N.J. Admin. Code § 10:46-2.1

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

Section 10:46-2.1 - General eligibility

(a) An individual must be determined eligible for services under this chapter before the Division can provide services, not including transitional planning to individuals under the age of 21.

(b) An individual must have a developmental disability in order to be determined eligible for services.

1. Neurological impairment is not a diagnosis itself. Diagnoses related to neurological impairments that establish developmental disability may include, but are not limited to: spina bifida, epilepsy, traumatic brain injury, and acquired brain injury.

2. Conditions that do not independently meet the criteria set forth in the definition of developmental disability include, but are not limited to:

i. An education classification of neurological impairment;

ii. Attention deficit hyperactivity disorder (ADHD);

iii. Learning disorder;

iv. Oppositional defiant disorder; and

v. Conduct disorder.

(c) An otherwise eligible individual who is not eligible for Medicaid shall receive time-limited services from the Division, not to exceed 30 days, when the following are met:

1. The services are necessary to address an immediate threat to life or safety;

2. The individual or his or her guardian complies with all requirements as determined by the Division, including, but not limited to, completing all necessary paperwork in an expedited manner and acknowledging, in writing, that the services are time-limited and will be terminated within 30 days unless the individual becomes eligible for Medicaid within that timeframe; and

3. The written authorization of the Assistant Commissioner has been obtained.

(d) An otherwise eligible individual receiving services from the Division, who was previously eligible for Medicaid and loses Medicaid eligibility, shall receive time-limited services not to exceed 60 days from the time of Medicaid ineligibility, provided that:

1. The individual or his or her guardian complies with all requirements as determined by the Division, including, but not limited to, completing all necessary paperwork in an expedited manner and acknowledging, in writing, that the services are time-limited for a period of 60 days unless the individual becomes eligible for Medicaid within that timeframe; and

2. The written authorization of the Assistant Commissioner has been obtained.

(e) An individual receiving services under (d) above shall receive services for an additional time-limited period not to exceed 30 days, provided the conditions in (c)1, 2, and 3 above are met.

(f) In order to receive waiver services, an individual or his or her guardian is responsible to apply, and become eligible for, the applicable Medicaid waiver. Individuals are also responsible to apply for and maintain all current and future benefits for which the applicant may be eligible, including, but not limited to, any applicable waiver, Social Security, SSI, Medicare, Medicaid, any other State or Federal benefits and any third-party support pursuant to statute, rule, court order, or contract. The individual is also required to comply with all of the requirements of the programs for which she or he is eligible in order to maintain eligibility for services.

(g) When an individual receives residential services from the Division funded through contract reimbursement, he or she is also required to contribute to the cost of care and maintenance. The requirements and financial ability of the individual and that of their legally responsible relatives to contribute to the cost of care and maintenance are set forth at N.J.A.C. 10:46D, Contributions for Care and Maintenance Requirements.

(h) At age 16, individuals may seek transitional planning from the Division. At age 18, individuals may apply for eligibility from the Division. The Division will not provide services to individuals, other than transitional planning, until the individual reaches 21 years of age.

1. Individuals who were determined eligible for services prior to January 22, 2013, shall be presumed eligible to receive Division services when they reach 21 years of age, except any individual born on or after January 1, 1997. Individuals born on or after January 1, 1997 shall be required to reapply to the Division for eligibility after they reach 18 years of age.

(i) The Division may, in its discretion, reevaluate an individual's eligibility at any time. A referral for reevaluation shall cite specific concerns regarding eligibility.

(j) It is the Division's policy to fund services in the State of New Jersey, except where the conditions stipulated at N.J.S.A. 30:6D-21.1 through 21.3 ( P.L. 2015, c. 192 ) exist.

N.J. Admin. Code § 10:46-2.1

Amended by 53 N.J.R. 1839(a), effective 11/1/2021