N.J. Admin. Code § 10:69-5.13

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:69-5.13 - Extension of Medicaid benefits

(a) Extended Medicaid benefits shall be provided to former AFDC-related Medicaid families in accordance with the provisions of this section for a period of 24 months beginning with the month in which the family no longer would have otherwise been eligible for AFDC-related Medicaid due to an increase in earned income.

1. When an AFDC-C or-F family loses eligibility for AFDC-related Medicaid due to the following reasons, Medicaid eligibility continues for a period of 24 months beginning with the month in which the family is no longer eligible for AFDC-related Medicaid:

i. Earnings or increased earnings from employment, including earnings from new employment;

ii. Increased hours of employment; or

iii. Receipt of New Jersey State unemployment or temporary disability insurance benefits.

2. New members added to the eligible family during the 24 month extension period, as appropriate, are not included under the extended coverage, with the exception of a child born to the family during the 24 month extension period. For children born during this period, the child and the mother may be eligible for additional coverage if the 60-day post-partum period continues beyond the termination of the extension period applicable to the remainder of the household, or if the child's 12-month guaranteed period of Medicaid eligibility continues beyond that termination date. In either case, Medicaid eligibility terminates at the end of the guaranteed eligibility period, if that termination date is later than the termination date of the 24 month Medicaid extension.

3. Eligibility for the 24-month Medicaid extension is not available for any month to any individual who, except for income or hours of employment, is not otherwise eligible to receive AFDC-related Medicaid. The following individuals shall not be included in the eligible family for Medicaid extension:

i. Any child who reaches the age of 18, or any child who is attending a secondary or vocational school full-time up to the month of graduation or age 19, except that such child shall be evaluated for Medicaid eligibility for other appropriate Medicaid programs; and

ii. All other family members who are receiving Medicaid extension solely because of the presence in the home of a child who "ages out," as in (a)3i above.

4. When an AFDC-C related Medicaid family loses eligibility as a result (wholly or in part) of the collection of child or spousal support through the Child Support and Paternity process, AFDC-related Medicaid eligibility continues for a period of four calendar months beginning with the month in which such ineligibility begins.

i. In order to qualify for this extension of Medicaid benefits, the family must have received and been eligible to receive AFDC-C-related Medicaid in at least three of the six months immediately preceding the month in which ineligibility for AFDC-related Medicaid begins;

ii. Eligibility for this extension shall be terminated for any child who reaches the age of 18, or any child who is attending a secondary or vocational school full-time up to the month of graduation or age 19, except that such child shall be evaluated for Medicaid eligibility for other appropriate Medicaid programs; and

iii. All other family members who are receiving Medicaid extension solely because of the presence in the home of a child who "ages out," as described in (a)4ii above, shall be terminated.

(b) Those cases that are in Medicaid extension only shall also be transferred to the new county of residence when the family moves from the county of origin in the same manner as active AFDC-related Medicaid cases. The procedures established at N.J.A.C. 10:69-3.24 are to be followed when transferring a case in Medicaid extension.

(c) AFDC applicants may be eligible for retroactive Medicaid benefits; such determinations are made by the CWA. The eligibility worker shall ask if the family has unpaid medical bills from the previous three months and shall provide the applicant with appropriate forms. The CWA shall make a determination of eligibility for each of the three previous months, based on the eligibility rules in this chapter.

(d) AFDC eligible families who would not have received any AFDC payments solely because the amount payable would be less than $ 10.00, are eligible for AFDC-related Medicaid benefits. Likewise, AFDC families who would have been ineligible for AFDC solely because of rounding of the amount that would otherwise be payable, are eligible for AFDC-related Medicaid benefits.

(e) For newborns of eligible women who have applied, before or on the date of the birth, and are eligible for Medicaid on the date of birth, except for a presumptively eligible pregnant woman, as defined at N.J.A.C. 10:72-6.1, who is subsequently found ineligible for the month the child was born, eligibility continues for both mother and child through the last day of the month in which the 60-day post-partum period ends, without regard to other program requirements. So long as the mother remains eligible, or would remain eligible if pregnant, the child remains eligible for Medicaid for a period of one year, whether or not application has been made for the child.

(f) Individuals who were admitted to a hospital and were subsequently referred to the CWA through the use of Form PA-1C, Public Assistance Inquiry, may be eligible for Medicaid benefits from the date the PA-1C was completed, provided:

1. Such individual was an inpatient at the time the referral was made;

2. Except for good cause, including, but not limited to, hospitalizations lasting for three or more months, the homebound status of the applicant, the CWA was unable to schedule a timely application appointment, or the hospital failed to inform the applicant to apply at the CWA, the individual applies for AFDC-related Medicaid benefits within three months after the referral is made.

i. If the CWA determines that the individual had good cause for not applying within three months, an extension may be granted for an additional three months.

ii. Newborns of eligible women are deemed to have applied and shall be added to the Medicaid case, effective the date of birth, upon receipt of a valid Form PA-1C (see N.J.A.C. 10:69-2.19 for coverage limits).

(g) Those cases that are in Medicaid extension only shall also be transferred to the new county of residence when the family moves from the county of origin in the same manner as active AFDC-related Medicaid cases. The procedures established at N.J.A.C. 10:69-3.24 are to be followed when transferring a case in Medicaid extension.

N.J. Admin. Code § 10:69-5.13

Amended by 49 N.J.R. 3729(a), effective 12/4/2017