N.J. Admin. Code § 10:90-13.6

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

Section 10:90-13.6 - Medically needy

(a) Individuals and families who are ineligible for WFNJ/GA, WFNJ/TANF, the Refugee Resettlement Program or SSI, because their income exceeds the standards established for the applicable program may apply to the county/municipal agency on a monthly basis for assistance in paying excessive medical costs. The provisions of this subsection are not applicable to the payment of bills for inpatient or outpatient hospitalization or for medical services rendered to an inpatient or outpatient by a hospital or hospital clinic. Those individuals who appear to be potentially eligible for the Medically Needy Program shall be referred to that program. Except as stated in (b) below, any person found eligible under the provisions of that program is not eligible for benefits under this subsection.

(b) Elderly, blind or disabled individuals who are ineligible for the SSI Program, because their income exceeds the SSI standard, shall be referred to the Medically Needy Program. That program, however, does not provide payment for prescribed drugs. Therefore, individuals not entitled to receive assistance in meeting the cost of drugs from any other source may apply to the county/municipal agency on a monthly basis for assistance in meeting excessive medical costs.

(c) When an individual's or family's income over and above the appropriate income level as explained in (d) below has been used to pay medical bills, any additional medical costs are considered excessive.

(d) For the purpose of determining excessive medical costs, the total available monthly income (see (e) below) of individuals, couples, or families with children is measured against the appropriate allowance standard. For elderly, blind, or disabled persons, the Medically Needy Program standard applies. For families with children, Schedule II applies (see N.J.A.C. 10:90-3.3(b) ). For all others, Schedule IV (see N.J.A.C. 10:90-3.5(b) ) or V (see N.J.A.C. 10:90-3.6(a) ), as appropriate, applies. Information about the current standards may be obtained by contacting the Division of Family Development.

(e) Form WFNJ/GA-19 will be used to determine income and the amount of excessive medical costs. Monthly earned income is adjusted by deducting any earned disregard, as appropriate (see N.J.A.C. 10:90-3.8), plus any child care necessary for employment of the parent(s) and/or court ordered support payments; no further disregards are recognized. This adjusted amount added to any unearned income equals the total monthly income available to the eligible unit.

(f) When the appropriate standard ((d) above) is subtracted from the total available income, the difference or "surplus" is the amount of medical expenses the client is expected to pay him or herself. When the client has proof of paid medical bills in the amount of the "surplus," the agency shall provide payment for any unpaid medical costs in excess of the "surplus," in accordance with the regulations and rates set forth in this subchapter.

(g)N.J.A.C. 10:90-1.2 and 2.11(b) shall constitute the application process relevant to the medically needy. See also N.J.A.C. 10:90-3.22 regarding redeterminations.

N.J. Admin. Code § 10:90-13.6

New Rule, R.1998 d.42, effective 1/20/1998.
See: 29 New Jersey Register 3971(b), 30 New Jersey Register 389(a).
Specially recodified from N.J.A.C. 10:90-3.5 and amended by R.2000 d.392, effective 9/1/2000 (to expire March 1, 2001).
See: 32 New Jersey Register 3615(a).
In (a), inserted a reference to NJ FamilyCare in the first sentence; and in (b), rewrote the first sentence.
Recodified from N.J.A.C. 10:90-3.5 and amended by R.2001 d.42, effective 12/27/2000.
See: 32 New Jersey Register 3615(a), 33 New Jersey Register 564(a).
In (a), inserted a reference to NJ FamilyCare in the first sentence; and in (b), rewrote the first sentence.
Amended by R.2003 d.226, effective 6/16/2003.
See: 34 New Jersey Register 2713(a), 35 New Jersey Register 2670(a).
In (a), deleted the reference to NJ FamilyCare; in (b), rewrote the first sentence.