable resource, if repair or replacement
of such resource occurs within nine months.
(1) The initial nine month period shall be extended for a reasonable period up to an
additional nine months when it is determined that the individual had good cause for not
replacing or repairing the resource. An individual will be found to have good cause when
circumstances beyond his or her control prevented the repair or replacement or the
contracting for the repair or replacement.
ii. The proceeds from the sale of a home which is excluded from the individual's
resources will also be excluded from resources to the extent that they are intended to be
used and are, in fact, used to purchase another home, which is similarly excluded, within
three months of the date of the proceeds. If the proceeds are not used in the above manner
they shall be counted toward the resource maximum.
9. Burial spaces intended for the use of the individual, his or her spouse, or any other
member of his or her immediate family and funds which are set aside for the burial
expenses of the individual or spouse, subject to the limits specified below.
i. The following definitions apply in regard to burial spaces or funds:
(1) Burial spaces are conventional grave sites, crypts, mausoleums, urns, or other
repositories which are customarily and traditionally used for the remains of deceased
persons.
(2) Funds set aside for burial include revocable burial contracts, burial trusts, and any
separately identifiable assets which are clearly designated as set aside for the expenses
connected with an individual's burial, cremation or other funeral arrangements.
(3) Funds in an irrevocable trust or other irrevocable arrangement which are available
for burial are funds held in an irrevocable burial contract and irrevocable burial trust, or an
amount in an irrevocable trust which is specifically identified for burial expenses.
(4) Immediate family includes an individual's minor and adult children, stepchildren and
adopted children, brothers, sisters, parents, adopted parents and spouses of those persons.
Dependency and living-in-the-same household are not factors. Immediate family does not
include the members of an ineligible spouse's family unless they meet this definition.
ii. The exclusion from resources of funds set aside for burial applies only when counting any portion of the funds toward the resource limit would cause ineligibility due to excess
resources.
(1) If the individual or couple would otherwise be ineligible and could be eligible with the
application of this exclusion and the individual or couple alleges that funds are set aside for
the burial of the eligible individual or his or her spouse, an affidavit indicating such must be
obtained.
(A) The amount of funds that may be excluded shall be determined and may not
exceed the maximum limit of $1,500 each for the individual and his or her spouse. The
maximum limit for each individual is reduced by an amount equal to the amount of funds
held in an irrevocable burial trust, an irrevocable burial contract, or other irrevocable
arrangement which is available to meet that individual's burial expenses. Each individual's
maximum limit is further reduced by the face value of any insurance policy on that
individual's life owned by him or her or his or her spouse if the cash surrender value of the
policy was excluded in determining the resources of the individual.
(B) In order for burial funds to be excluded, the funds must be separately identifiable
(that is, not commingled with other funds or assets which are not set aside for burial).
Additionally, the funds must be already designated as set aside for burial. If the funds are
not so designated, the funds may be excluded if the individual attests in writing, that he or
she intends to use the funds for his or her burial and agrees to submit within 30 days,
documentary evidence that the funds have been designated as set aside for burial.
(C) Any increase in the value of excluded burial funds due to interest on such funds
which were left to accumulate or appreciation of such funds after establishment of Medicaid
eligibility shall be excluded.
10. No portion of a cash reward provided to any individual by the Division for providing
information about fraud and/or abuse in any program administered in whole or in part by the
Division shall be included in the computation of income for financial eligibility purposes;
11. In order for the cash reward to continue to be excluded, the funds shall be separately
identifiable (that is, not commingled with the other funds or assets), but held in a separate
account. Any increase in the value of the excluded case reward shall also be excluded.
10:71-4.5 Resource eligibility standards
(a) For eligibility in the Medicaid Only Program, total countable resources are subject to the
following limits. (See N.J.A.C. 10:71-4.1(b) regarding definition of resources, N.J.A.C.
10:71-4.2 regarding countable resources, and N.J.A.C. 10:71-4.8 regarding resources of a
couple when one member is applying for Medicaid for institutional services.)
1. Resource eligibility is determined as of the first moment of the first day of the month.
Changes in the amount of countable resources subsequent to the first moment of the first
day of the month shall not affect eligibility.
2. In the case of checking accounts, the balance as of the first moment of the first day of
the month shall be reduced by the amount of any checks which have been drawn on the
account but which have not yet cleared the financial institution.
(b) Resource maximum for a couple: Participation in the program shall be denied or
terminated if the total value of a couple's countable resources exceeds $3,000.
1. Definition of a couple: A couple shall be defined as a man and a woman who are legally married, or who have been determined to be a couple by the Social Security Administration
for receipt of RSDI benefits, or who are living together in the same household and
presenting themselves to the community in which they live as husband and wife.
(c) Resource maximum for an individual: participation in the program shall be denied or
terminated if the total value of an individual's resources exceeds $2,000.
(d) Resource maximum (institutionalized individuals): The resource maximum for an
individual in (c) above applies equally to individuals institutionalized in a Title XIX approved
facility. Countable resources held in the institution (for example, trust funds, personal needs
accounts) together with those held outside the institution, are to be applied toward the
resource maximum. If the resource maximum is exceeded, Medicaid eligibility will cease.
(See also N.J.A.C. 10:71-4.8 regarding resource eligibility for institutionalized individuals.)
(e) The grandfather clause: An individual who satisfied the following criteria may have
his/her resource eligibility determined in accordance with procedures formerly used in New
Jersey's OAA, AB, and DA programs if it is more advantageous to the individual (see
Financial Assistance Manual, Chapter 300, for regulations in effect prior to January 1,
1974):
1. The individual was participating in the Medicaid program during December 1973 under
one of New Jersey's Federal programs for the aged, blind, or disabled;
2. The individual has, since December 1973, continuously resided in New Jersey;
3. The individual has, since December 31, 1973, continuously been an eligible individual,
an eligible spouse, or an essential person participating in the Medicaid program.
i. Essential person status (refers to spouse only): A spouse who received Medicaid
coverage in December 1973 because of his/her status as a person "essential" to the
existence of an eligible person is also considered eligible for receipt of Medicaid Only
benefits under the provision of the grandfather clause. Such spouse must continue to
reside with the eligible individual alone in order to retain his/her essential person status.
ii. Once an individual's essential person status is terminated, he/she must again apply for
benefits and be determined eligible or ineligible on the basis of criteria used for other newly
applying aged, blind, or disabled individuals.
(f) No portion of a cash reward provided to any individual by the Division for providing
information about fraud and/or abuse in any program administered in whole or in part by the
Division shall be included in the computation of income for financial eligibility purposes;
(g) In order for the cash reward to continue to be excluded, the funds shall be separately
identifiable (that is, not commingled with the other funds or assets), but held in a separate
account. Any increase in the value of the excluded case reward shall also be excluded.
Tuesday, July 14, 2009
10:71-4.1 Financial eligibility standards; resources
(a) The resources criteria and eligibility standards of this section apply to all applicants and
beneficiaries.
(b) Resources defined: For the purpose of this program a resource shall be defined as any
real or personal property which is owned by the applicant (or by those persons whose
resources are deemed available to him/her, as described in N.J.A.C. 10:71-4.6) and which
could be converted to cash to be used for his/her support and maintenance. Both liquid and
nonliquid resources shall be considered in the determination of eligibility, unless such
resources are specifically excluded under the provisions of N.J.A.C. 10:71-4.4(b).
(c) Availability of resources: In order to be considered in the determination of eligibility, a
resource must be "available." A resource shall be considered available to an individual
when:
1. The person has the right, authority, or power to liquidate real or personal property, or
his or her share of it:
2. Resources have been deemed available to the applicant (see N.J.A.C. 10:71-4.6
regarding deeming of resources); or
3. Resources arising from a third-party claim or action are considered available from the
date of receipt by the applicant/beneficiaries, his or her legal representative or other
individual acting on his or her legal behalf in accordance with the following definition and
provisions.
i. Definition of "availability of resources in third-party situations": In third-party situations in
which applicants/beneficiaries have brought an action or made a claim against a third party
who is or may be liable for payment of medical expenses related to the cause of the action
or claim, funds are considered available or countable at the moment of receipt by the
applicant/beneficiary, his or her legal representative, guardian, relative or any person acting
on the applicant's/beneficiary's behalf. Such funds should be considered available or
countable at the earliest date of receipt by any of the aforementioned entities.
(1) In determining resource eligibility in accordance with N.J.A.C. 10:71-4.5(a), those
funds actually available to the applicant/beneficiary or any person acting on his or her behalf
as of the first day of the month subsequent to the month of receipt shall be considered a
countable resource, unless otherwise excluded (see N.J.A.C. 10:71-4.4).
(2) If a bona fide lien or judgment exists against such funds, making all or some portion of
the funds inaccessible to the applicant/beneficiary, CBOSSs shall deduct the encumbrances
and consider the remaining amount as a countable resource.
(3) If between the date of receipt of such moneys and the first day of the subsequent
month the applicant/beneficiary pays outstanding medical expenses and/or other expenses,
the CBOSS shall consider only the funds remaining after such payment as a countable
resource.
(d) Evaluation of resources: The value of a resource shall be defined as the price that the resource can reasonably be expected to sell for on the open market in the particular
geographic area minus any encumbrances (that is, its equity value).
1. Real property:
i. Sole ownership: When the eligible individual is sole owner and has the right to dispose
of the property, the total equity value (see (d)1iv below) shall be counted toward the
resource maximum.
ii. Joint ownership or ownership in common: Under joint ownership or ownership in
common, the equity value of the property shall be divided by the number of owners and the
eligible individual's share counted toward the resource maximum.
iii. Ownership by the entirety: Ownership by the entirety (or tenancy by the entirety) refers
to property owned by a husband and wife whereby each member has ownership interest in
the whole property which is indivisible. When a married couple (either one or both are
eligible) is living together, the total equity value of all nonexempt property shall be counted
toward the resource maximum. The same policy shall apply to an eligible couple who have
been separated less than six months. If the eligible couple has been separated for six
months or more, one half of the value represents a resource to each individual. If one
spouse is institutionalized and the other spouse resides in the community, the extent to
which either spouse has ownership of the property shall be included pursuant to N.J.A.C.
10:71-4.8.
(1) When an eligible individual and an ineligible spouse own nonexempt property by the
entirety and the couple is separated for a full calendar month, the cooperation of both
owners is necessary to ascertain resource value. If the ineligible owner expresses
willingness to dispose of the property, then its value is divided by the number of owners. If
there is no such willingness by the ineligible owner, then no value may be assigned to the
property. (See also N.J.A.C. 10:71-4.4(b)6 regarding situations in which a co-owner refuses
to liquidate.)
iv. Equity value: The equity value of real property is the tax assessed value of the
property multiplied by the reciprocal of the assessment ratio as recorded in the most
recently issued State Table of Equalized Valuations, less encumbrance, if any. The Table is
available from the State of New Jersey, Department of the Treasury, Trenton, New Jersey
08625.
2. Savings and checking accounts: When a savings or checking account is held by the
eligible individual with other parties, all funds in the account are resources to the individual
so long as he or she has unrestricted access to the funds (that is, an "or" account)
regardless of their source. When the individual's access to the account is restricted (that is,
an "and" account), the CBOSS shall consider a pro rata share of the account toward the
appropriate resource maximum, unless the client and the other owner demonstrate that
actual ownership of the funds is in a different proportion. If it can be demonstrated that the
funds are totally inaccessible to the client, such funds shall not be counted toward the
resource maximum. Any question concerning access to funds should be verified through the
financial institution holding the account.
3. Verification of value: The CBOSS shall verify the equity value of resources through
appropriate and credible sources. Additionally, the CBOSS shall evaluate applicant's past
circumstances and present living standards in order to ascertain the existence of resources
which may not have been reported. If the applicant's resource statements are questionable, or there is reason to believe the identification of resources is incomplete, the CBOSS shall
verify the applicant's resource statements through one or more third parties.
i. Responsibility of applicant: If the third party contact is required in accordance with the
provisions above, the applicant shall cooperate fully with the verification process. If
necessary, the applicant shall provide written authorization allowing the CBOSS to secure
the appropriate information.
(e) Resource eligibility: Resource eligibility is determined as of the first moment of the first
day of each month. If an individual or couple is resource ineligible as of the first moment of
the first day of the month, subsequent changes within that month in the amount of countable
resources will not affect the original determination of ineligibility. If resource eligibility is
established as of the first moment of the first day of the month, resource eligibility is
established for the entire month regardless of any increase in the amount of countable
resources.
1. This policy applies equally to individuals and couples in the month of application.
Regardless of the date of application, resource eligibility is determined as of the first
moment of the first day of that month.
2. If, prior to the first moment of the first day of the month, the applicant or beneficiary has
drawn a check (or equivalent instrument) on a checking or similar account, the amount of
such check shall reduce the value of the account. The value of such accounts shall not be
reduced by any unpaid obligations for which funds have not already been committed by the
drafting of a check.
i. When checks have been drawn on an account, the CBOSS shall review the appropriate
account registers or check stubs to ascertain the actual balance as of the first moment of
the first day of the month. Full documentation of such circumstances is required.
(f) No portion of a cash reward provided to any individual by the Division for providing
information about fraud and/or abuse in any program administered in whole or in part by the
Division shall be included in the computation of income for financial eligibility purposes.
1. In order for the cash reward to continue to be excluded, the funds shall be separately
identifiable (that is, not commingles with other funds or assets), but held in a separate
account. Any increase in the value of the excluded cash reward shall also be excluded.
10:71-4.2 Countable resources
(a) Any resource which is not specifically excludable under the provisions of N.J.A.C.
10:71-4.4 shall be considered a countable resource for the purpose of determining Medicaid
Only eligibility.
1. No portion of a cash reward offered by the Division of an individual for providing
information about fraud and/or abuse in any program administered in whole or in part by the
Division shall be included in the computation of resources for financial eligibility purposes, if
the resource is maintained in a separate account, in accordance with N.J.A.C. 10:71 –
4.4(b).
(b) Verification of resources: If verification is required in accordance with the provisions of
N.J.A.C. 10:71-4.1(d)3, the CBOSS shall proceed in the following manner: establish whether or not real property is producing income consistent with its current market
value (see N.J.A.C. 10:71-4.4(b)5), inquiry shall be made of local real estate brokers, tax
assessors, or other persons knowledgeable of the prevailing rate of return on real property
in the community.
2. Nonexcludable household goods and/or personal effects: If the CBOSS determines that
certain household goods and/or personal effects are not excludable (see N.J.A.C. 10:71-
4.4), inquiry shall be made of one or more local merchants who deal in used household
goods or personal goods in order to determine the current market value of the resource.
3. The CBOSS shall verify the existence or nonexistence of any cash, savings of checking
accounts, time or demand deposits, stocks, bonds, notes receivable, or any other financial
instrument or interest. Verification shall be accomplished through contact with financial
institutions, such as banks, credit unions, brokerage firms, and savings and loan
associations. Minimally, the CBOSS shall contact those financial institutions in close
proximity to the residence of the applicant or the applicant's relatives and those institutions
which currently provide or previously provided services to the applicant.
(c) Documentation of verification: Any verification which occurs in connection with the
determination or evaluation of resources shall be fully documented in the case record.
(a) The resources criteria and eligibility standards of this section apply to all applicants and
beneficiaries.
(b) Resources defined: For the purpose of this program a resource shall be defined as any
real or personal property which is owned by the applicant (or by those persons whose
resources are deemed available to him/her, as described in N.J.A.C. 10:71-4.6) and which
could be converted to cash to be used for his/her support and maintenance. Both liquid and
nonliquid resources shall be considered in the determination of eligibility, unless such
resources are specifically excluded under the provisions of N.J.A.C. 10:71-4.4(b).
(c) Availability of resources: In order to be considered in the determination of eligibility, a
resource must be "available." A resource shall be considered available to an individual
when:
1. The person has the right, authority, or power to liquidate real or personal property, or
his or her share of it:
2. Resources have been deemed available to the applicant (see N.J.A.C. 10:71-4.6
regarding deeming of resources); or
3. Resources arising from a third-party claim or action are considered available from the
date of receipt by the applicant/beneficiaries, his or her legal representative or other
individual acting on his or her legal behalf in accordance with the following definition and
provisions.
i. Definition of "availability of resources in third-party situations": In third-party situations in
which applicants/beneficiaries have brought an action or made a claim against a third party
who is or may be liable for payment of medical expenses related to the cause of the action
or claim, funds are considered available or countable at the moment of receipt by the
applicant/beneficiary, his or her legal representative, guardian, relative or any person acting
on the applicant's/beneficiary's behalf. Such funds should be considered available or
countable at the earliest date of receipt by any of the aforementioned entities.
(1) In determining resource eligibility in accordance with N.J.A.C. 10:71-4.5(a), those
funds actually available to the applicant/beneficiary or any person acting on his or her behalf
as of the first day of the month subsequent to the month of receipt shall be considered a
countable resource, unless otherwise excluded (see N.J.A.C. 10:71-4.4).
(2) If a bona fide lien or judgment exists against such funds, making all or some portion of
the funds inaccessible to the applicant/beneficiary, CBOSSs shall deduct the encumbrances
and consider the remaining amount as a countable resource.
(3) If between the date of receipt of such moneys and the first day of the subsequent
month the applicant/beneficiary pays outstanding medical expenses and/or other expenses,
the CBOSS shall consider only the funds remaining after such payment as a countable
resource.
(d) Evaluation of resources: The value of a resource shall be defined as the price that the resource can reasonably be expected to sell for on the open market in the particular
geographic area minus any encumbrances (that is, its equity value).
1. Real property:
i. Sole ownership: When the eligible individual is sole owner and has the right to dispose
of the property, the total equity value (see (d)1iv below) shall be counted toward the
resource maximum.
ii. Joint ownership or ownership in common: Under joint ownership or ownership in
common, the equity value of the property shall be divided by the number of owners and the
eligible individual's share counted toward the resource maximum.
iii. Ownership by the entirety: Ownership by the entirety (or tenancy by the entirety) refers
to property owned by a husband and wife whereby each member has ownership interest in
the whole property which is indivisible. When a married couple (either one or both are
eligible) is living together, the total equity value of all nonexempt property shall be counted
toward the resource maximum. The same policy shall apply to an eligible couple who have
been separated less than six months. If the eligible couple has been separated for six
months or more, one half of the value represents a resource to each individual. If one
spouse is institutionalized and the other spouse resides in the community, the extent to
which either spouse has ownership of the property shall be included pursuant to N.J.A.C.
10:71-4.8.
(1) When an eligible individual and an ineligible spouse own nonexempt property by the
entirety and the couple is separated for a full calendar month, the cooperation of both
owners is necessary to ascertain resource value. If the ineligible owner expresses
willingness to dispose of the property, then its value is divided by the number of owners. If
there is no such willingness by the ineligible owner, then no value may be assigned to the
property. (See also N.J.A.C. 10:71-4.4(b)6 regarding situations in which a co-owner refuses
to liquidate.)
iv. Equity value: The equity value of real property is the tax assessed value of the
property multiplied by the reciprocal of the assessment ratio as recorded in the most
recently issued State Table of Equalized Valuations, less encumbrance, if any. The Table is
available from the State of New Jersey, Department of the Treasury, Trenton, New Jersey
08625.
2. Savings and checking accounts: When a savings or checking account is held by the
eligible individual with other parties, all funds in the account are resources to the individual
so long as he or she has unrestricted access to the funds (that is, an "or" account)
regardless of their source. When the individual's access to the account is restricted (that is,
an "and" account), the CBOSS shall consider a pro rata share of the account toward the
appropriate resource maximum, unless the client and the other owner demonstrate that
actual ownership of the funds is in a different proportion. If it can be demonstrated that the
funds are totally inaccessible to the client, such funds shall not be counted toward the
resource maximum. Any question concerning access to funds should be verified through the
financial institution holding the account.
3. Verification of value: The CBOSS shall verify the equity value of resources through
appropriate and credible sources. Additionally, the CBOSS shall evaluate applicant's past
circumstances and present living standards in order to ascertain the existence of resources
which may not have been reported. If the applicant's resource statements are questionable, or there is reason to believe the identification of resources is incomplete, the CBOSS shall
verify the applicant's resource statements through one or more third parties.
i. Responsibility of applicant: If the third party contact is required in accordance with the
provisions above, the applicant shall cooperate fully with the verification process. If
necessary, the applicant shall provide written authorization allowing the CBOSS to secure
the appropriate information.
(e) Resource eligibility: Resource eligibility is determined as of the first moment of the first
day of each month. If an individual or couple is resource ineligible as of the first moment of
the first day of the month, subsequent changes within that month in the amount of countable
resources will not affect the original determination of ineligibility. If resource eligibility is
established as of the first moment of the first day of the month, resource eligibility is
established for the entire month regardless of any increase in the amount of countable
resources.
1. This policy applies equally to individuals and couples in the month of application.
Regardless of the date of application, resource eligibility is determined as of the first
moment of the first day of that month.
2. If, prior to the first moment of the first day of the month, the applicant or beneficiary has
drawn a check (or equivalent instrument) on a checking or similar account, the amount of
such check shall reduce the value of the account. The value of such accounts shall not be
reduced by any unpaid obligations for which funds have not already been committed by the
drafting of a check.
i. When checks have been drawn on an account, the CBOSS shall review the appropriate
account registers or check stubs to ascertain the actual balance as of the first moment of
the first day of the month. Full documentation of such circumstances is required.
(f) No portion of a cash reward provided to any individual by the Division for providing
information about fraud and/or abuse in any program administered in whole or in part by the
Division shall be included in the computation of income for financial eligibility purposes.
1. In order for the cash reward to continue to be excluded, the funds shall be separately
identifiable (that is, not commingles with other funds or assets), but held in a separate
account. Any increase in the value of the excluded cash reward shall also be excluded.
10:71-4.2 Countable resources
(a) Any resource which is not specifically excludable under the provisions of N.J.A.C.
10:71-4.4 shall be considered a countable resource for the purpose of determining Medicaid
Only eligibility.
1. No portion of a cash reward offered by the Division of an individual for providing
information about fraud and/or abuse in any program administered in whole or in part by the
Division shall be included in the computation of resources for financial eligibility purposes, if
the resource is maintained in a separate account, in accordance with N.J.A.C. 10:71 –
4.4(b).
(b) Verification of resources: If verification is required in accordance with the provisions of
N.J.A.C. 10:71-4.1(d)3, the CBOSS shall proceed in the following manner: establish whether or not real property is producing income consistent with its current market
value (see N.J.A.C. 10:71-4.4(b)5), inquiry shall be made of local real estate brokers, tax
assessors, or other persons knowledgeable of the prevailing rate of return on real property
in the community.
2. Nonexcludable household goods and/or personal effects: If the CBOSS determines that
certain household goods and/or personal effects are not excludable (see N.J.A.C. 10:71-
4.4), inquiry shall be made of one or more local merchants who deal in used household
goods or personal goods in order to determine the current market value of the resource.
3. The CBOSS shall verify the existence or nonexistence of any cash, savings of checking
accounts, time or demand deposits, stocks, bonds, notes receivable, or any other financial
instrument or interest. Verification shall be accomplished through contact with financial
institutions, such as banks, credit unions, brokerage firms, and savings and loan
associations. Minimally, the CBOSS shall contact those financial institutions in close
proximity to the residence of the applicant or the applicant's relatives and those institutions
which currently provide or previously provided services to the applicant.
(c) Documentation of verification: Any verification which occurs in connection with the
determination or evaluation of resources shall be fully documented in the case record.
10:71-3.16 Medical assistance units
(a) Medicaid District Office (MDO): The Division of Medical Assistance and Health Services
has local medical offices throughout the State, known as Medicaid District Offices (MDOs).
The role of these offices is to provide liaison with providers of health services; provide
information about Medicaid to beneficiaries and members of the community; provide
utilization review in determining the medical need for certain covered services requiring prior
authorization; and provide information about Medicaid to, and cooperate with, appropriate
agencies in order to ensure maximum utilization of the services available through the
Medicaid program.
(b) Any questions with respect to policy, regulations, or procedures of the Medicaid
program should be directed to the appropriate MDO as listed at N.J.A.C. 10:49, Appendix,
Form #17.
(a) Medicaid District Office (MDO): The Division of Medical Assistance and Health Services
has local medical offices throughout the State, known as Medicaid District Offices (MDOs).
The role of these offices is to provide liaison with providers of health services; provide
information about Medicaid to beneficiaries and members of the community; provide
utilization review in determining the medical need for certain covered services requiring prior
authorization; and provide information about Medicaid to, and cooperate with, appropriate
agencies in order to ensure maximum utilization of the services available through the
Medicaid program.
(b) Any questions with respect to policy, regulations, or procedures of the Medicaid
program should be directed to the appropriate MDO as listed at N.J.A.C. 10:49, Appendix,
Form #17.
10:71-3.15 County board of social services responsibility and procedures; eligibility
factors
(a) The CBOSS shall be responsible for determining income and resource eligibility, as
outlined in N.J.A.C. 10:71-4, for Medicaid Only when applicant is receiving care in
institutions defined above. This does not include residents of the State psychiatric hospitals,
the State schools for the mentally retarded, Bergen Pines County Psychiatric Hospital, and
Essex County Hospital Center, which are the responsibility of the Institutional Services
Section of the Division of Medical Assistance and Health Services.
(b) When eligibility depends upon the disability or blindness factor, the determination of medical eligibility shall be the responsibility of the medical review team. The CBOSS shall
furnish the MRT with current, pertinent social and medical information as outlined in this
subchapter.
(c) When eligibility for Medicaid Only has been determined, the CBOSS will complete and
process a Medicaid Status File Transaction, Form MAP-1, within ten working days from the
date of such determination. The CBOSS will issue and distribute Medicaid validation stubs
to Medicaid Only beneficiaries who are not in long term care facilities. The CBOSS will
complete the statement of income available for nursing home payment (PR-1) (formerly PA-
3L) when appropriate.
(d) A determination of continuing eligibility shall be made in accordance with subchapter 5
of this chapter.
factors
(a) The CBOSS shall be responsible for determining income and resource eligibility, as
outlined in N.J.A.C. 10:71-4, for Medicaid Only when applicant is receiving care in
institutions defined above. This does not include residents of the State psychiatric hospitals,
the State schools for the mentally retarded, Bergen Pines County Psychiatric Hospital, and
Essex County Hospital Center, which are the responsibility of the Institutional Services
Section of the Division of Medical Assistance and Health Services.
(b) When eligibility depends upon the disability or blindness factor, the determination of medical eligibility shall be the responsibility of the medical review team. The CBOSS shall
furnish the MRT with current, pertinent social and medical information as outlined in this
subchapter.
(c) When eligibility for Medicaid Only has been determined, the CBOSS will complete and
process a Medicaid Status File Transaction, Form MAP-1, within ten working days from the
date of such determination. The CBOSS will issue and distribute Medicaid validation stubs
to Medicaid Only beneficiaries who are not in long term care facilities. The CBOSS will
complete the statement of income available for nursing home payment (PR-1) (formerly PA-
3L) when appropriate.
(d) A determination of continuing eligibility shall be made in accordance with subchapter 5
of this chapter.
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.
(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.
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.
(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.
10:71-3.11 Determination of disability and blindness eligibility; a State function
(a) The determination of disability and blindness eligibility for the Medicaid Only program is
a direct responsibility of the medical review team in the Division of Medical Assistance and
Health Services. Determination of all other factors of eligibility is the responsibility of the
CBOSSs. The medical review team is composed of a medical consultant; and a medical
social work consultant; it reviews Medicaid Only applications submitted by the CBOSSs.
(b) In situations where an applicant's disability or blindness appears to meet the definition in
section 12 of this subchapter, presumptive eligibility for either of these factors can be
granted with the approval of the Medical Review Team (MRT).
(c) If an individual has been determined disabled for Social Security purposes (that is, he or
she is currently receiving Disability Insurance Benefits), the CBOSS shall not refer the
individual to the Medical Review Team (MRT) for a determination of medical eligibility. The
individual shall be considered automatically eligible, in this respect, for Medicaid Only
benefits.
1. In the event the Social Security Administration determined within the 12 months prior to the application for Medicaid Only that the individual was not disabled, the MRT will not make
an independent determination of the applicant's disability but will be bound by the
determination of the Social Security Administration. If an individual whose Social Security or
SSI disability claim was denied within the last 12 months presents new or additional
evidence to support that claim, the CBOSS should refer the applicant to the Social Security
Administration for a reevaluation of its determination.
2. When the denial by the Social Security Administration occurred more than 12 months
prior to the application for Medicaid Only, the (MRT) will make an independent
determination of disability.
(a) The determination of disability and blindness eligibility for the Medicaid Only program is
a direct responsibility of the medical review team in the Division of Medical Assistance and
Health Services. Determination of all other factors of eligibility is the responsibility of the
CBOSSs. The medical review team is composed of a medical consultant; and a medical
social work consultant; it reviews Medicaid Only applications submitted by the CBOSSs.
(b) In situations where an applicant's disability or blindness appears to meet the definition in
section 12 of this subchapter, presumptive eligibility for either of these factors can be
granted with the approval of the Medical Review Team (MRT).
(c) If an individual has been determined disabled for Social Security purposes (that is, he or
she is currently receiving Disability Insurance Benefits), the CBOSS shall not refer the
individual to the Medical Review Team (MRT) for a determination of medical eligibility. The
individual shall be considered automatically eligible, in this respect, for Medicaid Only
benefits.
1. In the event the Social Security Administration determined within the 12 months prior to the application for Medicaid Only that the individual was not disabled, the MRT will not make
an independent determination of the applicant's disability but will be bound by the
determination of the Social Security Administration. If an individual whose Social Security or
SSI disability claim was denied within the last 12 months presents new or additional
evidence to support that claim, the CBOSS should refer the applicant to the Social Security
Administration for a reevaluation of its determination.
2. When the denial by the Social Security Administration occurred more than 12 months
prior to the application for Medicaid Only, the (MRT) will make an independent
determination of disability.
10:71-3.10 Disability and blindness factors
For purposes of determining medical eligibility for the Medicaid Only program, the disability
and blindness standards shall be the same as for the Supplemental Security Income
program under Title XVI of the Social Security Act, as amended by Public Law 92-603.
For purposes of determining medical eligibility for the Medicaid Only program, the disability
and blindness standards shall be the same as for the Supplemental Security Income
program under Title XVI of the Social Security Act, as amended by Public Law 92-603.
10:71-3.9 Age
(a) Age requirements are:
1. The applicant must be 65 years of age or older to be eligible based on age alone.
2. A disabled or blind child must be under 18 years of age, or under 22 years of age and a
student regularly attending school and neither married nor the head of the household.
3. A disabled or blind adult must be over 21 years of age and under 65 years of age or
between 18 years of age and 22 years of age if not a full-time student.
(b) The applicant must present acceptable proof of age. Among acceptable sources of
verification of age are:
1. Birth certificate;
2. Marriage certificate;
3. Church records--baptismal, confirmation membership;
4. Immigration or naturalization papers;
5. Census records;
6. School records;
7. Military service records;
8. Court records;
9. Employment records;
10. Records of public or private welfare agencies;
11. Voting records;
12. Medical records;
13. Affidavit from disinterested persons;
14. Driver's licenses; or
15. Insurance policies.
(c) CBOSSs shall maintain administrative controls to assure:
1. That a disabled or blind beneficiary who becomes 65 years of age continues to have his
or her eligibility determined on the basis of disability or blindness if it appears more
advantageous to the beneficiary;
2. That a disabled child beneficiary is processed as a disabled adult when reaching 18
years of age, or 22 years of age and a student regularly attending school and neither
married nor the head of the household; and
3. That a disabled child beneficiary is processed as a disabled adult when reaching 18
years of age and a student regularly attending school and either married or the head of a
household.
(a) Age requirements are:
1. The applicant must be 65 years of age or older to be eligible based on age alone.
2. A disabled or blind child must be under 18 years of age, or under 22 years of age and a
student regularly attending school and neither married nor the head of the household.
3. A disabled or blind adult must be over 21 years of age and under 65 years of age or
between 18 years of age and 22 years of age if not a full-time student.
(b) The applicant must present acceptable proof of age. Among acceptable sources of
verification of age are:
1. Birth certificate;
2. Marriage certificate;
3. Church records--baptismal, confirmation membership;
4. Immigration or naturalization papers;
5. Census records;
6. School records;
7. Military service records;
8. Court records;
9. Employment records;
10. Records of public or private welfare agencies;
11. Voting records;
12. Medical records;
13. Affidavit from disinterested persons;
14. Driver's licenses; or
15. Insurance policies.
(c) CBOSSs shall maintain administrative controls to assure:
1. That a disabled or blind beneficiary who becomes 65 years of age continues to have his
or her eligibility determined on the basis of disability or blindness if it appears more
advantageous to the beneficiary;
2. That a disabled child beneficiary is processed as a disabled adult when reaching 18
years of age, or 22 years of age and a student regularly attending school and neither
married nor the head of the household; and
3. That a disabled child beneficiary is processed as a disabled adult when reaching 18
years of age and a student regularly attending school and either married or the head of a
household.
10:71-3.8 Medicaid eligibility for individuals who enter New Jersey in order to secure
medical care (a) Federal and State statute and regulations expressly bar a duration-of- residence
requirement as a condition of eligibility. The New Jersey Medical Assistance and Health
Services Act authorizes a grant of medical assistance to a qualified applicant who is a
resident of the State which " ... means a person living, other than temporarily, within the
State."
(b) When an individual enters this State in order to receive medical care, and applies for
Medicaid to meet all or a portion of the costs of such care, the fact that the immediate
purpose of the move was to secure medical care does not, in and of itself, have the effect of
making this person ineligible for the medical assistance program. It is the responsibility of
the county welfare board to evaluate all such cases and to make an eligibility determination,
considering carefully all the following criteria:
1. Whether the move is a temporary one, being solely for the purpose of receiving medical
care for a limited time;
2. Whether the move is part of a carefully conceived social service plan which would serve
to meet other requirements of the individual in addition to purely physical needs, for
example, a person moves to a nursing home in order to be closer to relatives who are
interested in the person's welfare;
3. Whether there is a clear expression of intent on the part of the individual to remain
permanently in this State;
4. Whether there is objective evidence that the individual has, in fact, abandoned or not
abandoned residence in the State from which he/she came;
5. Whether the State in which the individual previously resided recognizes him/her as
having continuing eligibility under the Medicaid program (or other program providing
payment for medical care) of that jurisdiction.
(c) If, after full consideration of these factors, the CBOSS is satisfied that the individual has
become a resident of this State, then eligibility for medical assistance is established if the
person is otherwise eligible.
medical care (a) Federal and State statute and regulations expressly bar a duration-of- residence
requirement as a condition of eligibility. The New Jersey Medical Assistance and Health
Services Act authorizes a grant of medical assistance to a qualified applicant who is a
resident of the State which " ... means a person living, other than temporarily, within the
State."
(b) When an individual enters this State in order to receive medical care, and applies for
Medicaid to meet all or a portion of the costs of such care, the fact that the immediate
purpose of the move was to secure medical care does not, in and of itself, have the effect of
making this person ineligible for the medical assistance program. It is the responsibility of
the county welfare board to evaluate all such cases and to make an eligibility determination,
considering carefully all the following criteria:
1. Whether the move is a temporary one, being solely for the purpose of receiving medical
care for a limited time;
2. Whether the move is part of a carefully conceived social service plan which would serve
to meet other requirements of the individual in addition to purely physical needs, for
example, a person moves to a nursing home in order to be closer to relatives who are
interested in the person's welfare;
3. Whether there is a clear expression of intent on the part of the individual to remain
permanently in this State;
4. Whether there is objective evidence that the individual has, in fact, abandoned or not
abandoned residence in the State from which he/she came;
5. Whether the State in which the individual previously resided recognizes him/her as
having continuing eligibility under the Medicaid program (or other program providing
payment for medical care) of that jurisdiction.
(c) If, after full consideration of these factors, the CBOSS is satisfied that the individual has
become a resident of this State, then eligibility for medical assistance is established if the
person is otherwise eligible.
10:71-3.7 Eligibility of beneficiaries who leave New Jersey
(a) Whenever a beneficiary wishes to leave New Jersey either to establish a permanent
residence or for a temporary visit, he or she shall be advised of the effect of this plan on his
or her eligibility for continued medical assistance. Particular care should be taken to advise
the beneficiary how to present his or her New Jersey Medicaid validation stub and instruct
the provider where to send the bill, should the beneficiary need medical care or
hospitalization while out of the State on an approved temporary visit.
(b) It shall be the policy of this State that if a beneficiary leaves New Jersey with intent to
establish a permanent residence elsewhere, or for an indefinite period for purposes other
than a temporary visit, or if he or she decides to remain indefinitely in the place outside New
Jersey to which he or she had gone for a temporary visit, he or she ceases to be eligible to
receive Medicaid.
(c) Visits by a beneficiary for a period of not more than 30 days will be permitted without
affecting the beneficiary's eligibility. Absence for longer periods of time must be approved by
the Division of Medical Assistance and Health Services.
(a) Whenever a beneficiary wishes to leave New Jersey either to establish a permanent
residence or for a temporary visit, he or she shall be advised of the effect of this plan on his
or her eligibility for continued medical assistance. Particular care should be taken to advise
the beneficiary how to present his or her New Jersey Medicaid validation stub and instruct
the provider where to send the bill, should the beneficiary need medical care or
hospitalization while out of the State on an approved temporary visit.
(b) It shall be the policy of this State that if a beneficiary leaves New Jersey with intent to
establish a permanent residence elsewhere, or for an indefinite period for purposes other
than a temporary visit, or if he or she decides to remain indefinitely in the place outside New
Jersey to which he or she had gone for a temporary visit, he or she ceases to be eligible to
receive Medicaid.
(c) Visits by a beneficiary for a period of not more than 30 days will be permitted without
affecting the beneficiary's eligibility. Absence for longer periods of time must be approved by
the Division of Medical Assistance and Health Services.
10:71-3.6 Change of county residence
(a) Responsibility for case management shall be transferred from one county to the other
when a beneficiary moves to another county.
(b) A temporary visit by the beneficiary shall not be considered to be a change of county
residence until that visit has continued for more than a three month period.
1. Whenever it is determined that a beneficiary whose application has not been validated
has changed or is planning to change his or her residence from one county to another the
CBOSS of origin shall continue medical assistance while completing validation, subject to
the time limits set forth in the application process, then transfer the case without delay to the
receiving county in accordance with (b)2 below. If the CBOSS of origin is in the process of
obtaining medical records, it shall complete the process and forward the medical records to
the receiving county.
2. Whenever it is determined that a beneficiary whose application has been validated is
planning to change his or her residence from one county to another, it shall be the
responsibility of the CBOSS directors of the two counties concerned to effect the transfer
without interruption of medical assistance.
3. The county of origin shall initiate and the receiving county shall, on request, immediately
cooperate in accomplishing a full investigation of the circumstances surrounding the move.
4. If the move is permanent and the case warrants continued medical assistance, transfer
of the case shall be accomplished expeditiously by discontinuance of medical assistance in
the county of origin and award of medical assistance in the receiving county, to occur
simultaneously in the first month for which the CBOSS directors mutually so arranged.
5. The welfare of the client shall not be adversely affected and his or her right to
uninterrupted medical assistance if in need shall not be prejudiced by disagreement or other
administrative difficulty between the counties. Any adverse change in grant resulting from
transfer requires timely notice.
i. Since the Medicaid Only client retains the same Medicaid number when he or she
moves from one county to another, the county of origin shall not terminate the client from
the Medicaid status file, but only from its own register.
(c) The county of origin shall initiate and the receiving county shall, on request, immediately
undertake an investigation of the circumstances surrounding the move. If the move is
permanent, each county shall execute its respective responsibilities in accordance with (d)
and (e) below.
(d) Applicants: Applicants are those individuals applying for Medicaid in the county of origin
who move to the receiving county before the eligibility determination has been completed.
1. County of origin: The county of origin has the responsibility to:
i. Complete the eligibility determination process;
ii. Accrete the individual to the Medicaid Status File (MSF) with the correct effective date
of Medicaid eligibility and the new address (in the receiving county); and
iii. Within five working days of the eligibility determination, transfer the case record
material to the receiving county in accordance with (e)1i through iv below.
2. Receiving county: The receiving county has the responsibility to:
i. Communicate promptly with the client and/or the client's authorized representative upon
receipt of the case material to advise of the continued receipt of medical assistance; and
ii. Notify immediately in writing the county of origin of the date the case material was
received.
(e) Beneficiaries: Beneficiaries include all individuals determined eligible for Medicaid Only.
1. County of origin: The county of origin has the responsibility to:
i. Transfer, within five working days from the date it is notified of the actual move, a copy
of pertinent case material to the receiving county. Such material shall include, at a minimum,
a copy of the first application and most recent PA-1G form (including all verification), Social
Security numbers, the beneficiary's new address in the receiving county, and form PR-1
(formerly PA-3L), completed with the individual's circumstances current as of the month of
the transfer.
ii. Send with the above case material a cover letter specifying that the case is being
transferred and requesting written acknowledgment of receipt;
iii. Forward promptly to the receiving county copies of any other material mutually
identified as necessary for case administration; and
iv. Notify the receiving county if there will be a delay in providing any case material
described in (e)1i or iii above.
2. Receiving county: The receiving county has the responsibility to:
i. Communicate promptly with the client and/or the client's authorized representative when
case material is received. Such communication shall arrange for the client and/or the
client's authorized representative to make application within 10 working days of the contact
to ensure uninterrupted receipt of medical assistance;
ii. Notify immediately in writing the county of origin of the date the initial case material was
received;
iii. Determine eligibility for the individual. Identify and resolve questions of the eligibility
determination made by the county of origin and receiving county. Advise the county of
origin of any discrepancies in the eligibility determinations between the two counties;
iv. Certify eligibility for medical assistance (provided application to transfer has been
made) effective for the next month if the initial case material has been received before the
10th of the month;
v. Certify eligibility for medical assistance (provided application to transfer has been made)
for the second month after the month of receipt of initial case material when such material is
received on or after the 10th of the month;
vi. Update the Medicaid Status File (MSF), if necessary. If the individual is determined
eligible for Medicaid Only in the receiving county, there shall be no interruption of Medicaid
eligibility and no change to the MSF is necessary. If the individual is determined ineligible
for Medicaid Only in the receiving county, Medicaid eligibility shall be terminated, subject to
timely and adequate notice, and the individual deleted from the MSF; and
vii. Notify the county of origin of the date eligibility for medical assistance will begin or will
be terminated in the receiving county.
(f) Any case for which transfer procedures in (c) through (e) above are not begun within 30
days of the date of original referral, shall be promptly reported by the county of origin to the
Division of Medical Assistance and Health Services by letter, setting forth the pertinent
available facts. This does not mean that the actual transfer must be completed within 30
days, but rather that the procedures shall be commenced within that time.
(a) Responsibility for case management shall be transferred from one county to the other
when a beneficiary moves to another county.
(b) A temporary visit by the beneficiary shall not be considered to be a change of county
residence until that visit has continued for more than a three month period.
1. Whenever it is determined that a beneficiary whose application has not been validated
has changed or is planning to change his or her residence from one county to another the
CBOSS of origin shall continue medical assistance while completing validation, subject to
the time limits set forth in the application process, then transfer the case without delay to the
receiving county in accordance with (b)2 below. If the CBOSS of origin is in the process of
obtaining medical records, it shall complete the process and forward the medical records to
the receiving county.
2. Whenever it is determined that a beneficiary whose application has been validated is
planning to change his or her residence from one county to another, it shall be the
responsibility of the CBOSS directors of the two counties concerned to effect the transfer
without interruption of medical assistance.
3. The county of origin shall initiate and the receiving county shall, on request, immediately
cooperate in accomplishing a full investigation of the circumstances surrounding the move.
4. If the move is permanent and the case warrants continued medical assistance, transfer
of the case shall be accomplished expeditiously by discontinuance of medical assistance in
the county of origin and award of medical assistance in the receiving county, to occur
simultaneously in the first month for which the CBOSS directors mutually so arranged.
5. The welfare of the client shall not be adversely affected and his or her right to
uninterrupted medical assistance if in need shall not be prejudiced by disagreement or other
administrative difficulty between the counties. Any adverse change in grant resulting from
transfer requires timely notice.
i. Since the Medicaid Only client retains the same Medicaid number when he or she
moves from one county to another, the county of origin shall not terminate the client from
the Medicaid status file, but only from its own register.
(c) The county of origin shall initiate and the receiving county shall, on request, immediately
undertake an investigation of the circumstances surrounding the move. If the move is
permanent, each county shall execute its respective responsibilities in accordance with (d)
and (e) below.
(d) Applicants: Applicants are those individuals applying for Medicaid in the county of origin
who move to the receiving county before the eligibility determination has been completed.
1. County of origin: The county of origin has the responsibility to:
i. Complete the eligibility determination process;
ii. Accrete the individual to the Medicaid Status File (MSF) with the correct effective date
of Medicaid eligibility and the new address (in the receiving county); and
iii. Within five working days of the eligibility determination, transfer the case record
material to the receiving county in accordance with (e)1i through iv below.
2. Receiving county: The receiving county has the responsibility to:
i. Communicate promptly with the client and/or the client's authorized representative upon
receipt of the case material to advise of the continued receipt of medical assistance; and
ii. Notify immediately in writing the county of origin of the date the case material was
received.
(e) Beneficiaries: Beneficiaries include all individuals determined eligible for Medicaid Only.
1. County of origin: The county of origin has the responsibility to:
i. Transfer, within five working days from the date it is notified of the actual move, a copy
of pertinent case material to the receiving county. Such material shall include, at a minimum,
a copy of the first application and most recent PA-1G form (including all verification), Social
Security numbers, the beneficiary's new address in the receiving county, and form PR-1
(formerly PA-3L), completed with the individual's circumstances current as of the month of
the transfer.
ii. Send with the above case material a cover letter specifying that the case is being
transferred and requesting written acknowledgment of receipt;
iii. Forward promptly to the receiving county copies of any other material mutually
identified as necessary for case administration; and
iv. Notify the receiving county if there will be a delay in providing any case material
described in (e)1i or iii above.
2. Receiving county: The receiving county has the responsibility to:
i. Communicate promptly with the client and/or the client's authorized representative when
case material is received. Such communication shall arrange for the client and/or the
client's authorized representative to make application within 10 working days of the contact
to ensure uninterrupted receipt of medical assistance;
ii. Notify immediately in writing the county of origin of the date the initial case material was
received;
iii. Determine eligibility for the individual. Identify and resolve questions of the eligibility
determination made by the county of origin and receiving county. Advise the county of
origin of any discrepancies in the eligibility determinations between the two counties;
iv. Certify eligibility for medical assistance (provided application to transfer has been
made) effective for the next month if the initial case material has been received before the
10th of the month;
v. Certify eligibility for medical assistance (provided application to transfer has been made)
for the second month after the month of receipt of initial case material when such material is
received on or after the 10th of the month;
vi. Update the Medicaid Status File (MSF), if necessary. If the individual is determined
eligible for Medicaid Only in the receiving county, there shall be no interruption of Medicaid
eligibility and no change to the MSF is necessary. If the individual is determined ineligible
for Medicaid Only in the receiving county, Medicaid eligibility shall be terminated, subject to
timely and adequate notice, and the individual deleted from the MSF; and
vii. Notify the county of origin of the date eligibility for medical assistance will begin or will
be terminated in the receiving county.
(f) Any case for which transfer procedures in (c) through (e) above are not begun within 30
days of the date of original referral, shall be promptly reported by the county of origin to the
Division of Medical Assistance and Health Services by letter, setting forth the pertinent
available facts. This does not mean that the actual transfer must be completed within 30
days, but rather that the procedures shall be commenced within that time.
10:71-3.5 Resident defined
(a) 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 presently removing
therefrom.
(b) County residence is not an eligibility requirement and relates only to identification of the
CBOSS charged by law with responsibility for the official receipts, registration, and
processing of applications. The CBOSS is responsible for institutionalized (including nursing
homes, intermediate care facilities, and sheltered boarding homes) applicants and
recipients within its county regardless of previous county of residence.
(a) 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 presently removing
therefrom.
(b) County residence is not an eligibility requirement and relates only to identification of the
CBOSS charged by law with responsibility for the official receipts, registration, and
processing of applications. The CBOSS is responsible for institutionalized (including nursing
homes, intermediate care facilities, and sheltered boarding homes) applicants and
recipients within its county regardless of previous county of residence.
10:71-3.3 Citizenship; alien status-documentation requirements
(a) A person born in the United States is, by definition, a United States citizen. The United
States is defined as the Continental United States, Alaska, Hawaii, Puerto Rico, Guam, and
the Virgin Islands of the United States. Native-born persons of American Samoa and
Swain's Island are also regarded as citizens of the United States.
(b) Naturalized citizens are those persons upon whom United States citizenship is
conferred after birth. This may be accomplished through individual or collective
naturalization or, under certain conditions, citizenship may be derived from a naturalized
parent. Thus, a child(ren) of a naturalized parent(s) is automatically considered a
naturalized citizen(s). Women who themselves could be lawfully naturalized and, prior to
September 22, 1922, were married to citizens, or were married to aliens who became
citizens before that date, automatically became citizens. On and after that date, standard
immigration and naturalization service conditions have to be met before any person can
become a naturalized citizen.
1. A naturalized citizen, unless automatically naturalized as outlined above, should have
his/her naturalization certificate as proof of citizenship. If the applicant does not have this document, the county welfare board should contact the nearest Immigration and
Naturalization Service district office to verify that the applicant meets the requirements of a
naturalized citizen.
(c) The following aliens, if present in the United States prior to August 22, 1996, and if
otherwise meeting the eligibility criteria, are entitled to full Medicaid benefits:
1. An alien lawfully admitted for permanent residence;
2. A refugee admitted pursuant to section 207 of the Immigration and Nationality Act;
3. An asylee admitted pursuant to section 208 of the Immigration and Nationality Act;
4. An alien whose deportation has been withheld pursuant to section 243(h) of the
Immigration and Nationality Act;
5. An alien who has been granted parole for at least one year by the Immigration and
Naturalization Service pursuant to section 212(d)(5) of the Immigration and Nationality Act;
6. An alien who has been granted conditional entry pursuant to section 203(a)(7) of the
immigration law in effect prior to April 1, 1980;
7. An alien who is granted status as a Cuban or Haitian entrant pursuant to section 501(e)
of the Refugee Education Assistance Act of 1980;
8. An American Indian born in Canada to whom the provisions of section 289 of the
Immigration and Nationality Act apply;
9. A member of an Indian tribe as defined in section 4(e) of the Indian Self-Determination
and Education Assistance Act;
10. An alien who is admitted to the United States as an Amerasian immigrant pursuant to
section 584 of the Foreign Operations, Export Financing, and Related Programs
Appropriations Act of 1988;
11. An alien who is honorably discharged or who is on active duty in the United States
Armed Forces and his or her spouse and the unmarried dependent children of the alien or
spouse; and
12. Certain legal aliens who are victims of domestic violence and when there is a
substantial connection between the battery or cruelty suffered by an alien and his or her
need for Medicaid benefits, subject to certain conditions described below:
i. The alien has been battered or subjected to extreme cruelty in the United States by a
spouse or a parent;
ii. The alien has been battered or subjected to extreme cruelty in the United States by a
member of the spouse's or parent's family residing in the same household of the alien and
the spouse or parent acquiesced to such battery or cruelty;
iii. The alien's child has been battered or subjected to extreme cruelty in the United States
by the spouse or the parent of the alien (without the active participation of the alien in the
battery or cruelty);
iv. The alien's child has been battered or subjected to extreme cruelty in the United
States by a member of the spouse's or parent's family residing in the same household as
the alien and the spouse or parent acquiesced to and the alien did not actively take part in
such battery or cruelty;
v. In addition to the conditions described in (c)12i through iv above, if the individual
responsible for the battery or cruelty continues to reside in the same household as the
individual who was subjected to such battery or cruelty, then the alien shall be ineligible for full Medicaid benefits under this chapter;
vi. The county board of social services shall apply the definitions "battery" and "extreme
cruelty" and the standards for determining whether a substantial connection exists between
the battery or cruelty and the need for Medicaid as issued by the Attorney General of the
United States under his or her sole and unreviewable discretion, in accordance with 8
U.S.C. § 1641.
(d) The following aliens entering the United States on or after August 22, 1996, and if
otherwise meeting the eligibility criteria, are entitled to Medicaid benefits:
1. An alien lawfully admitted for permanent residence, but only after having been present
in the United States for five years;
2. A refugee admitted pursuant to section 207 of the Immigration and Nationality Act;
3. An asylee admitted pursuant to section 208 of the Immigration and Nationality Act;
4. An alien whose deportation has been withheld pursuant to section 243(h) of the
Immigration and Nationality Act;
5. An alien who has been granted parole for at least one year by the Immigration and
Naturalization Service pursuant to section 212(d)5 of the Immigration and Nationality Act,
but only after the alien has been present in the United States for five years;
6. An alien who has been granted conditional entry pursuant to section 203(a)(7) of the
immigration law in effect prior to April 1, 1980, but only after the alien has been present in
the United States for five years;
7. An alien who is granted status as a Cuban or Haitian entrant pursuant to section 501(e)
of the Refugee Education Assistance Act of 1980;
8. An American Indian born in Canada to whom the provisions of section 289 of the
Immigration and Nationality Act apply;
9. A member of an Indian tribe as defined in section 4(e) of the Indian Self-Determination
and Education Assistance Act;
10. An alien who is admitted to the United States as an Amerasian immigrant pursuant to
section 584 of the Foreign Operations, Export Financing, and Related Programs
Appropriations Act of 1988;
11. An alien who is honorably discharged or who is on active duty with the United States
Armed Forces and his or her spouse and the unmarried dependent children of the alien or
spouse; and
12. Certain aliens who are victims of domestic violence as specified in (c)12 above, but
only after the alien has been present in the United States for five years.
(e) Any alien who is not an eligible alien as specified in (c) and (d) above is ineligible for full
Medicaid benefits. Any such alien, if a resident of New Jersey and if he or she meets all
other Medicaid eligibility requirements, is entitled to Medicaid coverage for the treatment of
an emergency medical condition only.
1. An emergency medical condition is one of sudden onset that manifests itself by acute
symptoms of sufficient severity (including severe pain) such that the absence of immediate
medical attention could reasonably be expected to result in:
i. Placing the patient's health in serious jeopardy;
ii. Serious impairment to bodily functions; or
iii. Serious dysfunction of any bodily organ or part.
2. An emergency medical condition includes all labor and delivery for a pregnant woman.
It does not include routine prenatal or post-partum care.
3. Services related to an organ transplant procedure are not covered under services
available for treatment of an emergency medical condition.
(f) Persons claiming to be citizens and eligible aliens shall provide the county board of
social services with documentation of citizenship or alien status.
(g) As a condition of eligibility, all applicants for Medicaid (except for those applying solely
for services related to the treatment of an emergency medical condition) shall sign a
declaration under penalty of perjury that they are a citizen of the United States or an alien in
a satisfactory immigration status. In the case of a child or incompetent applicant, another
individual on the applicant's behalf shall complete the same written declaration under
penalty of perjury.
1. The following are acceptable documentation of United States citizenship:
i. A birth certificate;
ii. A religious record of birth recorded in the United States or its territories within three
months of birth. The document must show either the date of birth or the individual's age at
the time the record was created;
iii. A United States passport (not including limited passports which are issued for periods
of less than five years);
iv. A Report of Birth Abroad of a Citizen of the U.S. (Form FS-240);
v. A U.S. Citizen I.D. Card (INS Form-197, Nationality Certificate (INS Form N-550 or N-
570);
vi. A Certificate of Citizenship (INS Form N-560 or N-561);
vii. A Northern Mariana Identification Card (issued by the INS to a collectively naturalized
citizen of the United States who was born in the United States before November 3, 1986);
viii. An American Indian Card with a classification code "KIC" (issued by the INS to
identify U.S. citizen members of the Texas Band of Kickapoos); or
ix. A contemporaneous hospital record of birth in one of the 50 states, the District of
Columbia, Puerto Rico (on or after January 13, 1941), Guam (on or after April 10, 1899), the
U.S. Virgin Islands (on or after January 17, 1917), American Samoa, Swain's Island, or the
Northern Mariana Islands (unless the person was born to foreign diplomats residing in any
of these jurisdictions).
2. If an applicant presents an expired INS document or is unable to present any document
demonstrating his or her immigration status, the county board of social services shall refer
the applicant to the local INS district office to obtain evidence of status. If, however, the
applicant provides an alien registration number, but no documentation, the county board of
social services shall file INS Form G-845 along with the alien registration number with the
local INS district office to verify status.
3. The following sets forth acceptable documentation for eligible aliens:
i. Lawful Permanent Resident--INS Form I-551, or for recent arrivals, a temporary I-551
stamp in a foreign passport or on Form I-94.
ii. Refugee--INS Form I-94 annotated with stamp showing entry as refugee under section
207 of the Immigration and Nationality Act and date of entry into the United States; INS
Form I-688B annotated "274a. 12(a)(3)," I-766 annotated "A3," or I-571. Refugees usually
adjust to Lawful Permanent Resident status after 12 months in the United States, but for
purposes of determining Medicaid eligibility they are considered refugees. Refugees whose
status has been adjusted will have INS Form I-551 annotated "RE-6," "RE-7," "RE-8," or
"RE-9."
iii. Asylees--INS Form I-94 annotated with a stamp showing grant of asylum under section
208 of the Immigration and Nationality Act, a grant letter from the Asylum Office of the
Immigration and Naturalization Service, Forms 688B annotated "274a. 12(a)(5)," or I-766
annotated "A5."
iv. Deportation Withheld--Order of an Immigration Judge showing deportation withheld
under section 243(h) of the Immigration and Nationality Act and the date of the grant, or INS
Form I-688B annotated "274a. 12(a)(10)" or I-766 annotated "A10."
v. Parole for at Least a Year--INS Form I-94 annotated with stamp showing grant of
parole under section 212(d)(5) of the Immigration and Nationality Act and a date showing
granting of parole for at least a year.
vi. Conditional Entry under Law in Effect before April 1, 1980--INS Form I- 94 with stamp
showing admission under section 203(a)(7) of the Immigration and Nationality Act, refugeeconditional
entry, or INS Forms I-688B annotated "274a. 12(a)(3)" or I-766 annotated "A3."
vii. Cuban Haitian Entrant--INS Form I-94 stamped "Cuban/Haitian Entrant under section
212(d)(5) of the INA."
viii. An American Indian born in Canada--INS Form I-551 with code S13 or an unexpired
temporary I-551 stamp (with code S13) in a Canadian passport or on Form I-94.
ix. A member of certain Federally recognized Indian tribes--Membership card or other
tribal document showing membership in tribe is acceptable documentation.
x. Amerasian Immigrant--INS Form I-551 with the code AM1, AM2, or AM3 or passport
stamped with an unexpired temporary I-551 showing a code AN6, AM7, or AM8.
4. For aliens subject to the five-year waiting period before eligibility for Medicaid can be
established, the date of entry into the United States shall be determined as follows:
i. On INS Form I-94, the date of admission should be found on the refugee stamp. If
missing, the county board of social services should contact the INS local district office by
filing Form G-845, attaching a copy of the document;
ii. If the alien presents INS Form I-688B (Employment Authorization Document), I-766, or
I-571 (Refugee Travel Document), the county board of social services shall ask the alien to
present Form I-94. If that form is not available, the county board of social services shall
contact the INS via the submission of Form G-845, attaching a copy of the documentation
presented;
iii. If the alien presents a grant letter or court order, the date of entry shall be derived from
the date of the letter or court order. If missing, the county board of social services shall
contact the INS by submitting a Form G- 845, attaching a copy of the document presented.
5. For aliens who present themselves as on active duty or honorably discharged from the
United States Armed Forces, the following serve as documentation:
i. For discharge status, an original or notarized copy of the veteran's discharge papers
issued by the branch of service in which the applicant was a member;
ii. For active duty military status, an original or notarized copy, of the applicant's current orders showing the individual is on full-time duty with the U.S. Army, Navy, Air Force,
Marine Corps, or Coast Guard (full-time National Guard duty does not qualify), or a military
identification card (DD Form 2 (active));
iii. A self-declaration under penalty of perjury may be accepted pending receipt of
acceptable documentation.
(a) A person born in the United States is, by definition, a United States citizen. The United
States is defined as the Continental United States, Alaska, Hawaii, Puerto Rico, Guam, and
the Virgin Islands of the United States. Native-born persons of American Samoa and
Swain's Island are also regarded as citizens of the United States.
(b) Naturalized citizens are those persons upon whom United States citizenship is
conferred after birth. This may be accomplished through individual or collective
naturalization or, under certain conditions, citizenship may be derived from a naturalized
parent. Thus, a child(ren) of a naturalized parent(s) is automatically considered a
naturalized citizen(s). Women who themselves could be lawfully naturalized and, prior to
September 22, 1922, were married to citizens, or were married to aliens who became
citizens before that date, automatically became citizens. On and after that date, standard
immigration and naturalization service conditions have to be met before any person can
become a naturalized citizen.
1. A naturalized citizen, unless automatically naturalized as outlined above, should have
his/her naturalization certificate as proof of citizenship. If the applicant does not have this document, the county welfare board should contact the nearest Immigration and
Naturalization Service district office to verify that the applicant meets the requirements of a
naturalized citizen.
(c) The following aliens, if present in the United States prior to August 22, 1996, and if
otherwise meeting the eligibility criteria, are entitled to full Medicaid benefits:
1. An alien lawfully admitted for permanent residence;
2. A refugee admitted pursuant to section 207 of the Immigration and Nationality Act;
3. An asylee admitted pursuant to section 208 of the Immigration and Nationality Act;
4. An alien whose deportation has been withheld pursuant to section 243(h) of the
Immigration and Nationality Act;
5. An alien who has been granted parole for at least one year by the Immigration and
Naturalization Service pursuant to section 212(d)(5) of the Immigration and Nationality Act;
6. An alien who has been granted conditional entry pursuant to section 203(a)(7) of the
immigration law in effect prior to April 1, 1980;
7. An alien who is granted status as a Cuban or Haitian entrant pursuant to section 501(e)
of the Refugee Education Assistance Act of 1980;
8. An American Indian born in Canada to whom the provisions of section 289 of the
Immigration and Nationality Act apply;
9. A member of an Indian tribe as defined in section 4(e) of the Indian Self-Determination
and Education Assistance Act;
10. An alien who is admitted to the United States as an Amerasian immigrant pursuant to
section 584 of the Foreign Operations, Export Financing, and Related Programs
Appropriations Act of 1988;
11. An alien who is honorably discharged or who is on active duty in the United States
Armed Forces and his or her spouse and the unmarried dependent children of the alien or
spouse; and
12. Certain legal aliens who are victims of domestic violence and when there is a
substantial connection between the battery or cruelty suffered by an alien and his or her
need for Medicaid benefits, subject to certain conditions described below:
i. The alien has been battered or subjected to extreme cruelty in the United States by a
spouse or a parent;
ii. The alien has been battered or subjected to extreme cruelty in the United States by a
member of the spouse's or parent's family residing in the same household of the alien and
the spouse or parent acquiesced to such battery or cruelty;
iii. The alien's child has been battered or subjected to extreme cruelty in the United States
by the spouse or the parent of the alien (without the active participation of the alien in the
battery or cruelty);
iv. The alien's child has been battered or subjected to extreme cruelty in the United
States by a member of the spouse's or parent's family residing in the same household as
the alien and the spouse or parent acquiesced to and the alien did not actively take part in
such battery or cruelty;
v. In addition to the conditions described in (c)12i through iv above, if the individual
responsible for the battery or cruelty continues to reside in the same household as the
individual who was subjected to such battery or cruelty, then the alien shall be ineligible for full Medicaid benefits under this chapter;
vi. The county board of social services shall apply the definitions "battery" and "extreme
cruelty" and the standards for determining whether a substantial connection exists between
the battery or cruelty and the need for Medicaid as issued by the Attorney General of the
United States under his or her sole and unreviewable discretion, in accordance with 8
U.S.C. § 1641.
(d) The following aliens entering the United States on or after August 22, 1996, and if
otherwise meeting the eligibility criteria, are entitled to Medicaid benefits:
1. An alien lawfully admitted for permanent residence, but only after having been present
in the United States for five years;
2. A refugee admitted pursuant to section 207 of the Immigration and Nationality Act;
3. An asylee admitted pursuant to section 208 of the Immigration and Nationality Act;
4. An alien whose deportation has been withheld pursuant to section 243(h) of the
Immigration and Nationality Act;
5. An alien who has been granted parole for at least one year by the Immigration and
Naturalization Service pursuant to section 212(d)5 of the Immigration and Nationality Act,
but only after the alien has been present in the United States for five years;
6. An alien who has been granted conditional entry pursuant to section 203(a)(7) of the
immigration law in effect prior to April 1, 1980, but only after the alien has been present in
the United States for five years;
7. An alien who is granted status as a Cuban or Haitian entrant pursuant to section 501(e)
of the Refugee Education Assistance Act of 1980;
8. An American Indian born in Canada to whom the provisions of section 289 of the
Immigration and Nationality Act apply;
9. A member of an Indian tribe as defined in section 4(e) of the Indian Self-Determination
and Education Assistance Act;
10. An alien who is admitted to the United States as an Amerasian immigrant pursuant to
section 584 of the Foreign Operations, Export Financing, and Related Programs
Appropriations Act of 1988;
11. An alien who is honorably discharged or who is on active duty with the United States
Armed Forces and his or her spouse and the unmarried dependent children of the alien or
spouse; and
12. Certain aliens who are victims of domestic violence as specified in (c)12 above, but
only after the alien has been present in the United States for five years.
(e) Any alien who is not an eligible alien as specified in (c) and (d) above is ineligible for full
Medicaid benefits. Any such alien, if a resident of New Jersey and if he or she meets all
other Medicaid eligibility requirements, is entitled to Medicaid coverage for the treatment of
an emergency medical condition only.
1. An emergency medical condition is one of sudden onset that manifests itself by acute
symptoms of sufficient severity (including severe pain) such that the absence of immediate
medical attention could reasonably be expected to result in:
i. Placing the patient's health in serious jeopardy;
ii. Serious impairment to bodily functions; or
iii. Serious dysfunction of any bodily organ or part.
2. An emergency medical condition includes all labor and delivery for a pregnant woman.
It does not include routine prenatal or post-partum care.
3. Services related to an organ transplant procedure are not covered under services
available for treatment of an emergency medical condition.
(f) Persons claiming to be citizens and eligible aliens shall provide the county board of
social services with documentation of citizenship or alien status.
(g) As a condition of eligibility, all applicants for Medicaid (except for those applying solely
for services related to the treatment of an emergency medical condition) shall sign a
declaration under penalty of perjury that they are a citizen of the United States or an alien in
a satisfactory immigration status. In the case of a child or incompetent applicant, another
individual on the applicant's behalf shall complete the same written declaration under
penalty of perjury.
1. The following are acceptable documentation of United States citizenship:
i. A birth certificate;
ii. A religious record of birth recorded in the United States or its territories within three
months of birth. The document must show either the date of birth or the individual's age at
the time the record was created;
iii. A United States passport (not including limited passports which are issued for periods
of less than five years);
iv. A Report of Birth Abroad of a Citizen of the U.S. (Form FS-240);
v. A U.S. Citizen I.D. Card (INS Form-197, Nationality Certificate (INS Form N-550 or N-
570);
vi. A Certificate of Citizenship (INS Form N-560 or N-561);
vii. A Northern Mariana Identification Card (issued by the INS to a collectively naturalized
citizen of the United States who was born in the United States before November 3, 1986);
viii. An American Indian Card with a classification code "KIC" (issued by the INS to
identify U.S. citizen members of the Texas Band of Kickapoos); or
ix. A contemporaneous hospital record of birth in one of the 50 states, the District of
Columbia, Puerto Rico (on or after January 13, 1941), Guam (on or after April 10, 1899), the
U.S. Virgin Islands (on or after January 17, 1917), American Samoa, Swain's Island, or the
Northern Mariana Islands (unless the person was born to foreign diplomats residing in any
of these jurisdictions).
2. If an applicant presents an expired INS document or is unable to present any document
demonstrating his or her immigration status, the county board of social services shall refer
the applicant to the local INS district office to obtain evidence of status. If, however, the
applicant provides an alien registration number, but no documentation, the county board of
social services shall file INS Form G-845 along with the alien registration number with the
local INS district office to verify status.
3. The following sets forth acceptable documentation for eligible aliens:
i. Lawful Permanent Resident--INS Form I-551, or for recent arrivals, a temporary I-551
stamp in a foreign passport or on Form I-94.
ii. Refugee--INS Form I-94 annotated with stamp showing entry as refugee under section
207 of the Immigration and Nationality Act and date of entry into the United States; INS
Form I-688B annotated "274a. 12(a)(3)," I-766 annotated "A3," or I-571. Refugees usually
adjust to Lawful Permanent Resident status after 12 months in the United States, but for
purposes of determining Medicaid eligibility they are considered refugees. Refugees whose
status has been adjusted will have INS Form I-551 annotated "RE-6," "RE-7," "RE-8," or
"RE-9."
iii. Asylees--INS Form I-94 annotated with a stamp showing grant of asylum under section
208 of the Immigration and Nationality Act, a grant letter from the Asylum Office of the
Immigration and Naturalization Service, Forms 688B annotated "274a. 12(a)(5)," or I-766
annotated "A5."
iv. Deportation Withheld--Order of an Immigration Judge showing deportation withheld
under section 243(h) of the Immigration and Nationality Act and the date of the grant, or INS
Form I-688B annotated "274a. 12(a)(10)" or I-766 annotated "A10."
v. Parole for at Least a Year--INS Form I-94 annotated with stamp showing grant of
parole under section 212(d)(5) of the Immigration and Nationality Act and a date showing
granting of parole for at least a year.
vi. Conditional Entry under Law in Effect before April 1, 1980--INS Form I- 94 with stamp
showing admission under section 203(a)(7) of the Immigration and Nationality Act, refugeeconditional
entry, or INS Forms I-688B annotated "274a. 12(a)(3)" or I-766 annotated "A3."
vii. Cuban Haitian Entrant--INS Form I-94 stamped "Cuban/Haitian Entrant under section
212(d)(5) of the INA."
viii. An American Indian born in Canada--INS Form I-551 with code S13 or an unexpired
temporary I-551 stamp (with code S13) in a Canadian passport or on Form I-94.
ix. A member of certain Federally recognized Indian tribes--Membership card or other
tribal document showing membership in tribe is acceptable documentation.
x. Amerasian Immigrant--INS Form I-551 with the code AM1, AM2, or AM3 or passport
stamped with an unexpired temporary I-551 showing a code AN6, AM7, or AM8.
4. For aliens subject to the five-year waiting period before eligibility for Medicaid can be
established, the date of entry into the United States shall be determined as follows:
i. On INS Form I-94, the date of admission should be found on the refugee stamp. If
missing, the county board of social services should contact the INS local district office by
filing Form G-845, attaching a copy of the document;
ii. If the alien presents INS Form I-688B (Employment Authorization Document), I-766, or
I-571 (Refugee Travel Document), the county board of social services shall ask the alien to
present Form I-94. If that form is not available, the county board of social services shall
contact the INS via the submission of Form G-845, attaching a copy of the documentation
presented;
iii. If the alien presents a grant letter or court order, the date of entry shall be derived from
the date of the letter or court order. If missing, the county board of social services shall
contact the INS by submitting a Form G- 845, attaching a copy of the document presented.
5. For aliens who present themselves as on active duty or honorably discharged from the
United States Armed Forces, the following serve as documentation:
i. For discharge status, an original or notarized copy of the veteran's discharge papers
issued by the branch of service in which the applicant was a member;
ii. For active duty military status, an original or notarized copy, of the applicant's current orders showing the individual is on full-time duty with the U.S. Army, Navy, Air Force,
Marine Corps, or Coast Guard (full-time National Guard duty does not qualify), or a military
identification card (DD Form 2 (active));
iii. A self-declaration under penalty of perjury may be accepted pending receipt of
acceptable documentation.
10:71-3.2 Citizenship; requirements
(a) The applicant must be a resident of the United States who is either a citizen or an alien
who can be classified as an eligible alien in accordance with this subchapter.
1. An individual who cannot be classified as an eligible alien in accordance with this
subchapter due to changes mandated by the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (Public Law 104-193) but who was residing in a Medicaidcertified
nursing facility prior to January 29, 1997, will continue to be eligible for medical
assistance until the individual is no longer eligible for long-term care services.
(a) The applicant must be a resident of the United States who is either a citizen or an alien
who can be classified as an eligible alien in accordance with this subchapter.
1. An individual who cannot be classified as an eligible alien in accordance with this
subchapter due to changes mandated by the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (Public Law 104-193) but who was residing in a Medicaidcertified
nursing facility prior to January 29, 1997, will continue to be eligible for medical
assistance until the individual is no longer eligible for long-term care services.
10:71-3.1 General provisions
(a) Eligibility must be established in relation to each legal requirement to provide a valid
basis for granting or denying medical assistance.
(b) The applicant's statements regarding his/her eligibility, as set forth in the application
form, are evidence. The statements must be consistent and meet prudent tests of
credibility. Incomplete or questionable statements shall be supplemented and substantiated
by corroborative evidence from other pertinent sources, either documentary or
nondocumentary:
1. Documentary sources of evidence present factual information recorded at some
previous date by a disinterested party and filed as part of a record. Examples: certificates,
legal papers, insurance policies, licenses, bills, receipts, notices of RSDI benefits, and so
forth.
2. Nondocumentary sources of evidence are factual oral statements which appear to be
reliable by individuals, based on the observation and personal knowledge of applicant's
circumstances.
(a) Eligibility must be established in relation to each legal requirement to provide a valid
basis for granting or denying medical assistance.
(b) The applicant's statements regarding his/her eligibility, as set forth in the application
form, are evidence. The statements must be consistent and meet prudent tests of
credibility. Incomplete or questionable statements shall be supplemented and substantiated
by corroborative evidence from other pertinent sources, either documentary or
nondocumentary:
1. Documentary sources of evidence present factual information recorded at some
previous date by a disinterested party and filed as part of a record. Examples: certificates,
legal papers, insurance policies, licenses, bills, receipts, notices of RSDI benefits, and so
forth.
2. Nondocumentary sources of evidence are factual oral statements which appear to be
reliable by individuals, based on the observation and personal knowledge of applicant's
circumstances.
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.
(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.
10:71-2.14 Disposition of application
(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 authority to make case decisions other than approvals.
(b) The director may delegate such authority to any staff member or members as he/she
may determine. He/she shall exercise this right of delegation in such a way as to assure the
available at all times of some staff member possessing the requisite authority to make
decisions and to authorize payment by the Division of Medical Assistance and Health
Services.
(c) Applications which may be held for the welfare board are:
1. Those where immediate medical need is not indicated; or
2. Those where the director believes that there is valid cause to question the available
evidence on any point of eligibility, or where the case presents a special problem;
3. If so held, the application shall be identified in the narrative portion of the minutes, and
in each instance shall include a brief statement of the question or special problem involved
and the decision of the board.
(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 authority to make case decisions other than approvals.
(b) The director may delegate such authority to any staff member or members as he/she
may determine. He/she shall exercise this right of delegation in such a way as to assure the
available at all times of some staff member possessing the requisite authority to make
decisions and to authorize payment by the Division of Medical Assistance and Health
Services.
(c) Applications which may be held for the welfare board are:
1. Those where immediate medical need is not indicated; or
2. Those where the director believes that there is valid cause to question the available
evidence on any point of eligibility, or where the case presents a special problem;
3. If so held, the application shall be identified in the narrative portion of the minutes, and
in each instance shall include a brief statement of the question or special problem involved
and the decision of the board.
10:71-2.13 Supervisory review and approval
(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
conference, and, if necessary, the issue shall be referred to a higher administrative level for
disposition.
(d) All records of application shall be approved in writing by the supervisor following review,
either by signature or initialed transcript signature.
(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
conference, and, if necessary, the issue shall be referred to a higher administrative level for
disposition.
(d) All records of application shall be approved in writing by the supervisor following review,
either by signature or initialed transcript signature.
10:71-2.12 Recommendation for agency decision
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
statement of income available for nursing home payment PR-1 (formerly PA-3L) will be
completed in appropriate cases.
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
statement of income available for nursing home payment PR-1 (formerly PA-3L) will be
completed in appropriate cases.
10:71-2.10 Collateral investigation
(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
information.
(c) The applicants will usually be able to help select the most likely sources of information
about themselves. If they are unwilling to have the necessary inquiries made and are unwilling to secure the required information from such sources themselves, then it shall be
explained that the CBOSS will be unable to certify entitlement to Medicaid Only.
(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
information.
(c) The applicants will usually be able to help select the most likely sources of information
about themselves. If they are unwilling to have the necessary inquiries made and are unwilling to secure the required information from such sources themselves, then it shall be
explained that the CBOSS will be unable to certify entitlement to Medicaid Only.
10:71-2.7 Reports to the Commission for the Blind and Visually Impaired under
specified circumstances
By law, the CBOSS is required to report to the Commission for the Blind and Visually
Impaired, every individual coming to its attention who is known to be, or who is believed
likely to become, permanently blind. The permanent information shall be registered with the
Commission in the prescribed form.
specified circumstances
By law, the CBOSS is required to report to the Commission for the Blind and Visually
Impaired, every individual coming to its attention who is known to be, or who is believed
likely to become, permanently blind. The permanent information shall be registered with the
Commission in the prescribed form.
10:71-2.6 Registration procedures and record of inquiries
(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, or
reassignment of previous number to a reapplication or reopened application;
3. Preparation of appropriate form PA-9, registration card.
(b) So far as possible, registration shall be completed on the same day that application for
assistance is made. If the application is made outside the CBOSS office, registration shall
be completed within three working days.
(c) An inquiry is any request for information about assistance programs which is not a
request for an application. A record is necessary only when the inquiry requires follow-up
action.
(d) The Institutional Services Section makes Medicaid Only referrals for adults
contemplating discharge from specific state and county institutions. These cases are to be
registered within two working days.
(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, or
reassignment of previous number to a reapplication or reopened application;
3. Preparation of appropriate form PA-9, registration card.
(b) So far as possible, registration shall be completed on the same day that application for
assistance is made. If the application is made outside the CBOSS office, registration shall
be completed within three working days.
(c) An inquiry is any request for information about assistance programs which is not a
request for an application. A record is necessary only when the inquiry requires follow-up
action.
(d) The Institutional Services Section makes Medicaid Only referrals for adults
contemplating discharge from specific state and county institutions. These cases are to be
registered within two working days.
10:71-2.5 Application policy and procedure
(a) Application for Medicaid Only may be taken by the CBOSS 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 for Medicaid Only.
(c) In Medicaid Only, an individual who wishes to apply may be confined at home or at an
institution, or may be subject to a critical illness or injury which impedes action on his or her
own behalf. Consequently, the CBOSS shall accept any one of the following, in order of
priority as listed, as an authorized agent for the purpose of initiating an application:
1. A relative by blood or marriage;
2. A staff member of a public or private welfare agency of which the person is a client, who
has been designated by the agency to so act;
3. A physician or attorney of whom the person is respectively a patient or client;
4. A staff member of an institution or facility in which a person is receiving care, who has
been designated by the institutional facility to so act
(a) Application for Medicaid Only may be taken by the CBOSS 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 for Medicaid Only.
(c) In Medicaid Only, an individual who wishes to apply may be confined at home or at an
institution, or may be subject to a critical illness or injury which impedes action on his or her
own behalf. Consequently, the CBOSS shall accept any one of the following, in order of
priority as listed, as an authorized agent for the purpose of initiating an application:
1. A relative by blood or marriage;
2. A staff member of a public or private welfare agency of which the person is a client, who
has been designated by the agency to so act;
3. A physician or attorney of whom the person is respectively a patient or client;
4. A staff member of an institution or facility in which a person is receiving care, who has
been designated by the institutional facility to so act
10:71-2.4 Intake policy and procedure
(a) "Intake" is a term applied to the CBOSS'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 arranged promptly. Such inquiries shall be recorded
as inquiries unless and until there is an interview which results in a decision to make
application for assistance.
(c) When the inquiry is by letter or telephone, an appointment, if requested, shall be
arranged promptly. An application for Medicaid Only is not to be taken if applicant plans to
or has applied for SSI.
(d) All inquiries and referrals shall be cleared with the State Data Exchange (SDX) and any
previous information on file shall be made available to the worker for the initial interview.
(a) "Intake" is a term applied to the CBOSS'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 arranged promptly. Such inquiries shall be recorded
as inquiries unless and until there is an interview which results in a decision to make
application for assistance.
(c) When the inquiry is by letter or telephone, an appointment, if requested, shall be
arranged promptly. An application for Medicaid Only is not to be taken if applicant plans to
or has applied for SSI.
(d) All inquiries and referrals shall be cleared with the State Data Exchange (SDX) and any
previous information on file shall be made available to the worker for the initial interview.
10:71-2.3 Policy and procedure on prompt disposition
(a) The maximum period of time normally essential to process an application for the aged is
30 days; for the disabled or blind, 60 days.
(b) "Date of effective disposition" based upon either administrative or board action means:
1. In the case of an approved application, the effective date of the application. (Either the
date of application, or the date of form PA-1C, whichever is earlier);
2. In the case of a denied application, the date on which written notification informing the
applicant of his or her lack of eligibility and the reason therefor is sent to him or her;
3. In the case of a withdrawn application, the date on which written notification confirming
to the client that the agency has taken cognizance of his or her voluntary withdrawal is sent
to him or her; or
4. In the case of a dismissed application, the date on which written notification informing
the applicant of the dismissal and the reasons therefor is sent to him or her.
(c) It is recognized that there will be exceptional cases where the proper processing of an
application cannot be completed within the 30/60 day period. Where substantially reliable
evidence of eligibility is still lacking at the end of the designated period, the application may
be continued in pending status. In each such case, the CBOSS shall be prepared to
demonstrate that the delay resulted from one of the following:
1. Circumstances wholly within the applicant's control; or
2. A determination to afford the applicant, whose proof of eligibility has been inconclusive,
a further opportunity to develop additional evidence of eligibility before final action on his or
her application; or
3. An administrative or other emergency that could not reasonably have been avoided; or
4. Circumstances wholly outside the control of both the applicant and CBOSS.
(d) When the complete processing of an application is delayed beyond 30 days for the
aged or 60 days for the blind or disabled, written notification shall be sent to the applicant on
or before the expiration of such period, setting forth the specific reasons for delay.
(e) Each county director of welfare shall arrange operational procedures and establish appropriate operational controls within his or her staff organization to expedite the
processing of applications and assure the maximum possible compliance with these
standards.
(f) Control records on the exceptional cases shall disclose at any time the identity of all
applications which have been in pending status beyond normal limits for processing and the
reason therefore. Such record shall be adequate to make possible the preparation of a
report of such information at any time it might be requested by the CBOSS or the Division of
Medical Assistance and Health Services.
(a) The maximum period of time normally essential to process an application for the aged is
30 days; for the disabled or blind, 60 days.
(b) "Date of effective disposition" based upon either administrative or board action means:
1. In the case of an approved application, the effective date of the application. (Either the
date of application, or the date of form PA-1C, whichever is earlier);
2. In the case of a denied application, the date on which written notification informing the
applicant of his or her lack of eligibility and the reason therefor is sent to him or her;
3. In the case of a withdrawn application, the date on which written notification confirming
to the client that the agency has taken cognizance of his or her voluntary withdrawal is sent
to him or her; or
4. In the case of a dismissed application, the date on which written notification informing
the applicant of the dismissal and the reasons therefor is sent to him or her.
(c) It is recognized that there will be exceptional cases where the proper processing of an
application cannot be completed within the 30/60 day period. Where substantially reliable
evidence of eligibility is still lacking at the end of the designated period, the application may
be continued in pending status. In each such case, the CBOSS shall be prepared to
demonstrate that the delay resulted from one of the following:
1. Circumstances wholly within the applicant's control; or
2. A determination to afford the applicant, whose proof of eligibility has been inconclusive,
a further opportunity to develop additional evidence of eligibility before final action on his or
her application; or
3. An administrative or other emergency that could not reasonably have been avoided; or
4. Circumstances wholly outside the control of both the applicant and CBOSS.
(d) When the complete processing of an application is delayed beyond 30 days for the
aged or 60 days for the blind or disabled, written notification shall be sent to the applicant on
or before the expiration of such period, setting forth the specific reasons for delay.
(e) Each county director of welfare shall arrange operational procedures and establish appropriate operational controls within his or her staff organization to expedite the
processing of applications and assure the maximum possible compliance with these
standards.
(f) Control records on the exceptional cases shall disclose at any time the identity of all
applications which have been in pending status beyond normal limits for processing and the
reason therefore. Such record shall be adequate to make possible the preparation of a
report of such information at any time it might be requested by the CBOSS or the Division of
Medical Assistance and Health Services.
10:71-2.2 Responsibilities in the application process
(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 for, and evaluation of health services rendered under, Medicaid Only; maintains
administrative liaison with other departmental divisions; and provides professional, medical
and paramedical staff which is advisory to this Division in all matters of health care relevant
to the administration of Medicaid Only. This Division contracts with CBOSSs for
reimbursement of costs of administering the Medicaid Only program.
(b) The Division of Medical Assistance and Health Services and the Commissioner of the
Department of Human Services shall establish policy and procedures for the application
process and supervise the operation of and compliance with the policy and procedures so
established.
(c) The CBOSS exercises direct responsibility in the application process to:
1. Inform the applicants about the purpose and eligibility requirements for Medicaid Only,
inform them of their rights and responsibilities under its provisions and inform applicants of
their right to a fair hearing;
2. Receive applications;
3. Assist the applicants in exploring their eligibility for assistance;
4. Make known to the applicants the appropriate resources and services both within the agency and the community, and, if necessary, assist in their use;
5. Assure the prompt and accurate submission of eligibility data to the Medicaid status files
for eligible persons and prompt notification to ineligible persons of the reason(s) for their
ineligibility;
6. The CBOSSs shall also provide supportive social services which will enhance cure and
rehabilitation of beneficiaries of Medicaid Only.
(d) As a participant in the application process, an applicant shall:
1. Complete, with assistance from the CBOSS if needed, any forms required by the
CBOSS as a part of the application process;
2. Assist the CBOSS in securing evidence that corroborates his/her statements;
3. Report promptly any change affecting his or her circumstances
(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 for, and evaluation of health services rendered under, Medicaid Only; maintains
administrative liaison with other departmental divisions; and provides professional, medical
and paramedical staff which is advisory to this Division in all matters of health care relevant
to the administration of Medicaid Only. This Division contracts with CBOSSs for
reimbursement of costs of administering the Medicaid Only program.
(b) The Division of Medical Assistance and Health Services and the Commissioner of the
Department of Human Services shall establish policy and procedures for the application
process and supervise the operation of and compliance with the policy and procedures so
established.
(c) The CBOSS exercises direct responsibility in the application process to:
1. Inform the applicants about the purpose and eligibility requirements for Medicaid Only,
inform them of their rights and responsibilities under its provisions and inform applicants of
their right to a fair hearing;
2. Receive applications;
3. Assist the applicants in exploring their eligibility for assistance;
4. Make known to the applicants the appropriate resources and services both within the agency and the community, and, if necessary, assist in their use;
5. Assure the prompt and accurate submission of eligibility data to the Medicaid status files
for eligible persons and prompt notification to ineligible persons of the reason(s) for their
ineligibility;
6. The CBOSSs shall also provide supportive social services which will enhance cure and
rehabilitation of beneficiaries of Medicaid Only.
(d) As a participant in the application process, an applicant shall:
1. Complete, with assistance from the CBOSS if needed, any forms required by the
CBOSS as a part of the application process;
2. Assist the CBOSS in securing evidence that corroborates his/her statements;
3. Report promptly any change affecting his or her circumstances
10:71-2.1 Definitions
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. The application process is primarily
geared toward the determination of basic eligibility. However, since intake by its very nature
involves a combination of services and income maintenance functions, a service worker
shall be available as required during such process.
"Applicant," in Medicaid Only, means the aged, disabled or blind individual or his/her
authorized agent who executes the formal written application (PA- 1G).
"Approved" means that the applicant has been determined to be eligible for Medicaid Only.
"CBOSS" means county board of social services.
"Disposition of the application" means the official determination of the CBOSS that one of
the following actions is appropriate: approval or rejection as defined in the section.
"MRT" means Medical Review Team.
"New application" means a written request for assistance from an individual or his/her
agent who has never previously requested assistance in any county in the State under the
Medicaid Only program.
"Pending application" means the general term for application, reapplication, reopened
application or transfer application prior to official disposition.
"Poverty guidelines" means, with respect to a household, the income poverty line as
prescribed and revised at least annually pursuant to 42 U.S.C. § 9902(2). The poverty
guidelines are a simplified version of the Federal Government's statistical poverty thresholds
used by the Census Bureau to prepare its statistical estimates of the number of persons and
families in poverty. The poverty guidelines issued by the Department of Health and Human
Services pursuant to 42 U.S.C. § 9902(2) are used for administrative purposes, for example,
for determining whether a person or family is financially eligible for assistance or services
under a particular Federal program.
"Reapplication" means a written request for assistance by the individual whose previous
application was rejected in any county in the State and who requests reconsideration of
his/her current eligibility for Medicaid Only.
"Registration" means the action of the CBOSS in assigning a control number to an
application.
"Rejected" is an inclusive term (for statistical purposes) for the following actions:
1. Denied means that the applicant has been determined to be ineligible for assistance for
a specific reason.
2. Dismissed means official recognition that eligibility need not be considered further
because:
i. The applicant died (however, if there were unpaid medical bills incurred subsequent to
inquiry or application, whichever occurred first, the application process is to be completed);
or
ii. The applicant cannot be located; or
iii. The application was registered in error; or
iv. The applicant moved to another county in New Jersey during the application process.
3. Withdrawn means that the applicant decided not to pursue the application further.
"Reopened application" means a written request by a former beneficiary in any county in
the State for reconsideration of his or her current eligibility for the program.
"Transfer application" means a written request for assistance by the individual who at the
time of registration is still receiving assistance through the CBOSS of another county from
which he or she moved.
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. The application process is primarily
geared toward the determination of basic eligibility. However, since intake by its very nature
involves a combination of services and income maintenance functions, a service worker
shall be available as required during such process.
"Applicant," in Medicaid Only, means the aged, disabled or blind individual or his/her
authorized agent who executes the formal written application (PA- 1G).
"Approved" means that the applicant has been determined to be eligible for Medicaid Only.
"CBOSS" means county board of social services.
"Disposition of the application" means the official determination of the CBOSS that one of
the following actions is appropriate: approval or rejection as defined in the section.
"MRT" means Medical Review Team.
"New application" means a written request for assistance from an individual or his/her
agent who has never previously requested assistance in any county in the State under the
Medicaid Only program.
"Pending application" means the general term for application, reapplication, reopened
application or transfer application prior to official disposition.
"Poverty guidelines" means, with respect to a household, the income poverty line as
prescribed and revised at least annually pursuant to 42 U.S.C. § 9902(2). The poverty
guidelines are a simplified version of the Federal Government's statistical poverty thresholds
used by the Census Bureau to prepare its statistical estimates of the number of persons and
families in poverty. The poverty guidelines issued by the Department of Health and Human
Services pursuant to 42 U.S.C. § 9902(2) are used for administrative purposes, for example,
for determining whether a person or family is financially eligible for assistance or services
under a particular Federal program.
"Reapplication" means a written request for assistance by the individual whose previous
application was rejected in any county in the State and who requests reconsideration of
his/her current eligibility for Medicaid Only.
"Registration" means the action of the CBOSS in assigning a control number to an
application.
"Rejected" is an inclusive term (for statistical purposes) for the following actions:
1. Denied means that the applicant has been determined to be ineligible for assistance for
a specific reason.
2. Dismissed means official recognition that eligibility need not be considered further
because:
i. The applicant died (however, if there were unpaid medical bills incurred subsequent to
inquiry or application, whichever occurred first, the application process is to be completed);
or
ii. The applicant cannot be located; or
iii. The application was registered in error; or
iv. The applicant moved to another county in New Jersey during the application process.
3. Withdrawn means that the applicant decided not to pursue the application further.
"Reopened application" means a written request by a former beneficiary in any county in
the State for reconsideration of his or her current eligibility for the program.
"Transfer application" means a written request for assistance by the individual who at the
time of registration is still receiving assistance through the CBOSS of another county from
which he or she moved.
10:71-1.11 Availability of chapter
(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 chapter up-to-date will
have a copy available under their regulations.
(c) Each legal services office will be furnished with a copy of this chapter free of charge.
(d) Welfare, social service and other non-profit organizations will be furnished with a copy
of the chapter at no cost by an official written request to the Division of Medical Assistance
and Health Services.
(e) All supplementary State policy directives will routinely be sent to those who have been
supplied with the chapter. A mailing list will be maintained by the Division.
(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 chapter up-to-date will
have a copy available under their regulations.
(c) Each legal services office will be furnished with a copy of this chapter free of charge.
(d) Welfare, social service and other non-profit organizations will be furnished with a copy
of the chapter at no cost by an official written request to the Division of Medical Assistance
and Health Services.
(e) All supplementary State policy directives will routinely be sent to those who have been
supplied with the chapter. A mailing list will be maintained by the Division.
10:71-1.8 County board of social services responsibility; chapter
The director of the CBOSS 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.
The director of the CBOSS 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.
10:71-1.6 Basic principles of administration
(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 appropriate application form.
2. The applicants or beneficiaries are the primary source of information. However, it is the
responsibility of the agency to make the determination of eligibility and to use secondary
sources when necessary, with the applicant's knowledge and consent.
3. No duplication of assistance: No beneficiary of Medicaid Only shall receive, during the
same period, any other medical assistance from the State or any political subdivision thereof
with respect to any maintenance requirements or other need for which allowance is made in
the Medicaid Only program (see N.J.A.C. 10:71-3.14 regarding inmates of correctional
institutions). The food stamp program is not considered a duplication of public assistance.
4. There shall be strict adherence to law and complete conformity with administrative
policies. Requirements other than those established by law or regulations shall not be
imposed on any person as a condition of receiving medical assistance.
5. The applicants or beneficiaries shall have the right to request appeal on the action or
inaction of the agency whenever they believe that they have not been given full
consideration under the law. A fair hearing shall be conducted by an impartial official of the
Department of Human Services in accordance with prescribed procedure when:
i. An application for Medicaid Only is denied;
ii. An application for Medicaid Only is not acted upon by the county welfare board within
30 days for the aged and 60 for the disabled or blind; or
iii. Medicaid Only is terminated.
6. Information about applicants and beneficiaries and their circumstances shall not be
disclosed except as required for the proper and efficient administration of the program and
only to those agencies involved in the lawful administration or operation of public welfare
functions or services.
7. There shall be no discrimination on grounds of race, color, religion, sex, national origin
or marital, parental or birth status by state or local agencies in the administration of any
public assistance program.
10:71-1.7 Examination or review of chapter
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 CBOSS office for examination or
review during regular office hours on regular work days.
(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 appropriate application form.
2. The applicants or beneficiaries are the primary source of information. However, it is the
responsibility of the agency to make the determination of eligibility and to use secondary
sources when necessary, with the applicant's knowledge and consent.
3. No duplication of assistance: No beneficiary of Medicaid Only shall receive, during the
same period, any other medical assistance from the State or any political subdivision thereof
with respect to any maintenance requirements or other need for which allowance is made in
the Medicaid Only program (see N.J.A.C. 10:71-3.14 regarding inmates of correctional
institutions). The food stamp program is not considered a duplication of public assistance.
4. There shall be strict adherence to law and complete conformity with administrative
policies. Requirements other than those established by law or regulations shall not be
imposed on any person as a condition of receiving medical assistance.
5. The applicants or beneficiaries shall have the right to request appeal on the action or
inaction of the agency whenever they believe that they have not been given full
consideration under the law. A fair hearing shall be conducted by an impartial official of the
Department of Human Services in accordance with prescribed procedure when:
i. An application for Medicaid Only is denied;
ii. An application for Medicaid Only is not acted upon by the county welfare board within
30 days for the aged and 60 for the disabled or blind; or
iii. Medicaid Only is terminated.
6. Information about applicants and beneficiaries and their circumstances shall not be
disclosed except as required for the proper and efficient administration of the program and
only to those agencies involved in the lawful administration or operation of public welfare
functions or services.
7. There shall be no discrimination on grounds of race, color, religion, sex, national origin
or marital, parental or birth status by state or local agencies in the administration of any
public assistance program.
10:71-1.7 Examination or review of chapter
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 CBOSS office for examination or
review during regular office hours on regular work days.
10:71-1.5 Administrative organization
The Medicaid Only program is administered by the county boards of social services
(CBOSS) of the State of New Jersey through the Division of Medical Assistance and Health
Services in the Department of Human Services. The CBOSSs contract with the Division of
Medical Assistance and Health Services for the purpose of providing Medicaid Only benefits
to eligible persons.
The Medicaid Only program is administered by the county boards of social services
(CBOSS) of the State of New Jersey through the Division of Medical Assistance and Health
Services in the Department of Human Services. The CBOSSs contract with the Division of
Medical Assistance and Health Services for the purpose of providing Medicaid Only benefits
to eligible persons.
10:71-1.4 Information on the chapter
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
applicable to "Medicaid Only." The criteria for determination of eligibility are based on SSI
policy and procedure which do not necessarily coincide with standards for other public
assistance programs and therefore require separate instructions.
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
applicable to "Medicaid Only." The criteria for determination of eligibility are based on SSI
policy and procedure which do not necessarily coincide with standards for other public
assistance programs and therefore require separate instructions.
10:71-1.3 Living arrangements
(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 qualify for SSI may be eligible for
Medicaid Only.
(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 qualify for SSI may be eligible for
Medicaid Only.
10:71-1.2 Choice of program by applicant
(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 chapter.
(b) Persons who are neither aged, blind nor disabled qualify for Medicaid benefits when
they are determined by the county board of social services to be eligible for AFDC-related
Medicaid program. Persons whose eligibility is thus established may choose to receive
Medicaid Only benefits without accepting money payments. Regulations governing these
programs are set forth in the AFDC- related Medicaid chapter (N.J.A.C. 10:69).
(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 chapter.
(b) Persons who are neither aged, blind nor disabled qualify for Medicaid benefits when
they are determined by the county board of social services to be eligible for AFDC-related
Medicaid program. Persons whose eligibility is thus established may choose to receive
Medicaid Only benefits without accepting money payments. Regulations governing these
programs are set forth in the AFDC- related Medicaid chapter (N.J.A.C. 10:69).
10:71-1.1 General introduction
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 provides cash payments to the aged, blind and disabled. Individuals who desire
medical care only apply through the county board of social services for the Medicaid Only
program under Title XIX.
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 provides cash payments to the aged, blind and disabled. Individuals who desire
medical care only apply through the county board of social services for the Medicaid Only
program under Title XIX.
Sunday, June 14, 2009
ELDER LAW & ESTATE ADMINISTRATION BOOK AND AUDIO FOR SALE
Book elder law & estate administration including:
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• Living Trusts (Revocable/Irrevocable) as an Estate Planning Tool Why it should be used; disadvantages; revocable vs. irrevocable; Insurance Trusts; sample forms
• Basic Tax Considerations Jointly-held property; “I love you” Will; no Will at all; insurance owned by client; unlimited marital deduction; estate planning in the testamentary document; sample forms/letters
• Estate Administration - New Probate Law in New Jersey Probate process; duties of executor/fiduciary; gathering of assets; tax returns; tax waivers; access to property; sample forms/checklists
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Speakers:
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KENNETH A. VERCAMMEN, ESQ.
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MARTIN A. SPIGNER, ESQ.
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Book elder law & estate administration including:
• Why Have a Will? Gathering information; standard provisions; designation of fiduciaries; protective clauses; sample forms; Ethics - who is the client?
• Powers of Attorney Types of POAs; what should be included; why clients need them; POAs and Living Wills; sample forms
• Living Trusts (Revocable/Irrevocable) as an Estate Planning Tool Why it should be used; disadvantages; revocable vs. irrevocable; Insurance Trusts; sample forms
• Basic Tax Considerations Jointly-held property; “I love you” Will; no Will at all; insurance owned by client; unlimited marital deduction; estate planning in the testamentary document; sample forms/letters
• Estate Administration - New Probate Law in New Jersey Probate process; duties of executor/fiduciary; gathering of assets; tax returns; tax waivers; access to property; sample forms/checklists
• Medicaid Planning in Light of Federal Medicaid Reform Countable assets of Medicaid applicant; income cap/Medical needy standard; look-back period; transfers of property; personal residence; Medicaid estate recovery rules …and more
This practical program is designed to provide the nuts and bolts of elder law practice & estate administration practice to general practitioners and young lawyers, as well as to more experienced estate planners and professionals who help senior citizens. You’ll also gain insight on how Federal Medicaid Reform will impact seniors.
Speakers:
THOMAS D. BEGLEY, JR., ESQ.,
KENNETH A. VERCAMMEN, ESQ.
Chair, ABA Estate Planning & Probate Law Committee
2006 NJSBA Municipal Court Practitioner of the Year
KATHLEEN A. SHERIDAN, ESQ.
MARTIN A. SPIGNER, ESQ.
Handbook 45.00 [$36 NJSBA Member Price] pages ] Item M57809
Handbook with Audio CD $189 [$149 NJSBA Member Price Item CDP57809
*NJSBA Member Price – To qualify for this reduced price, you must provide your NJSBA Member# at the time you place your order
Contact: New Jersey Institute for Continuing Legal Education (732)214-8500
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