N.J. Admin. Code § 10:72-6.1

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:72-6.1 - Scope

(a) The presumptive eligibility determination makes it possible for a pregnant woman to receive ambulatory prenatal care from a Medicaid participating provider for a temporary period prior to application for Medicaid benefits and while a Medicaid application is being processed by the county welfare agency. Presumptive eligibility continues until the county welfare agency reaches its formal eligibility determination as follows:

1. The period of presumptive eligibility begins on the date a qualified provider determines that, based on information provided by the pregnant woman, the woman meets the requirements and standards of this chapter applicable to pregnant women.

2. The period of presumptive eligibility will terminate:

i. If the woman has filed an application with the county welfare agency, on or before the last day of the month subsequent to the month in which she was determined presumptively eligible, or on the date a determination of eligibility or ineligibility for Medicaid is made by the county welfare agency; or

ii. If the pregnant woman fails to file an application with the county welfare agency, on the last day of the month subsequent to the month in which she was determined presumptively eligible.

(b) A qualified provider shall be:

1. A participating Medicaid provider;

2. Currently certified by the New Jersey Department of Health as a provider of HealthStart Comprehensive Maternity Care Services (see N.J.A.C. 10:49-3). A provider certified only for Medical Maternity Care Services, Health Support Services, or Pediatric Preventive Services shall not be a qualified provider for purposes of this subchapter;

3. A provider of the following services:

i. Outpatient hospital services; or

ii. Clinic services furnished by or under the direction of a physician, without regard to whether or not the clinic itself is administered by a physician; and

4. Trained and approved by the Division of Medical Assistance and Health Services for the purposes of making presumptive eligibility determinations.

i. The Division of Medical Assistance and Health Services will monitor the presumptive eligibility determinations made by qualified providers. In the event the review discloses a pattern of incorrect presumptive eligibility determinations or failure to adhere to procedural requirements, appropriate staff of the Division will initiate corrective action. Continued incorrect presumptive eligibility determinations or failure to adhere to procedural requirements will result in the Division revoking approval for that provider to make presumptive eligibility determinations.

N.J. Admin. Code § 10:72-6.1

Amended by R.1989 d.498, effective 9/18/1989.
See: 21 New Jersey Register 1791(a), 21 New Jersey Register 2998(a).
Clarification of process for presumptive eligibility.
Amended by R.1992 d.10, effective 1/6/1992.
See: 23 New Jersey Register 2827(a), 24 New Jersey Register 100(a).
Added new text to (a) and (a)2i. and ii. regarding presumptive eligibility.
In (b)4.i.: technical revisions.