N.J. Admin. Code § 10:141-1.5

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:141-1.5 - Eligibility for services and supports

(a) Applicants to the Fund must meet the following eligibility requirements. Responsibility for adherence to the criteria shall be vested with the Division Director, and shall remain an administrative function of the Division:

1. Clinical requirements:

i. The applicant has survived a traumatic brain injury as defined in this chapter;

ii. The applicant requires, and is requesting, post acute care services/support directly related to the traumatic brain injury;

iii. It has been established, by clinical opinion, that the provision of the requested service/support will restore, enhance or maintain function; and

iv. Clinical documentation of need shall be provided by a practitioner other than the practitioner rendering the care or service;

2. Financial requirements:

i. The requested expenditure shall not exceed established program caps as set forth at N.J.A.C. 10:141-1.4;

ii. The applicant demonstrates the inability to pay for the requested services or supports from income or assets;

iii. The applicant or his or her immediate family's liquid assets do not exceed $ 100,000, and that those assets are otherwise committed, or not available to fund the requested services;

iv. There are no trust funds, settlements, gifts or donations for which the applicant is eligible, and which are available on a timely basis, to meet the applicant's needs;

v. There are no other funds, insurance coverage, or public or private programs for which the applicant is eligible, to provide the requested care, services, or supports for the applicant, in a timely manner;

vi. Payment for services/supports rendered prior to the receipt of formal Committee approval, shall be ineligible for reimbursement;

vii. To the extent of funds provided to the individual, the Fund shall have first claim to any future monies received by the person with a traumatic brain injury as a result of a settlement or other payment made in connection with the traumatic brain injury; and

viii. The Fund may place a financial lien on any appreciable property purchased using Fund resources. The lien shall be no more than the amount issued by the Fund at the time of purchase, and shall be executed where:

(1) The property is being sold by the beneficiary;

(2) The beneficiary enters a long-term care facility; or

(3) The ownership of the property is transferred to an individual other than the original beneficiary; and

3. Residency requirements:

i. The applicant shall be a citizen or permanent resident of the United States, as defined by the Immigration and Nationality Act, Pub. L. 82-414, living in New Jersey, and shall be a resident of New Jersey at least three consecutive months prior to the date of application. Applicants shall maintain legal residence in New Jersey during the period in which supports and services are being provided under the Fund to remain eligible;

ii. The residence of a minor child shall be determined to be that of the parent(s) or legal guardian;

iii. The responsibility to furnish proof of residence shall be that of the applicant or the parent or guardian of a minor child;

iv. Absence from the State of New Jersey for a period of 12 months or more is prima facie evidence of abandonment of domicile;

v. Seasonal residents of New Jersey are excluded from eligibility. Seasonal or temporary residents of the State of whatever duration shall not constitute domicile. Migrant workers who can demonstrate a history of residence in New Jersey shall be eligible for consideration; and

vi. The Fund shall suspend the application for, or the provision of supports and services to, an individual who is or becomes incarcerated or committed to an institution as defined by 42 CFR 435.1008 and 435.1009, incorporated herein by reference, as amended and supplemented. Applications or awards may be reinstated upon release or discharge if eligibility and need continue.

(b) In the event that the Fund is unable to provide funding for all eligible individuals, persons will be given priority according to the following criteria and these criteria will be applied in descending order, and in combination, by the Committee to the eligible applicants in the current review cycle. The Committee will record the basis for its decisions. The criteria to be utilized to determine the order of selection will be:

1. Provision of the service/support to protect or maintain health and safety;

2. Provision of services will prevent institutionalization or facilitate discharge to the community from an institution;

3. Income/resources of the individual shall be considered. Individuals with lowest income or resources shall be served first. In circumstances where the applicant/beneficiary is a minor, the income and revenue of the child's parent or guardian shall be considered;

4. Situations where Fund services will be utilized as an alternative to enrollment in the Managed Long-Term Supports and Services (MLTSS) Program;

5. Applicants who have never received previously requested support and service from the Fund; and

6. Applicants who have previously received supports from the Fund and are making an additional request.

(c) The Fund makes no guarantee of continued supports and services to any beneficiary beyond the expiration of the current award. Each decision is rendered based on the financial status of the Fund and the specific circumstances of the beneficiary at the time of a request.

(d) All awards for services and supports under the Fund become void upon the death of the beneficiary.

(e) The Fund may at its discretion suspend payment for previously awarded services under any of the following circumstances:

1. Continued provision of services demonstrates a risk to the health and safety to the applicant, family member or service provider;

2. The service is not being utilized for its intended purpose;

3. The service is not yielding a documented clinical benefit; or

4. Continued provision of services is no longer in the financial best interest of the Fund.

(f) Authority to suspend services shall rest with the Division Director or designee. He or she shall report any suspensions to the TBI Fund Review Committee at its next meeting.

(g) Suspension of services shall have no impact on applicant's/beneficiary's eligibility for the Fund as set forth in (a)1 through 3 above.

N.J. Admin. Code § 10:141-1.5

Amended by 49 N.J.R. 1683(a), effective 6/19/2017