10:71-4.10 Transfer of assets
(a) The provisions of this section shall apply, effective June 18, 2001, only to persons who
are receiving an institutional level of services, including individuals who are receiving
services under a 42 U.S.C. § 1915(c) home and community care waiver under Medicaid, or
who are seeking that level of service, and who have transferred assets on or after August
11, 1993. An individual shall be ineligible for institutional level services through the Medicaid
program if he or she (or his or her spouse) has disposed of assets at less than fair market
value at any time during or after the 36 month period, or the 60 month period in the case of
a transfer to a trust, immediately before:
1. In the case of an individual who is already eligible for Medicaid benefits, the date the
individual becomes an institutionalized individual; or
2. In the case of an individual not already eligible for Medicaid benefits, the date the
individual applies for Medicaid as an institutionalized individual.
(b) The following definitions shall apply to the transfer of assets:
1. Individual means:
i. The individual him or herself who is applying for benefits;
ii. The individual's spouse;
iii. A person, including a court or administrative body, with legal authority to act in place of
or on behalf of the individual or the individual's spouse;
iv. Any person including a court or administrative body, acting at the direction or upon the
request of the individual or the individual's spouse.
2. An institutionalized individual, for the purposes of this chapter, is a person who is
receiving care in a Medicaid certified nursing facility, intermediate care facility for the
mentally retarded (ICFMR), or a licensed special hospital (Class C) or Title XIX psychiatric
hospital (if under the age of 21 or age 65 and over). For purposes of this chapter, an
institutionalized individual shall also include a person seeking benefits under a home or
community care waiver program. An institutionalized individual shall not include a person
who is receiving care in an acute care general hospital.
3. Assets shall include all income and resources of the individual and of the individual's
spouse. Assets shall also include income and resources which the individual or the
individual's spouse is entitled to but does not receive because of action or inaction by the
individual or the individual's spouse; or by any person, including a court or administrative
body with the legal authority to act in place of or on behalf of the individual or the individual's
spouse; or any person, including a court or administrative body, acting at the direction of or
upon the request of the individual or the individual's spouse. Examples of actions that would
cause income or resources not to be received shall include, but shall not be limited to:
i. Irrevocably waiving pension income;
ii. Waiving the right to receive an inheritance, including spousal elective share pursuant to
N.J.S.A. 3B:8-10;
iii. Not accepting or accessing injury settlements;
iv. Tort settlements which are diverted by the defendant into a trust or similar device to be
held for the benefit of an individual who is a plaintiff; and
v. Refusal to take legal action to obtain a court ordered payment that is not being paid,
such as child support or alimony.
4. Resources, for the purpose of asset transfer, shall include all resources, both included
and excluded, in accordance with the provisions of this chapter. For example, the transfer of
a home, even if it is serving as the individual's principal place of residence, shall be subject
to the transfer of assets provisions.
5. Income, for the purposes of this section, shall have the same definition as found in
N.J.A.C. 10:71-5. In determining whether a transfer of assets involves countable income,
the income disregards in N.J.A.C. 10:71-5 shall be applied.
6. Fair-market value shall be an estimate of the value of an asset, based on generally
available market information, if sold at the prevailing price at the time it was actually
transferred. Value shall be based on the criteria for evaluating assets as found in N.J.A.C.
10:71-4.1(d).
i. In determining whether or not an asset was transferred for fair-market value, only
tangible compensation, with intrinsic value shall be considered. For example, a transfer for
"love and affection" shall not be considered a transfer for fair market value.
ii. In regard to transfers intended to compensate a friend or relative for care or services
provided in the past, care and services provided for free at the time they were delivered
shall be presumed to have been intended to be delivered without compensation. In regard
to transfers allegedly intended to compensate a friend or a relative for care or services that
were provided in the past, care and services provided for free at the time they were
delivered shall be presumed to have been intended to be delivered without compensation.
Thus, a transfer of assets to a friend or relative for the alleged purpose of compensating for
care or services provided free in the past shall be presumed to have been transferred for no
compensation. This presumption may be rebutted by the presentation of credible
documentary evidence preexisting the delivery of the care or services indicating the type
and terms of compensation. Further, the amount of compensation or the fair market value of
the transferred asset shall not be greater than the prevailing rates for similar care or
services in the community. That portion of compensation in excess of the prevailing rate
shall be considered to be uncompensated value.
iii. Under a life estate, an individual who owns property transfers the ownership of that
property to another individual, while retaining for the rest of his or her life, or the life of
another person, certain rights to that property. A life estate entitles the owner of the life
estate to possess, use, and obtain profits from the property as long as he or she lives,
although actual ownership of the property has passed to another individual. In a transaction
involving a life estate, a transfer of assets is involved. In determining whether a penalty shall
be assessed in the case of a transfer involving a life estate, the value of the asset
transferred and the value of the life estate shall be computed. The value of the asset
transferred is computed by determining the fair market value. The value of the life estate is
calculated in accordance with the life estate table published by the Health Care Financing
Administration (HCFA) at 49 FR Vol. 49 No. 93, 5-11-84 and 26 C.F.R. 20.2031-7. The
value of the life estate is determined by multiplying the current market value of the property
by the life estate factor that corresponds to the grantor's age. The value of the life estate is
then subtracted from the value of the asset transferred to determine the portion of the asset
that was transferred for less than fair market value. If only the value of the transferred
portion is needed, the current market value of the asset is multiplied by the remainder factor.
The transfer in which a life estate is retained shall be considered a transfer for less than fair
market value whenever the value of the asset transferred is greater than the value of the
rights conferred by the life estate.
7. Uncompensated value (UV) shall be the difference between the fair market value at the
time of the transfer (less any outstanding loans, mortgages or other encumbrances on the
asset) and the amount of consideration received for the asset. If the asset was jointly owned
before disposal, the UV considered shall be only the individual's share of that value (see
N.J.A.C. 10:71- 4.1(d)). If the individual is seeking institutional services or applying for an
institutional level of services and has a spouse residing in the community, the UV
considered shall be either spouse's share of that value (see N.J.A.C. 10:71-4.8).
8. In order for a transfer of assets to be considered to be for the sole benefit of a spouse,
disabled child, or disabled individual under the age of 65, for the purposes of this
subchapter, the transfer shall have been arranged in such a way that no individual except
the spouse, disabled child, or disabled individual under age 65 can, in any way, benefit from
the assets transferred either at the time of the transfer, or at any time in the future. For the
purpose of this subchapter, the person administering the funds shall only be compensated
for the reasonable costs that can be directly attributable to the administration of the funds
and for compensation for that administration. In no event shall such compensation exceed
the amounts allowed by law for the administration of trusts. The transfer of asset penalty
exemption for transfers made for the sole benefit of the spouse, disabled child or disabled
individual under the age of 65 does not impact the treatment of trust pursuant to N.J.A.C.
10:71-4.11.
i. If the transfer instrument provides that there are beneficiaries other than a blind or
disabled child, or a disabled individual under the age of 65, the sole benefit requirement
shall not have been met if the instrument fails to provide that the State shall be the first
remaining beneficiary of residual funds prior to disbursement to any other beneficiary.
9. The look-back period shall be either 36 or 60 months, in accordance with the following:
i. In the case of an individual who is already eligible for Medicaid benefits, the 36-month
period prior to the date the individual becomes institutionalized.
ii. In the case of an individual not already eligible for Medicaid benefits, the 36-month
period prior to the date the individual applied for Medicaid as an institutionalized individual.
iii. When a portion of a trust is treated as a transfer, the look-back period shall be
extended to 60 months from the date the individual applied for Medicaid as an
institutionalized individual, or for a non-institutionalized individual, the date the individual
applied for Medicaid, or, if the date the transfer was made is later, then the date the transfer
was made (see N.J.A.C. 10:71-4.11(e)1iii).
iv. Penalties of ineligibility shall be assessed for transfers which take place during or after
the look-back period. Periods of ineligibility cannot be imposed for resource transfers which
take place prior to the look-back period.
(c) If an individual or his or her spouse described in (a) above (including any person acting
with power of attorney or as a guardian for such individual) has sold, given away, or
otherwise transferred any assets (including any interest in an asset or future rights to an
asset) within the look-back period, the following steps shall be taken and shall be fully
documented in the case record:
1. The fair market value (FMV) of the asset shall be ascertained;
2. The amount of compensation received by the individual for the transfer shall be
determined. The uncompensated value (UV), if any, shall be determined by subtracting the
FMV from the amount of compensation received;
3. The amount of the UV, if any, shall be added to the amount of the other countable
resources;
4. The period of ineligibility for institutional level services that would result from the asset
transfer shall be determined (see N.J.A.C. 10:71- 4.10(l));
5. In all cases where the amount of uncompensated value would result in a period of
ineligibility, the applicant shall be notified of the determination via Form PA-13. The Form
PA-13 shall advise the applicant that he or she may rebut the presumption that an asset
was transferred at less than fair market value in order to qualify for Medicaid coverage for
institutional level care (see (i) below).
(d) The provisions of this section shall apply whether or not the asset would have been
considered excluded or exempt at the time of its disposal or transfer. However, an individual
shall not be ineligible for an institutional level of care because of the transfer of his or her
equity interest in a home which serves (or served immediately prior to entry into institutional
care) as the individual's principal place of residence and the title to the home was
transferred to:
1. The legally married spouse of the individual;
2. A child of the institutionalized individual who is under the age of 21 or a child of any age
who is blind or totally and permanently disabled. In the event that the child does not have a
determination from the Social Security Administration of blindness or disability, the
blindness or disability shall be evaluated by the Disability Review Team of the Division of
Medical Assistance and Health Services, in accordance with N.J.A.C. 10:71-3.13;
3. A brother or sister of the institutionalized individual who already had an equity interest in
the home prior to the transfer and who was residing in the home for a period of at least one
year immediately before the individual becomes an institutionalized individual; or
4. A son or daughter of the institutionalized individual (other than described in (d)2 above)
who was residing in the individual's home for a period of at least two years immediately
before the date the individual becomes an institutionalized individual and who has provided
care to such individual which permitted the individual to reside at home rather than in an
institution or facility.
i. The care provided by the individual's son or daughter for the purposes of this
subchapter shall have exceeded normal personal support activities (for example, routine
transportation and shopping). The individual's physical or mental condition shall have been
such as to require special attention and care. The care provided by the son or daughter
shall have been essential to the health and safety of the individual and shall have consisted
of activities such as, but not limited to, supervision of medication, monitoring of nutritional
status, and insuring the safety of the individual.
(e) The application of a transfer penalty as set forth in this section shall not apply when:
1. The assets were transferred to a trust established for the sole benefit of an individual
under 65 years of age who is disabled as defined by the Social Security Administration;
2. The assets were transferred to the individual's spouse or to another for the sole benefit
of the individual's spouse;
3. The assets were transferred from the individual's spouse to another for the sole benefit
of the individual's spouse (see N.J.A.C. 10:71-4.10(b) 7);
4. The assets were transferred to the community spouse subsequent to the application for
Medicaid in accordance with N.J.A.C. 10:71-4.8(a)3; or
5. The assets were transferred from the individual or individual's spouse to the individual's
child who is blind or permanently and totally disabled.
i. In the event that the child does not have a determination from the Social Security
Administration of blindness or disability, the blindness or disability will be evaluated by the
Disability Review Unit of the Division of Medical Assistance and Health Services in
accordance with the provisions of N.J.A.C. 10:71-3.13.
(f) In determining whether an asset was transferred for the sole benefit of a spouse, child or
disabled individual as defined in N.J.A.C. 10:71-4.10(b) 8, the transfer shall be
accomplished via a written instrument of transfer, such as a trust document, which legally
binds the parties to a specific course of action and which clearly sets out the conditions
under which the transfer was made, as well as who can benefit from the transfer. Moreover,
the written instrument shall state that the State of New Jersey shall be the first remaining
beneficiary. A transfer without such a document shall not be considered to have been made
for the sole benefit of the spouse, child or disabled individual.
(g) When the asset was transferred at fair market value, the application shall be processed
as usual. No special procedure shall be required.
(h) When the uncompensated value of transferred assets would result in no period of
ineligibility for long-term care level services, the application shall be processed as usual.
(i) When the uncompensated value of transferred assets results in a period of ineligibility for
long-term care level services, eligibility for long-term care services shall be denied and the
procedures below shall be followed:
1. The applicant shall be notified via Form PA-13 that there has been a transfer of assets
for less than fair market value, the amount of the uncompensated value and the length of
the penalty period. The Form PA-13 shall state that the law presumes that a transfer of
assets at less than fair market value is for the purpose of establishing Medicaid eligibility for
long-term level care services.
2. The applicant shall be advised that he or she may rebut the presumption that the
transfer of assets was for the purpose of establishing Medicaid eligibility (see (j) below).
(j) Any applicant or beneficiary may rebut the presumption that assets were transferred to
establish Medicaid eligibility by presenting convincing evidence that the assets were
transferred exclusively (that is, solely) for some other purpose. The applicant shall be
assisted in obtaining information when necessary. However, the burden of proof shall rest
with the applicant. When the applicant expresses the desire to rebut the presumption that
he or she transferred assets to establish Medicaid eligibility, the procedures below shall be
followed.
1. The applicant's statement concerning the circumstances of the transfer shall be included
in the case record. The statement shall include, but need not be limited to, the following:
i. The applicant's stated purpose for transferring the asset;
ii. The applicant's attempt to dispose of the asset at fair market value;
iii. The applicant's reasons for accepting less than the fair market value for the asset;
iv. The applicant's means of and plans for, supporting himself or herself after the transfer;
and
v. The applicant's relationship, if any, to the person(s) to whom the asset was transferred.
2. The applicant shall be asked to submit any pertinent evidence (for example, legal
documents, realtor agreements, and relevant correspondence) with regard to the transfer.
3. Statements shall be taken from other individuals, if such statements are material to the
decision. The statement shall indicate if such individual has or had a relationship with the
applicant and the extent of the relationship (that is, related by blood or marriage, friendship).
(k) The presence of one or more of the following factors, while not conclusive, may indicate
that the assets were transferred exclusively for some purpose other than establishing
Medicaid eligibility for long term care services:
1. The occurrence after transfer of the asset of:
i. Traumatic onset of disability;
ii. Unexpected loss of other assets which would have precluded Medicaid eligibility; or
iii. Unexpected loss of income which would have precluded Medicaid eligibility;
2. Court-ordered transfer (when the court is not acting on behalf of, or at the direction of,
the individual or the individual's spouse); or
3. Evidence of good faith effort to transfer the asset at fair market value.
(l) Agency determination pursuant to client rebuttal shall be as follows:
1. The presumption that assets were transferred to establish Medicaid eligibility shall be
considered successfully rebutted only if the applicant demonstrates that the asset was
transferred exclusively for some other purpose.
2. If the applicant had some other purpose for transferring the asset, but establishing
Medicaid eligibility appears to have been a factor in his or her decision to transfer, the
presumption shall not be considered successfully rebutted.
3. The agency's determination shall not include an evaluation of the merits of the
applicant's stated purpose of transferring assets. The determination shall only deal with
whether or not the applicant has proven that the transfer was solely for some purpose other
than establishing Medicaid eligibility.
4. The final determination regarding the purpose of the transfer shall be made at a
supervisory level at the county board of social services and shall be documented in the case
record.
5. The applicant shall be sent a notice of the decision, which shall include information on
his or her right to a fair hearing in accordance with N.J.A.C. 10:49-10.
(m) For the purposes of this subchapter, the penalty period shall be the period of time
during which payment for long-term care level services is denied. An institutionalized
individual who is ineligible for payment of long-term care services as a result of an asset
transfer shall be precluded from eligibility, but shall be entitled to ancillary services if
otherwise eligible.
1. In accordance with 42 U.S.C. § 1396p(c)(1)(E), the penalty period for asset transfer
shall be the number of months equal to the total, cumulative uncompensated value of all
assets transferred by the individual, on or after the look-back date, divided by the average
monthly cost of nursing home services in the State of New Jersey adjusted annually in
accordance with the change in the Consumer Price Index-All Urban Consumers, rounded up
to the nearest dollar. The annual adjustment to the average monthly cost of nursing home
services in New Jersey shall be published as a notice of administrative change in the New
Jersey Register. As of November 2003, the average cost is $6,050. The result of this
division shall be rounded down. The penalty period shall begin with the month of the
resource transfer. There shall be no limit on the length of the penalty period.
i. For the purpose of determining a penalty period, the transfer of real property shall be
considered to have occurred the date the title is recorded or registered with the appropriate
office.
2. In the case of an asset transfer which occurs during an existing asset transfer penalty
period, the penalty for the subsequent transfer shall not begin until the expiration of the
previous penalty period.
3. When assets have been transferred in amounts and/or frequencies that would make the
calculated penalty periods overlap or structured to run consecutively, the uncompensated
value of all the asset transfers shall be added together and divided by the average cost of
nursing home care. This will result in a single penalty period, beginning on the first day of
the month in which the first transfer was made. For example: An individual transfers $15,000
in January, $15,000 in February, and $15,000 in March. Calculated individually, the penalty
periods would overlap. Because the three penalty periods overlap, each of the asset
transfers shall be added together and divided by the average cost of nursing home care
creating a single penalty period beginning on January 1.
4. When assets have been transferred in such a way that the penalty periods would not
overlap, or are not structured to run consecutively, each asset transfer shall be treated as a
separate event, each with its own penalty period. For example: An individual transfers
$15,000 in January, $15,000 in November and $15,000 in March of the following year. The
penalty period for the January transfer would be January and February. The penalty for the
November transfer would be November and December. The penalty period for the March
transfer would be March and April of the following year.
(n) When an individual's income is given or assigned in some manner, such gift or
assignment shall be considered an asset transfer. The following standards shall be used to
determine the penalty period:
1. Income, in order to be considered transferred, shall have been irrevocably assigned or
otherwise unavailable to the individual. If income has been waived or deferred and that
waiver or deferral can be reversed, the waived or deferred income shall be considered
available to the individual, regardless of whether the income is actually received, and shall
be counted in the determination of eligibility.
2. In the event an individual gives up his or her rights to receive a lump sum payment or
transfers a lump sum payment in the month it is received, the period of ineligibility shall be
based on the amount of the lump sum payment to which he or she was otherwise entitled.
3. In the event a stream of income (that is, income received on a regular basis), such as a
pension, is transferred, the county board of social services shall make a determination of the
total projected amount of income that has been transferred, based on the individual's life
expectancy. This determination shall be based on the most recent life expectancy tables
published by the Health Care Financing Administration. In determining the projected
amount, the county board of social services shall strictly adhere to the life expectancy tables
without adjustment for the individual's medical condition or other factors. The projection
shall be based on the value of the income at the time of transfer and there shall be no
attempt to account for future cost-of-living adjustments over the life expectancy of the
individual.
4. In determining if there has been a transfer of income, the county board of social services
need not ascertain the individual's spending habits over the appropriate look-back period.
Unless there is a reason to believe otherwise, the county board of social services shall
assume that the individual's income was legitimately spent on the normal costs of living. The
county board of social services may ask questions of the applicant and/or the applicant's representative concerning past and present sources and levels of income and whether the
individual has transferred income to others.
(o) When an asset is held by an individual in common with another person or persons via
joint tenancy, tenancy in common, joint ownership, or similar arrangements, the asset (or
the affected share of the asset) shall be considered to be transferred by the individual when
any action is taken, either by the individual or any other person, that reduces or eliminates
the individual's ownership or control of the asset.
1. If the addition of another name to the ownership of an asset does not change the
individual's ownership interest, the action does not constitute a resource transfer. For
instance, if another name is added to an individual's account with the term "or," the
individual shall not be considered to have transferred assets since he or she continues to
have unrestricted access to the funds. In the event the newly added owner subsequently
withdraws the funds from the account, that action shall be considered to be a transfer by the
individual. The transfer shall be considered to have occurred on the date that the funds are
withdrawn from the account.
2. If the addition of another name to the ownership of an asset restricts the individual's
access, right to sell or otherwise dispose of the asset (for example, the addition of another
name requires that the new co-owner(s) agree to the sale or disposal of the asset where no
such agreement was necessary before), the addition of the name shall constitute a transfer
of assets. The transfer shall be considered to have occurred on the date that the additional
name was added to the account. In the case of real property for the purpose of this chapter,
if another name is added to a deed, the transfer shall be considered to have occurred the
date the new deed is recorded.
3. N.J.A.C. 10:71-4.1 shall apply to determine what portion of a jointly owned resource is
presumed to belong to the individual. Any portion belonging to the individual that is
withdrawn by another owner shall be considered a transfer of assets. If the individual can
satisfactorily establish that the withdrawn funds were, in fact, the sole property of, and were
contributed to the account by the other owner, and thus never belonged to the individual,
the withdrawal of those funds shall not result in the imposition of an asset transfer penalty.
(p) Annuity provisions shall be as follows:
1. Any annuity purchase in which the entity issuing the annuity is not a commercial
financial institution shall be considered to be a transfer of an asset in order to qualify for
Medicaid benefits, regardless of the terms of the annuity payout. The entire amount
transferred into such an annuity shall be the amount considered in determining eligibility.
2. Any commercial annuity purchased which is not actuarially sound, based on the life
expectancy of the individual (as set forth in life expectancy tables published by the Health
Care Financing Administration) or term certain (the length of payout is specified and
payment does not terminate upon the death of the annuitant) shall be considered to be a
transfer of an asset in order to qualify for Medicaid benefits. In the event that an annuity is
not actuarially sound at the time of purchase, the amount that shall be considered to have
been transferred at less than fair market value shall be that proportion of the annuity
purchase price which is not actuarially sound. This shall be the same proportion as the
amount by which the pay-out period exceeds the life expectancy of the individual at the time
of the annuity purchase. (Life expectancy divided by the pay-out period of the annuity multiplied by the purchase amount of the annuity is subtracted from the total amount of the
annuity to determine the uncompensated value.)
i. If an annuity is purchased for a community spouse with any portion of the couple's
funds and the annuity purchase price exceeds the amount of the protective share of the
community spouse, as determined in accordance with the procedures specified at N.J.A.C.
10:71-4.8(a), the amount in excess of the community spouse's protected share shall be
counted in determining the applicant's eligibility.
(q) Upon imposition of a period of ineligibility for long-term care level services because of
an asset transfer, the county board of social services shall notify the applicant/beneficiary of
his or her right to request an undue hardship exception. An applicant/beneficiary may apply
for an exception to the transfer of asset penalty if he or she can show that the penalty will
cause an undue hardship to him or herself. The applicant/beneficiary shall provide sufficient
documentation to support the request for an undue hardship waiver to the county board of
social services within 20 days of notification of the transfer penalty.
1. For the purposes of this chapter, undue hardship shall be considered to exist when:
i. The application of the transfer of assets provisions would deprive the
applicant/beneficiary of medical care such that his or her health or his or her life would be
endangered. Undue hardship may also exist when application of the transfer of assets
provisions would deprive the individual of food, clothing, shelter, or other necessities of life;
and
ii. The applicant/beneficiary can irrefutably demonstrate the transferred assets are
beyond his or her control and that the assets cannot be recovered. The
applicant/beneficiary shall demonstrate that he or she made good faith efforts, including
exhaustion of remedies available at law or in equity, to recover the assets transferred.
2. Undue hardship shall not exist when the application of a transfer penalty merely causes
the applicant/beneficiary an inconvenience or restricts his or her lifestyle.
3. In the event that a waiver of undue hardship is denied, neither the Department of
Human Services, the Department of Health and Senior Services, nor the county boards of
social services shall have any obligation to take any action to assure that payment of
services is provided during the penalty period.
4. If the request for undue hardship consideration is denied by the CBOSS, the CBOSS
shall notify the applicant of the denial and that the applicant may request a fair hearing in
accordance with the provisions of N.J.A.C. 10:49- 10.

10:71-4.9 Resource assessment
(a) At the beginning of the first continuous period of institutionalization (beginning on or
after September 30, 1989), the institutionalized spouse or the community spouse (or a
representative of either spouse) may request an assessment of the couple's total countable
resources. The purpose of the assessment is to establish the community spouse's share of
the couple's total countable resources (see N.J.A.C. 10:71-4.8(a)).
(b) The county board of social services shall, upon a request for a resource assessment,
advise the requesting parties of the documentation and verification necessary to make the
assessment. When the necessary documentation and verification is not submitted to the
county board of social services in a timely manner, the requesting parties shall be advised
that the resource assessment cannot be completed. Upon receipt of all relevant
documentation of resources from the couple the county board of social services shall
establish the total countable resources of the couple. The county board of social services
shall notify both members of the couple of the total value assigned to their combined
countable resources and the community spouse's share of those resources. A copy of the
notice shall be retained at the county board of social services.
1. The county shall complete the resource assessment and notify the requesting parties of
its results within 45 calendar days of the request unless third party verification has not been
received by the county board of social services or the requesting parties request a delay.
(c) At the time of providing the couple with a copy of the resource assessment, the county
board of social services shall advise the couple that there is no immediate right to a fair
hearing on the county's resource assessment, but that there will be an opportunity to appeal
the findings of the assessment when and if the institutionalized spouse applies for Medicaid.

10:71-4.8 Institutional eligibility; resources of a couple
(a) In the determination of resource eligibility for an individual requiring long-term care, the
county board of social services shall establish the combined countable resources of a
couple as of the first period of continuous institutionalization beginning on or after
September 30, 1989. This determination shall be made upon request for a resource
assessment in accordance with N.J.A.C. 10:71-4.9 or at the time of application for Medicaid
benefits. The total countable resources of the couple shall include all resources owned by
either member of the couple individually or together. The county board of social services
shall establish a share of the resources to be attributed to the community spouse in
accordance with this section. (No community spouse's share of resources may be
established if the institutionalized individual's current continuous period of institutionalization
began at any time before September 30, 1989.)
1. The community spouse's share of the couple's combined countable resources is based
on the couple's countable resources as of the first moment of the first day of the month of
the current period of institutionalization beginning on or after September 30, 1989 and shall
not exceed $92,760, as indexed annually in accordance with 42 U.S.C. § 1396r-5(g) and
published as a notice in the New Jersey Register, and unless authorized in (a)4 or 5 below.
The community spouse's share of the couple's resources shall be the greater of:
i. $18,552, as indexed annually in accordance with 42 U.S.C. § 1396r-5(g) and published
as a notice in the New Jersey Register; or
ii. One half of the couple's combined countable resources.
2. In determining the resource eligibility of the institutionalized spouse, the community
spouse's share of the resources is subtracted from couple's total combined resources as of
the first moment of the first day of the month of application for Medicaid. If the remaining
resources are less than or equal to $2,000, the institutionalized spouse is resource eligible.
If the remaining resources exceed $2,000, eligibility may not be established.
i. In the case of an individual whose eligibility for institutional care is determined in
accordance with the rules applicable for New Jersey Care (see N.J.A.C. 10:72 et seq.),
resource eligibility will exist when the couple's combined resources, less the community
spouse's share of the resources, are equal to or less than $4,000.
3. To the extent that the community spouse's share of the combined resources are not
already owned by the community spouse, the ownership of the community spouse's share
of the resources must be transferred to the community spouse within 90 days of a
determination of eligibility for institutional Medicaid services. The CBOSS may extend the
transfer period if individual circumstances warrant a longer period to affect the transfer.
Resources not transferred by the end of the 90-day period (or extension) shall be counted in
the determination of eligibility for the institutionalized individual.
i. Eligibility for the institutionalized individual shall be established pending the actual
transfer of the resources if he or she attests, in writing, that he or she intends to transfer the
community spouse's share of the resources to the community spouse.
4. If a court of competent jurisdiction has ordered that resources be transferred to the
community spouse in an amount higher than that authorized in (a)1 above, the higher courtordered
amount shall be recognized as the community spouse's share. Any resource
transferred under such a court order shall not be subject to the resource transfer penalty
described at N.J.A.C. 10:71-4.7.
5. If, in accordance with N.J.A.C. 10:71-5.7(d), additional resources have been authorized
to be set aside for the community spouse in order to provide for a sufficient income
maintenance level, such additional resources are not subject to the limitation in this section
on the community spouse's share of the couple's combined resources. Any resource
transferred to the community spouse under this provision shall not be subject to the
resource transfer provision described at N.J.A.C. 10:71-4.7.
6. For purposes of this section, an institutionalized individual does not include any
individual who is not likely to remain in a Title XIX facility for a period of 30 consecutive
days. If a physician has not certified that the individual's stay in the facility is expected to be
a period of 30 or more consecutive days, that individual's Medicaid eligibility will be
determined as if he or she continued to reside in the community until he or she has been in
a Title XIX facility (or a combination of Title XIX facilities) for a period of 30 consecutive
days.
7. For purposes of this section, a continuous period of institutionalization means 30
consecutive days of institutional care in a medical institution, and/or Medicaid funded home
and community-based waiver services. Continuity is broken by absences from the
institution for 30 consecutive days or the non-receipt of home or community based services
for 30 consecutive days.
8. For purposes of determining the community spouse's share of the couple's resources
only, countable resources of a couple shall include all resources not subject to exclusion
under N.J.A.C. 10:71-4.4, except that one automobile shall be excluded without regard to
the dollar limits set forth at N.J.A.C. 10:71-4.4(b)2 and personal effects and household
goods shall be excluded without regard to the dollar limits set forth at N.J.A.C. 10:71-
4.4(b)3.
9. In determining retroactive eligibility (the three-month period immediately preceding the
month of application) based on the first Medicaid application in a continuous period of
institutionalization, the community spouse's share of the resources shall be deducted from
the couple's combined total resources. If the institutionalized individual subsequently files
another Medicaid application for the same continuous period of institutionalization,
retroactive eligibility will be based on all resources actually owned by the institutionalized individual.

10:71-4.7 Transfer of resources
(a) The provisions of this section shall apply only to persons who are receiving an
institutional level of services, including individuals who are receiving services under a 42
U.S.C. § 1915(c) home and community care waiver under Medicaid, or who are seeking
that level of services and who have transferred resources, except as specified in N.J.A.C.
10:71-4.10. An individual shall be ineligible for institutional level services through the
Medicaid program if he or she (or his or her spouse) has disposed of resources at less than
fair market value at any time during or after the 36 month period immediately before:
1. In the case of an individual who is already eligible for Medicaid benefits, the date the
individual becomes an institutionalized individual; or
2. In the case of an individual not already eligible for Medicaid benefits, the date that the
individual applies for Medicaid as an institutionalized individual.
(b) The following definitions shall apply in situations regarding the transfer of resources:
1. Fair market value: The fair market value (FMV) is equal to the current market value at
the time of resource disposal. The FMV shall be determined in accordance with the
evaluation instructions set forth in N.J.A.C. 10:71- 4.1(d).
2. Uncompensated value: The uncompensated value (UV) is the difference between the
FMV of a nonexcludable resource (less any encumbrances) and the compensation received
by the individual. If the resource was jointly owned before disposal, the UV considered is
only the individual's share of that value (see N.J.A.C. 10:71-4.1(d)).
3. Institutionalized individual: An institutionalized individual for the purposes of this
section is a person who is receiving care in a Medicaid certified skilled nursing facility,
intermediate care facility (level A or B and ICFMR) and licensed special hospital (Class B or
C) or Title XIX psychiatric hospital (if under the age of 21 or age 65 and over). Effective
October 1, 1990, an institutionalized individual shall include an individual receiving care in a
Medicaid certified nursing facility (NF). For the purposes of this section, an institutionalized
individual shall include a person seeking benefits under a home or community care waiver
program, not including the Home Care Expansion Program. An institutionalized individual
shall not include a person who is receiving care in an acute care general hospital.
4. Penalty period: The penalty period is the period of ineligibility for Medicaid coverage for
institutional level care established for an individual as a result of the transfer of a resource
for less than fair market value. The penalty period begins with the month of the resource
transfer and is the lesser of:
i. 30 months; or
ii. The number of months resulting from dividing the uncompensated value of the
transferred resource by statewide monthly average lowest semi-private room rate for
Medicaid certified nursing facilities as calculated annually. The current average through
December 31, 1990 is $3,376.
(c) General procedures: If an individual or his or her spouse described in (a) above
(including any person acting with power of attorney or as a guardian for such individual) has
sold, given away, or otherwise transferred any resources (including any interest in a
resource or future rights to a resource) within the 30 months preceding the date of
application or entry into institutional care, the following steps shall be taken and fully
documented in the case record:
1. Ascertain and document the FMV of the resource.
2. Document the amount of compensation received by the individual for the transfer.
3. Determine the UV, if any.
4. Add the amount of the UV, if any, to the amount of other countable resources.
5. Notify the applicant, in all cases when any amount of UV is established, of the
determination via Form PA-13 before the application is approved or denied.
6. Advise the applicant that he or she may rebut the presumption that a resource was
transferred at less than FMV in order to qualify for Medicaid coverage for institutional care
(see (i) below).
(d) The provisions of this section apply whether or not the resource would have been
considered an excluded resource at the time of its disposal or transfer. However, an
individual shall not be ineligible for an institutional level of care because of the transfer of his
or her equity interest in a home which serves (or served immediately prior to entry into
institutional care) as the individual's principal place of residence and the title to the home
was transferred to:
1. The institutionalized individual's spouse;
2. A child of the institutionalized individual who is under the age of 21 or a child of any age
who is blind or totally and permanently disabled;
i. In the event that the child does not have a determination from the Social Security
Administration of blindness or disability, the blindness or disability shall be evaluated by the
Medical Review Team of the Division of Medical Assistance and Health Services in
accordance with the provisions of N.J.A.C. 10:71-3.13;
3. A brother or sister of the institutionalized individual who already had an equity interest
in the home prior to the transfer and who was residing in the home for a period of at least
one year immediately before the individual becomes an institutionalized individual; or
4. A son or daughter of the institutionalized individual (other than described in (d)2 above)
who was residing in the individual's home for a period of at least two years immediately
before the date the individual becomes an institutionalized individual and who has provided
care to such individual which permitted the individual to reside at home rather than in an
institution or facility.
i. The care provided by the individual's son or daughter must have exceeded normal
personal support activities (for example, routine transportation and shopping). The
individual's physical or mental condition must have been such as to require special attention
and care. The care provided by the son or daughter must have been essential to the health
and safety of the individual and consisted of activities such as, but not limited to, supervision
of medication, monitoring of nutritional status, and insuring the safety of the individual.
(e) The provisions of this section do not apply to the following resource transfer situations:
1. The resources were transferred to the community spouse (or to another individual for
the sole benefit of the community spouse) prior to the entry into institutional care so long as
the resources were not subsequently transferred by the community spouse;
i. If funds were transferred to another individual for the sole benefit of the community
spouse prior to entry into institutional care, in order that the transfer not be considered to
have been for the purposes of qualifying for Medicaid, the funds must have been transferred
in the form of a legally binding trust document specifying that the trustee(s) may use the
funds solely for the benefit of the community spouse. Should the transferred funds not be
so designated, the transfer shall be presumed to be for the purpose of qualifying for
Medicaid in accordance with the provisions of this section;
2. The resources were transferred to the community spouse subsequent to the application
for Medicaid in accordance with N.J.A.C. 10:71-4.8(a)3; or
3. The resources were transferred from the institutionalized individual or the community
spouse to the institutionalized individual's child who is blind or permanently and totally
disabled.
i. In the event that the child does not have a determination from the Social Security
Administration of blindness or disability, the blindness or disability will be evaluated by the
Disability Review Section of the Division of Medical Assistance and Health Services in
accordance with the provisions of N.J.A.C. 10:71-3.13.
(f) Resource transferred at fair market value: When the resource was transferred at FMV,
the application shall be processed as usual. No special procedure is required.
(g) Resource transferred, resource limit not exceeded: When the UV of a transferred
resource, combined with other countable resources does not exceed the applicable
resource limit, the application shall be processed as usual.
(h) Resource transferred, resource limit exceeded: When the UV of a transferred
resource, combined with other countable resources, exceeds the resource limit, eligibility for
institutional level services shall be denied and the procedures below followed:
1. Notify the applicant via Form PA-13 that he or she has transferred a resource at less
than FMV, the amount of the UV and the length of the penalty period. Explain that the law
states that transfer of a resource at less than FMV is presumed to be for the purpose of
establishing Medicaid eligibility for institutional services.
2. Advise the applicant that he or she may rebut the presumption (see (i) below).
3. Prepare a list of such cases for control purposes. The control list shall include the case
number, client's name, Social Security number, date of resource disposal, FMV of the
resource, amount of UV, and the start and end dates of the period of ineligibility for
institutional level services.
(i) Rebuttal of presumption that the resource was transferred to establish eligibility: All
applicants or beneficiaries may rebut the presumption that a resource was transferred to
establish Medicaid eligibility. If the individual wishes to rebut such presumption, explain that
it will be his or her responsibility to present convincing evidence that the resource was
transferred exclusively (that is, solely) for some other purpose. The applicant should be
assisted in obtaining information when necessary. However, the burden of proof rests with
the applicant. Accordingly, when the applicant expresses the desire to rebut the agency's
presumption that he or she transferred a nonexcludable resource to establish Medicaid
eligibility, the procedures below shall be followed.
1. The applicant's statement concerning the circumstances of the transfer shall be
recorded. The statement should include, but need not be limited to, the following:
i. The applicant's stated purpose for transferring the resource;
ii. The applicant's attempt to dispose of the resource at FMV;
iii. The applicant's reasons for accepting less than FMV for the resource;
iv. The applicant's means of, or plans for, supporting himself or herself after the transfer;
v. The applicant's relationship, if any, to the person(s) to whom the resource was
transferred.
2. Request the applicant to submit any pertinent documentary evidence (for example,
legal documents, realtor agreements, relevant correspondence).
3. Take statements from other individuals if material to the decision.
(j) Factors which may indicate that the transfer was for some other purpose: The presence
of one or more of the following factors, while not conclusive, may indicate that resources
were transferred exclusively for some purpose other than establishing Medicaid eligibility.
1. The occurrence after transfer of the resource of:
i. Traumatic onset of disability;
ii. Unexpected loss of other resources which would have precluded Medicaid eligibility;
iii. Unexpected loss of income which would have precluded Medicaid eligibility.
2. Resources that would have been below the resource limit during each of the preceding
30 months if the transferred resource has been retained.
3. Court-ordered transfer.
4. Evidence of good faith effort to transfer the resource at FMV.
(k) Agency determination pursuant to client rebuttal:
1. The presumption that a resource was transferred to establish Medicaid eligibility is
successfully rebutted only if the applicant demonstrates that the resource was transferred
exclusively for some other purpose.
2. If the applicant had some other purpose for transferring the resource, but establishing
Medicaid eligibility seems to have been a factor in his or her decision to transfer, the
presumption is not successfully rebutted.
3. The determination will not include an evaluation of the merits of the applicant's stated
purpose of transferring a resource. The determination will only deal with whether or not the
applicant has proven that the transfer was solely for some purpose other than establishing
Medicaid eligibility.
4. The final determination regarding the purpose of the transfer shall be made at a
supervisory level and documented in the case record.
5. The applicant shall be sent a notice of the decision which shall include his or her right to
a fair hearing.
(l) In the case of any resource transfer which occurred between April 1, 1990 and August
20, 1990 and which would otherwise be subject to the provisions of this section, the period
of ineligibility for institutional services shall be the lesser of:
1. 24 months; or
2. The number of months resulting from the application of the calculation at N.J.A.C.
10:71-4.7(b)4ii.

10:71-4.6 Deeming of resources
(a) When an applicant/beneficiary is an adult residing in the same household with his or her
ineligible spouse or is a child residing in the same household with his or her parent(s) or
spouse of parent, the resources of the ineligible spouse or parent(s) is considered in the determination of eligibility. The amount included as resources to the applicant/beneficiary,
whether or not it is actually available, is termed deemed resources.
(b) Applicant/beneficiary living alone: If the applicant/beneficiary lives alone, only his or her
countable resources shall be applied to the resource maximum for an individual.
(c) Applicant/beneficiary couple: In the case of an applicant/beneficiary couple, the total
amount of the husband's and wife's combined countable resources shall be applied to the
resource maximum for a couple. Such individuals will continue to have resources treated in
this manner until they have been separated for one calendar month. At such time, the
individuals will be considered to be living alone.
1. If one member of an eligible couple enters a Title XIX institution, only the resources of
the institutionalized individual will be counted in the determination of his or her eligibility
beginning with the date of admission except as provided in N.J.A.C. 10:71-4.8.
(d) Applicant/beneficiary living with ineligible spouse: If the applicant/beneficiary lives with
an ineligible spouse, all countable resources of the ineligible spouse are deemed to the
applicant/beneficiary. The value of the total countable resources is compared to the
resource maximum for a couple. Such individuals will continue to have resources treated in
this manner until they have been separated for one full calendar month. At such time, the
individuals will be considered to be living alone.
1. Separation due to institutionalization: If one member of the couple enters a Title XIX
institution, only the resources of the institutionalized individual will be counted in the
determination of his or her eligibility beginning with the date of admission except as
provided in N.J.A.C. 10:71- 4.8.
(e) Applicant/beneficiary unmarried and under 18 years of age, living with parents: If the
applicant/beneficiary is an unmarried child under the age of 18 years of age who lives with
his or her parents (including stepparents), the total value of all countable resources in
excess of the appropriate parental resource maximum, cited in (e)2 below, shall be applied
toward the resource maximum for an individual (see N.J.A.C. 10:71-4.5). A child will be
considered to be not living with his or her parents when he or she has ceased living with
them for a period of one calendar month.
1. Child not living with parents due to institutionalization: If a physician has certified that
the child's duration of stay in a Title XIX facility (or a combination of such facilities) is
expected to be 30 consecutive days or more, such child shall be considered to be not living
with his/her parents at the time of such certification. In such circumstances, only the child's
own countable resources shall be applied to the resource maximum for an individual.
2. Parental resource maximums (including stepparents):
i. One parent: The total value of countable resources in excess of the source limit for an
individual (see N.J.A.C. 10:71-4.5) shall be applied toward the eligible child's resource
maximum.
ii. Two parents: The total value of countable resources in excess of the resource limit for
a couple (see N.J.A.C. 10:71-4.5) shall be applied toward the eligible child's resource
maximum.
3. More than one eligible child: If there is more than one eligible child in the household,
the total value of countable resources in excess of the appropriate parental maximum shall
be equally divided among such children. In cases of this nature, no part of the value of such
resources shall be allocated to ineligible children residing in the household.
(f) Deeming resources of an alien's sponsor: When the sponsor of an alien is subject to
deeming provisions (see N.J.A.C. 10:71-5.7) any countable resources of the sponsor in
excess of the appropriate resource limit (the resource limit for an individual or the resource
limit for a couple if the sponsor resides with his or her spouse) shall be considered to be
resources of the alien in addition to whatever resources the alien has.

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.

10:71-4.3 (Reserved)

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.

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.

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.

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.

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.