N.J. Admin. Code § 10:49-2.8

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

Section 10:49-2.8 - Presumptive eligibility

(a) "Presumptive eligibility" means an expedited process whereby selected certified HealthStart Comprehensive Maternity Care providers make preliminary Medicaid eligibility determinations on behalf of pregnant women (see HealthStart in applicable Provider Services Manuals and N.J.A.C. 10:49-19). This is a preliminary process to determine presumptive eligibility prior to the determination of Medicaid eligibility or ineligibility by the CWA.

1. Approved HealthStart Maternity Care providers (independent clinics and hospital outpatient departments) may determine presumptive eligibility for pregnant women who require ambulatory prenatal services from Medicaid participating providers.

2. A NJ FamilyCare one-page application can be used to apply for presumptive eligibility (PE) for Medicaid/NJ FamilyCare services. This is the only application that the pregnant woman will need to complete. The HealthStart PE provider shall send a copy of the completed one-page application to the CWA to determine full Medicaid/NJ FamilyCare eligibility using the NJ FamilyCare application instructions and documentation requirements.

(b) A presumptively eligible pregnant woman is entitled to all Medicaid covered services with the exception of inpatient hospital and nursing facility care services. Although Medicaid HealthStart services must be provided only by a HealthStart provider, other Medicaid covered services may be provided to a presumptively eligible pregnant woman by any participating Medicaid provider.

(c) A presumptively eligible pregnant woman is eligible for a period of time, which will end:

1. If the woman has not provided verification documents to the CWA, on or before the last day of the month subsequent to the date of the presumptive eligibility determination; or

2. If the woman has provided verification documents to the CWA, by the last day of the month subsequent to the month in which she was determined presumptively eligible, or on the day eligibility or ineligibility for Medicaid benefits is determined by the CWA.

(d) A presumptively eligible pregnant woman will be issued a plastic Medicaid/NJ FamilyCare Health Benefits Identification (HBID) Card. This card is the only document acceptable for the identification of a presumptively eligible pregnant woman. The HBID Card is for identification purposes only and is not a proof of current eligibility.

1. As part of the presumptive eligibility process, a presumptively eligible pregnant woman will be given an HBID Emergency Services Letter to use as identification when seeking emergency services prior to receiving the HBID card in the mail (see Appendix, N.J.A.C. 10:49). This HBID Emergency Services Letter contains pertinent information, which the provider will need in order to submit claims for services provided to the beneficiary. This is not valid proof of eligibility for Medicaid/NJ FamilyCare and should not be used by the provider for presumptive eligibility purposes. A request for reimbursement based solely upon the presentation of the HBID Emergency Services Letter does not guarantee payment.

2. Even with the identification through the HBID Card, each time a service is rendered the provider shall verify the presumptive eligibility status of a pregnant woman, prior to the delivery of ambulatory services. Eligibility can be verified by calling the toll free telephone number listed on the HBID Card which is available seven days a week, 24 hours a day, inquiring online at http://www.njmmis.com or swiping the HBID card through the reader provided by an eligibility vendor.

3. A provider's failure to verify eligibility prior to the delivery of services shall result in the denial of payment for those services if the individual was not eligible at that time. The provider should note that a pregnant woman's presumptive eligibility may be terminated at any time.

N.J. Admin. Code § 10:49-2.8

Amended by R.1996 d.320, effective 7/15/1996.
See: 28 N.J.R. 1589(a), 28 N.J.R. 3572(a).
Recodified from N.J.A.C. 10:49-2.6 and amended by R.1997 d.354, effective 9/2/1997.
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
Substituted "CWA" for "county welfare agency" throughout; and in (a), inserted N.J.A.C references. Former section recodified to N.J.A.C. 10:49-2.8.
Recodified from N.J.A.C 10:49-2.7 by R.1998 d.116, effective 1/30/1998 (operative February 1, 1998; to expire July 31, 1998).
See: 30 N.J.R. 713(a).
Former N.J.A.C. 10:49-2.8, Medicaid retroactive eligibility, recodified as N.J.A.C. 10:49-2.9.
Adopted concurrent proposal, R.1998 d.426, effective 7/24/1998.
See: 30 N.J.R. 713(a), 30 N.J.R. 3034(a).
Readopted provisions of R.1998 d.116 without change.
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 (a) and in (c)2, substituted "CWA" for "CBOSS"; added (a)2; in (b), substituted "participating" for "appropriate"; in the introductory paragraph of (c), inserted a comma following "time"; in (c)1 and (c)2, substituted "provided verification documents to the CWA" for "filed an application with the CBOSS"; and rewrote the introductory paragraph of (d) and (d)1 and (d)2.