N.J. Admin. Code § 10:71-8.2

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

Section 10:71-8.2 - Redetermination of medical eligibility

(a) Redetermination of disability and blindness factors shall be done for every Medicaid Only beneficiary at intervals set by the Division of Medical Assistance and Health Services, Medical Review Team (MRT), except those beneficiaries who are currently receiving SSA Disability Insurance Benefits. The redetermination review date is designated on Form PA-8, Record of Action: Medical Eligibility Factor (see 10:71-3.13(g) ).

(b) An individual who has been determined to be disabled or statutorily blind shall, if requested with reasonable notice, present himself or herself for and submit to examinations or tests, and shall submit medical and other evidence necessary for the purpose of determining whether he or she continues to be disabled or statutorily blind.

(c) In Medicaid Only cases, the CWA shall take into account the redetermination review date on Form PA-8 in scheduling both the annual review and interim visits. The CWA may adjust the date for case submittal to the Medical Review Team, to coincide as closely as is practical with either the annual review or with an interim visit, but such adjustment shall assure that the case will be submitted not more than two months earlier and in no event later than the date originally set on Form PA-8.

(d) The Medical Review Team will maintain a control file in order to ensure appropriate and timely reevaluation by the Medical Review Team. The Medical Review Team will notify the county welfare agency one month in advance of cases scheduled for such review by means of Form PA-655, Cases for Medical Review Team Reevaluation Due During the Month.

(e) The eligibility worker shall organize his or her caseload controls (notebooks, index, and other related materials or equipment) so that he or she will be alerted sufficiently in advance of redetermination review dates to enable him or her to obtain any specific medical information or reports requested on the last Form PA-8. The data and reports so submitted must be "current."

(f) When a case is to be submitted to the Medical Review Team for redetermination review, the eligibility worker shall prepare Form PA-6A, Interim Medical Social Report in detail. Form PA-6A shall be placed on top of all forms, reports and related data previously submitted.

(g) Medicaid coverage shall be continued, if financial and resource eligibility continues to exist, unless and until the CWA is advised by the Medical Review Team that the individual no longer meets the disability and blindness requirements or the individual withdraws voluntarily.

(h) Upon receipt of records from the Medical Review Team, the CWA shall follow the procedures as outlined in 10:71-3.13(g).

N.J. Admin. Code § 10:71-8.2

Amended by R.1995 d.651, effective 12/18/1995.
See: 27 N.J.R. 3543(a), 27 N.J.R. 5046(a).
Amended by R.2000 d.415, effective 10/16/2000.
See: 32 N.J.R. 2565(a), 32 N.J.R. 3844(a).
Rewrote the section.
Amended by R.2012 d.025, effective 2/6/2012.
See: 43 N.J.R. 804(a), 44 N.J.R. 230(a).
Substituted "CWA" for "CBOSS" and deleted "(MRT)" following "Medical Review Team" throughout; and in (d), substituted "Medical Review Team" for "medical review team (MRT)" and substituted "the county welfare agency" for "county board of social services".