N.J. Admin. Code § 10:49-2.3
Current through Register Vol. 56, No. 21, November 4, 2024
Section 10:49-2.3 - Persons eligible under the Medically Needy program(a) The eligibility rules for persons eligible under the Medically Needy program are included in N.J.A.C. 10:70.(b) A Medicaid beneficiary under the Medically Needy program is limited to those medical services listed in 10:49-5.3. Services shall be provided in conjunction with specific program requirements as outlined in the second chapter of the applicable Provider Services Manual.(c) To be determined Medically Needy under the Medicaid Program, it is necessary for the person to meet categorical eligibility requirements, have income and/or resources in excess of the categorical standards, and have insufficient funds to meet his or her medical expenses. Medically Needy persons shall be in one of the following groups: 2. Needy children (under 21 years of age); or3. The aged (65 years of age or older), the blind or the disabled.(d) There are special income and resource levels established for the Medically Needy. If a person meets one of the categories listed in (c) above and has income and/or resources above categorical program levels but less than or equal to the Medically Needy income and resource levels, he or she shall be determined as Medically Needy eligible. However, if a person meets one of the categories listed in (c) above and meets the Medically Needy resource level but has income which exceeds the Medically Needy income level, eligibility may be established through the "spend-down" process.1. "Spend-down" is the process whereby a person may apply incurred medical expenses to offset income above the Medically Needy income level, and thereby adjust his or her income to meet the Medically Needy income limit.(e) Medically Needy eligibility for all groups, including the aged, blind and disabled, shall be determined by the CWA for both the retroactive and prospective period. 1. Each Medically Needy applicant/beneficiary shall reapply for benefits every six months. Eligibility may be established the first day of that six-month period or on any date during the six-month period that spend-down is met.2. Eligibility shall be verified by providers on each visit by reviewing the Medicaid Eligibility Identification Card (MEI) (FD-73/l78) (see N.J.A.C. 10:49-2.14 --Validation Form). For those cards issued for the month within the six month period in which the spend-down is met, the card will reflect the date that eligibility begins after the spend-down is met.(f) Claims for Medically Needy covered services provided during an eligible period may be submitted to the program for reimbursement using standard Medicaid procedures. Services provided prior to the effective date of eligibility shall be the client's liability, except for certain "special" claims. 1. "Special" claims are claims for Medically Needy covered services that were not used to meet the spend-down and were rendered between the first of the month in which eligibility is established and the date of eligibility.2. The CWA shall identify "special" claims, which may be reimbursed under the program and shall provide a Medically Needy Claim Transmittal (Form FD-311, see Appendix, N.J.A.C. 10:49). Such claims shall be submitted hard copy with Form FD-311 attached.N.J. Admin. Code § 10:49-2.3
Amended by R.1997 d.354, effective 9/2/1997.
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
Inserted new (a); recodified former (a) through (e) as (b) through (f); in (b) and (e)1, substituted "Medicaid beneficiary" for "Medicaid recipient"; in (d), amended internal cites; and in (e)2, amended N.J.A.C. reference.
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
In the introductory paragraph of (e) and in (f)2, substituted "CWA" for "CBOSS"; in (f)1, deleted "that appears on the Medicaid Eligibility Identification Card" from the end; and in (f)2, inserted a comma following the first occurrence of "claims".