N.J. Admin. Code § 10:71-8.1

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

Section 10:71-8.1 - Other agency responsibilities

(a) Determination of continuing eligibility: The eligibility of each case shall be redetermined at least once every 12 months. This redetermination provides an opportunity to evaluate the total situation and enables the eligibility worker to ascertain whether the individual's eligibility has changed.

1. It shall be the agency's responsibility to review indications of ineligibility as they occur and to discontinue Medicaid Only eligibility when appropriate and without delay. The agency shall notify each applicant/beneficiary of any agency decision that relates to his or her eligibility status in accordance with the provisions of (d) below and 8.3.

2. The individual, or his or her authorized representative, shall execute a formal written application, Form PA-1G, Application and Affidavit for Medical Assistance Only (Aged, Blind, or Disabled), for continuance of assistance at least once every 12 months.

(b) Process of redetermination:

1. Redeterminations of eligibility require the completion of Form PA-1G-NJR2 (Redetermination Form). The CWA may require that the form be completed during a face-to-face interview. However, at the option of the CWA, and with the approval of the beneficiary, the face-to-face interview may be eliminated. Form PA-1G-NJR2 (Redetermination Form) may be mailed to and completed by the beneficiary and mailed to the CWA. All factors of eligibility subject to change (with the exception of disability and blindness factors) must be verified or reverified.

i. When a loss of assistance will result, the face-to-face interview shall be required, unless the agency documents a clear refusal by the beneficiary to have a face-to-face meeting. Before benefits are terminated, a beneficiary shall be offered a face-to-face home visit. The visit shall not be required to be in the office, but at the beneficiary's request, in the home.

2. Redetermination of financial and resource eligibility: The eligibility worker shall review all eligibility factors in accordance with the provisions set forth in N.J.A.C. 10:71-3, 4, and 5. Particular attention shall be directed to identification of any changes in resources and income.

3. Completion of the Medicaid Eligibility Worksheet: It is the responsibility of the eligibility worker to complete a new Form PA-1E when eligibility is to be continued, or terminated. A PR-1 Statement of Income Available for Long Term Care Facility Payment should be prepared for persons in institutions only when there is a change with regard to the amount of income available for medical reimbursement.

4. Need for institutional care: Official review of this factor on a routine basis is not required, but when medical or social evidence indicates that specific determination should be made, the CWA shall institute such an investigation.

(c) Recording and recommendation: A Summary Report, Form PA-2D, concerning all pertinent information shall be completed for each contact with the individual, whenever it occurs. Whenever a change in circumstances affects any facet of eligibility, a Medicaid Eligibility Worksheet (Form PA-1E) shall be prepared. The summary shall clearly state the basis for any termination of eligibility. Following each redetermination of eligibility, it is the responsibility of the eligibility worker to recommend that eligibility be continued or terminated.

(d) Notice of agency decision: Each applicant/beneficiary shall receive written notice of any agency decision which relates to his or her eligibility status at least 10 days prior to any change in his or her eligibility status.

N.J. Admin. Code § 10:71-8.1

Amended by R.2000 d.396, effective 10/2/2000.
See: 32 N.J.R. 2420(a), 32 N.J.R. 3570(a).
Rewrote the section.
Amended by R.2000 d.415, effective 10/16/2000.
See: 32 N.J.R. 2565(a), 32 N.J.R. 3844(a).
Rewrote the section.
Amended by R.2012 d.025, effective 2/6/2012.
See: 43 N.J.R. 804(a), 44 N.J.R. 230(a).
In the introductory paragraph of (b)1 and in (b)4, substituted "CWA" for "CBOSS" throughout.