N.J. Admin. Code § 10:91-3.1

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

Section 10:91-3.1 - Financial need standard and survey

(a) The financial need standard is a test which shall be used to determine a client's ability to pay for certain services. For those clients who qualify, the Commission shall provide the cost of these services. For clients who do not qualify, the standard establishes the level of their responsibility toward the cost of those services. The Financial Survey Form and the Financial Participation Worksheet are the documents used to gather and analyze information needed to determine financial eligibility. The exception is college tuition assistance where the Commission utilizes the standard forms required by many college applicants for financial aid.

(b) The following concerns the Financial Survey Form:

1. A financial survey form shall be completed for each new and readmitted client at the time of the first authorization for any services subject to financial need. The client supplies the information and the primary caseworker completes the form.

2. Survey forms shall not be mailed to clients for completion.

3. Income may be verified by pay stubs, or check stubs from pensions or benefits. The caseworker may request the previous year's income tax forms to identify any additional income or to verify the number of individuals reported as dependent on family income. Dependent refers to the total number of individuals dependent on family income, consistent with what is reported on IRS income tax forms.

4. A home occupied by a client as a residence is not counted as a resource. Income from property shall be counted after deducting the cost of operation and maintenance from the gross income received.

5. Existing insurance policies shall not be counted as a resource but clients are advised to check to see whether they are eligible for disability payments. Disability payments received shall be counted as income at the time they are received.

6. Personal effects such as personal apparel, jewelry, and household effects shall not be counted as a resource.

7. The client or parents shall be told that the financial survey form and financial participation worksheet shall become part of the client's confidential case record.

8. Client or parent refusal to provide financial information or to sign the financial survey form shall be noted in the client's case record.

9. A copy of the completed survey shall be offered to the client, and mailed if requested.

10. The Financial Survey Form is as follows:

FINANCIAL SURVEY FORM

1. Client Name and SS#

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2. Counselor and date

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ANNUAL FAMILY INCOME:

3. Amount of Gross Pay of Client (Before Deductions)

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4. Amount of Husband/Father Gross Pay (If applicable)

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5. Amount of Wife/Mother Gross Pay (If applicable)

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6. Amount of Guardian and/or other contributing family member Gross Pay

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In items 7 through 16, list the amount, how often paid and when benefits will cease:

7. Unemployment/Temporary Disability Insurance

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8. Worker's Compensation

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9. VA Pension

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10. Supplemental Security Income

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11. Social Security Retirement or Disability

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12. Welfare

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13. Income from property

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14. Alimony or child support

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15. Other income (specify)

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16. GROSS TOTAL CASH INCOME FROM ALL SOURCES (TOTAL LINES 3-15)

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17. Total Number of Persons Depending on Family Income, Including Client

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MEDICAL INSURANCE: (Check appropriate Space) ... Blue Cross; ... Blue Shield; ... Rider J or Major Medical; ... Medicare-Part A ... or Part B ...; ... Medicaid; ... Other; Specify ...

The information given above is a true statement of my financial condition.

Signature of Client/Guardian

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A review of the information on this form on the following date(s) indicates that there had not been a substantial change in the client's financial situation:

Date No. 1:

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Date No. 2:

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Date No. 3:

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Date No. 4:

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(c) The Financial Participation Scale at 10:91-3.4(a) establishes the client's level of financial responsibility toward the cost of the service(s) or equipment.

(d) The Financial Participation Worksheet includes the following instructions and calculation:

1. Enter the cost of the services in the space "A" below;

2. Locate the Sliding Fee scale corresponding to the family size and identify the income range into which the annual gross income fits. (See line 16 on the Financial Survey Form);

3. Locate the applicable percentage to the right of that range. Enter that percentage in the space "B" below;

4. Multiply the cost of the services by that percentage; and

5. The result obtained is to be written at "C" below. This is the amount of the consumer's financial participation in the acquisition of the services.

A.	.............	x	B.	...................	=	C.	.......................
	Cost of			Applicable			Amount of Consumer's
	Services			percentage			Participation

ANNUAL FINANCIAL CONTRIBUTION ARRANGEMENT: (See 10:91-3.4 )

N.J. Admin. Code § 10:91-3.1