N.J. Admin. Code § 10:70-3.4

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

Section 10:70-3.4 - Eligibility group criteria

(a) Eligibility for the Medically Needy Program is limited to groups of persons within two specified eligibility categories. An individual must meet the definition of one of the categories below to be eligible for the Medically Needy Program.

(b) The following eligibility groups are within the AFDC-related eligibility category:

1. Pregnant women: Needy pregnant women of any age during the term of a medically verified pregnancy, through the end of the month during which the 60th day from delivery occurs.

i. A child born to a woman eligible as a pregnant woman under the provisions of this chapter shall remain eligible for a period not less than 60 days from his or her birth, and up to one year so long as the mother remains eligible for Medicaid, or would remain eligible if pregnant, whether or not application has been made, if the child lives with his or her mother.

2. Children under the age of 21: Needy children under the age of 21.

i. Children under the age of 21 may be eligible regardless of: Parental deprivation; school attendance; emancipation; residence with parent(s) or other caretaker relative(s); or Work Incentive program (WIN) or other AFDC employment or training requirements.

ii. A child may be eligible for program benefits when temporarily absent from his or her family in accordance with the provisions of 10:69-3.28 through 3.30.

(c) The following eligibility groups are within the SSI-related eligibility category:

1. Aged: Needy persons who are 65 years of age or older.

2. Blind: Needy persons who are statutorily blind. Statutory blindness is central visual acuity of 20/200 or less in the better eye with the use of correcting lens. An eye which has a limitation in the field of vision so that the widest diameter of the visual field subtends at an angle no greater than 20 degrees is considered to have a central visual acuity of 20/200 or less.

i. Persons who are receiving Social Security disability benefits as a result of blindness are presumed to be blind for purposes of this program.

ii. Except for persons described in (c)2i above, the determination of statutory blindness is the responsibility of the Division of Medical Assistance and Health Services, Disability Review Section.

3. Disabled: Needy persons who are disabled. Disability is the inability to do any substantial gainful activity by reason of any 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. The severity of impairment must be such that the individual is unable to do his or her previous work or any other substantial gainful activity which exists in the national economy. In the determination of a person's ability to do any other work, residual functional capacity, age, education, and work experience are considered.

i. Disability for children under the age of 18 is any medically determinable physical or mental impairment which compares in severity to an impairment that would make an adult disabled.

ii. Persons who are receiving Social Security disability benefits are presumed to be disabled for purposes of this program.

iii. Except for persons described in (c)3ii above, the determination of disability is the responsibility of the Division of Medical Assistance and Health Services, Disability Review Section.

(d) Under certain circumstances, an individual may be considered for eligibility under both the SSI-related and AFDC-related categories (for example, a blind child under the age of 21). Such an individual may select the category under which he or she wishes to be considered for program eligibility upon being advised by the county board of social services of the option and the consequences thereof.

N.J. Admin. Code § 10:70-3.4

Amended by R.1989 d.397, effective 8/7/1989.
See: 21 N.J.R. 965(a), 21 N.J.R. 2383(a).
Provisions on eligibility of newborn and specification of time limit of eligibility of mother after delivery added at (b).
Amended by R.1991 d.331, effective 7/1/1991.
See: 23 N.J.R. 964(a), 23 N.J.R. 2042(a).
Shift in administrative functions from Division of Public Welfare, Bureau of Medical Affairs, Medical Review Team to Division of Medical Assistance and Health Services, Disability Review Section.
Amended by R.2006 d.364, effective 10/16/2006.
See: 38 N.J.R. 2368(a), 38 N.J.R. 4480(c).
In the introductory paragraph of (b), deleted "AFDC-related:" from the beginning; in (b)1, inserted "pregnant"; in (b)2ii, updated N.J.A.C. references; in the introductory paragraph of (c), deleted "SSI-related:" from the beginning; in (c)1, substituted "who are" for "aged"; and in (d), substituted "board of social services" for "welfare agency".