N.J. Admin. Code § 10:72-2.1

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

Section 10:72-2.1 - Application

(a) Application for Medicaid benefits for pregnant women and infants shall be accomplished by the completion and signing of Form FD-335 for pregnant women and infants as well as any addenda to that form as prescribed by the Division of Medical Assistance and Health Services. Application for Medicaid benefits for aged, blind, or disabled individuals shall be accomplished by the completion and signing of Form PA-1G as well as any addenda to that form as prescribed by the Division of Medical Assistance and Health Services.

1. The application for the program shall be executed by:

i. The pregnant woman (regardless of age);

ii. The parent, guardian, or caretaker relative of an infant or a blind or disabled child for whom Medicaid is sought; or

iii. The aged, blind or disabled individual.

2. For cases in which, because of confinement, illness, incapacity, disability, or lack of competence of a person specified in (a)1 above, the application may be executed on behalf of such person by:

i. A relative by blood or marriage;

ii. A staff member of a public or private welfare or social service agency of which the person seeking assistance is a client and who has been designated by the agency to so act;

iii. An attorney or physician of the person seeking Medicaid benefits; or

iv. A staff member of an institution or facility in which the individual is receiving care and who has been designated by the institution or facility to so act.

3. A legal guardian shall be recognized as an authorized agent to execute an application on behalf of any individual.

(b) The county welfare agency, under policies and procedures established by the Division of Medical Assistance and Health Services, has the direct responsibility in the application process to:

1. Inform applicants of the purpose of and the eligibility requirements for the Medicaid program, including their rights to a fair hearing;

2. Receive applications and review them for completeness, consistency, and reasonableness;

3. Assist program applicants in exploring their eligibility for program benefits;

4. Make known to program applicants the appropriate resources and services both within the agency and in the community; and

5. Assure the prompt and accurate submission of eligibility data to the Medicaid Eligibility File for eligible persons and prompt notification to ineligible persons of the reason for their ineligibility.

(c) As part of the application process, an applicant for Medicaid has the responsibility to:

1. Complete, with the assistance of the county welfare agency as required, any forms required as part of the application process;

2. Assist the county welfare agency in securing evidence that verifies his or her statements regarding eligibility;

3. Provide medical confirmation of pregnancy when Medicaid benefits are sought on that basis; and

4. Submit to necessary medical tests and examinations to determine disability or blindness and provide the county welfare agency with evidence relating to that determination.

(d) For any application for Medicaid benefits under the provisions of this chapter, the county welfare agency must accomplish disposition of the application as soon as all factors of eligibility are met and verified but not later than 30 days from the date of application (or from the date of the inquiry form PA-1C, if applicable) for pregnant women, children, and aged individuals. For disabled and blind individuals, the standard for application disposition is 60 days. Exceptions to the timeliness standard appear in (d)2 below.

1. "Disposition of the application" means the official determination by the county welfare agency of eligibility or ineligibility of the applicant(s) for Medicaid.

2. Disposition of the application may exceed the applicable processing standard when substantially reliable evidence of eligibility or entitlement for benefits is lacking at the end of the processing period. In such circumstances, the application may be continued in pending status. The county welfare agency shall fully document in the case record the circumstances of the delayed application processing. The processing standard may be exceeded for any of the following:

i. Circumstances wholly within the control of the applicant;

ii. A determination by the county welfare agency, when evidence of eligibility or entitlement is incomplete or inconclusive, to afford the applicant additional time to provide evidence of eligibility before final action on the application;

iii. An administrative or other emergency that could not reasonably have been avoided;

iv. Circumstances wholly beyond the control of both the applicant and the county welfare agency.

3. When disposition of the application is delayed beyond the processing standard, the county welfare agency shall provide the applicant written notification prior to the expiration of the processing period setting forth the specific reasons for the delay.

4. Each county welfare agency director shall establish appropriate operational controls to expedite the processing of applications and to assure maximum compliance with the processing standard.

i. The county welfare agency shall maintain control records which identify all pending applications which have exceeded the processing standard and the reason therefor. The record shall be adequate to make possible the preparation of reports of such information as may be requested by the Division of Medical Assistance and Health Services.

(e) The following actions on an application qualify as disposition of an application for purposes of the processing standard:

1. Approved: The applicant has been determined eligible for Medicaid;

2. Denied: The applicant has been determined ineligible for Medicaid;

3. Dismissed: A decision by the county welfare agency that the application process need not be completed because:

i. The applicant has died (the application process must be completed if there are unpaid medical bills for covered services in the retroactive coverage period or subsequent to program application);

ii. The applicant cannot be located;

iii. The application was registered in error;

iv. The applicant has moved out of the State during the application process and there are no unpaid bills for the time period beginning with the retroactive eligibility period up to the date of relocation.

4. Withdrawn: The applicant requests that eligibility for the Medicaid program be no longer considered.

N.J. Admin. Code § 10:72-2.1

Amended by R.1987 d.380, effective 8/27/1987.
See: 19 N.J.R. 1324(a), 19 N.J.R. 1731(a).
(b)5: missing text inserted.
Emergency Adoption, R.1988 d.96, effective 3/7/1988.
See: 20 N.J.R. 548(a).
Substantially amended.
Readoption of Concurrent Proposal, R.1988 d.212, effective 5/16/1988.
See: 20 N.J.R. 548(a), 20 N.J.R. 1103(a).
Amended by R.1992 d.364, effective 9/21/1992.
See: 24 N.J.R. 2145(a), 24 N.J.R. 3343(a).
New form numbers added; unpaid bill provision added at (e)3iv.
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).
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.