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New Jersey Administrative Code
Title 10 - HUMAN SERVICESChapter 72 - NEW JERSEY CARE ... SPECIAL MEDICAID PROGRAMS MANUAL
Subchapter 1 - INTRODUCTION
Section 10:72-1.1 - Program scope

N.J. Admin. Code § 10:72-1.1

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Current through Register Vol. 56, No. 21, November 4, 2024
Section 10:72-1.1 - Program scope
(a) This chapter contains the criteria for Medicaid eligibility for certain pregnant women and infants not eligible under the provisions of N.J.A.C. 10:69, as well as, certain aged, blind and disabled persons not eligible under the provisions of N.J.A.C. 10:71.
1. Because the eligibility criteria established by the rules contained within this chapter are more liberal than those applicable under AFDC-related Medicaid and SSI-related Medicaid, pregnant women, infants, and aged, blind or disabled individuals losing Medicaid eligibility because of financial reasons should be evaluated under the provisions of this chapter for the possibility of continuing Medicaid eligibility.
2. Except for children between the ages of one and 19, persons financially ineligible for Medicaid under the provisions of N.J.A.C. 10:69 and 10:71 and who are income ineligible for Medicaid under the provisions of this chapter shall be evaluated for eligibility as Medically Needy under the provisions of N.J.A.C. 10:70.
i. Persons determined eligible for the Medically Needy Program may be also determined eligible as specified low-income Medicare beneficiaries.
3. Infants not eligible under the provisions of N.J.A.C. 10:69, 10:71 or 10:72 should be evaluated for NJ FamilyCare under the provisions of N.J.A.C. 10:79.
(b) Medicaid eligibility under the provisions of this chapter is limited to:
1. Pregnant women; and
2. Infants under the age of one.
3. Aged, blind, and disabled individuals (as defined by Title XIX of the Social Security Act), who otherwise meet the requirements specified in this chapter. For purposes of this chapter, an aged individual is a person who is 65 years of age or older.
4. Aged, blind and disabled individuals (as defined in (b)3 above) who qualify as specified low-income Medicare beneficiaries.
i. Specified low-income Medicare beneficiaries must be residents of the State, must be receiving Medicare benefits, Parts A and B, and must meet the income and resource requirements specified in 10:72-4.1(b) and 4.5(b).
ii. The enrollment and outreach process for specified low-income Medicare beneficiaries is administered by the Department of Health and Senior Services, through the Office of Pharmaceutical Assistance to the Aged and Disabled (PAAD), using the standard PAAD application form.
iii. Persons determined eligible as specified low-income Medicare beneficiaries are entitled to payment of Medicare Part B Premiums only, beginning in the month of application and up to three prior months.
iv. The Division of Medical Assistance and Health Services shall promptly notify any applicant for, or beneficiary of, the specified low-income Medicare beneficiary benefit, in writing, of any agency decision affecting the application disposition or the receipt of the benefit. When a decision relates to any adverse action which may entitle an individual to a fair hearing, the action may not be implemented until at least 10 days after the mailing of the notice. Such notices shall conform with provisions at 10:72-5.1(b).
(c) Retroactive Medicaid eligibility is available beginning with the third month prior to the month of application for Medicaid for any month during which the applicant meets all eligibility criteria and during which the applicant has unpaid medical expenses for covered services. In order to qualify for retroactive coverage, an individual need not be determined eligible at the time of application for Medicaid benefits. Application for retroactive Medicaid coverage may be made on behalf of a deceased person, so long as the person was alive during a portion of the three-month period immediately prior to the month of application and he or she has unpaid medical expenses for Medicaid covered services.
1. Retroactive Medicaid coverage is not available under the provisions of this chapter for an infant for any period prior to the effective date of program coverage for the age of the child.

N.J. Admin. Code § 10:72-1.1

Emergency Amendment, R.1988 d.96, effective 2/2/1988 (expired April 2, 1988).
See: 20 N.J.R. 548(a).
Substantially amended.
Adopted Concurrent Proposal, R.1988 d.212, effective 5/16/1988.
See: 20 N.J.R. 548(a), 20 N.J.R. 1103(a).
Emergency Amendment, R.1991 d.223, effective 3/28/1991 (operative April 1, 1991; expires May 27, 1991).
See: 23 N.J.R. 1200(a).
Deleted obsolete language and adopted Federally required coverage pursuant to Omnibus Budget Reconciliation Act of 1989.
Adopted Concurrent Proposal, R.1991 d.302, effective 5/24/1991.
See: 23 N.J.R. 1200(a), 23 N.J.R. 1945(a).
Provisions of emergency amendment R.1991 d.223 readopted without change.
Emergency Amendment, R.1991 d.445, effective 7/29/1991 (expires September 27, 1991).
See: 23 N.J.R. 2543(a).
In (c)1: revised text to add 133 percent guideline for retroactive Medicaid coverage.
Adopted Concurrent Proposal, R.1991 d.526, effective 10/21/1991.
See: 23 N.J.R. 2453(a), 23 N.J.R. 3144(a).
Provision of emergency amendment R.1991 d.526 adopted without change.
Amended by R.1992 d.484, effective 12/7/1992.
See: 24 N.J.R. 1860(a), 24 N.J.R. 4378(a).
Eligibility expanded to include children of specified ages born after September 30, 1983.
Administrative Correction to (a).
See: 25 N.J.R. 704(a).
Amended by R.1993 d.369, effective 7/19/1993.
See: 25 N.J.R. 1042(b), 25 N.J.R. 3217(a).
Amended by R.1997 d.379, effective 9/15/1997.
See: 29 N.J.R. 2541(a), 29 N.J.R. 4136(a).
In (b)3, inserted ", who otherwise meet the requirements specified in this chapter"; and in (a)4ii, substituted "enrollment and outreach process" for "eligibility determination process" and "administered by the Department of Health and Senior Services" for "is the responsibility of the Division of Medical Assistance and Health Services".
Amended by R.1998 d.116, effective 1/30/1998 (operative February 1, 1998; to expire July 31, 1998).
See: 30 N.J.R. 713(a).
In (a), added an exception at the beginning of 2, and added 3; and in (b), rewrote 2.
Adopted concurrent proposal, R.1998 d.426, effective 7/24/1998.
See: 30 N.J.R. 713(a), 30 N.J.R. 3034(a).
Readopted provisions of R.1998 d.116 with changes, effective 8/17/1998.
Administrative correction.
See: 39 N.J.R. 4401(a).
Amended by R.2008 d.30, effective 1/22/2008.
See: 39 N.J.R. 3704(a), 40 N.J.R. 723(a).
In the introductory paragraph of (a) and in (a)2 and (a)3, updated the N.J.A.C. references; in the introductory paragraph of (a) and in (b)4, deleted the comma following "blind"; in (a)2i and (b)4, substituted "specified low-income Medicare beneficiaries" for "Specified Low-Income Medicare Beneficiaries"; in (a)3, substituted "FamilyCare" for "KidCare"; in (b)4iii, deleted ", but no earlier than January 1, 1993" from the end; in (b)4iv, substituted "specified low-income Medicare beneficiary" for "Specified Low-Income Medicare Beneficiary"; in the introductory paragraph of (c), inserted a comma preceding "so"; and in (c)1, deleted the last sentence.