N.J. Admin. Code § 10:70-2.1

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:70-2.1 - Application

(a) Application for the Medically Needy Program shall be accomplished by the completion and signing of Form PA-1G for SSI-related cases and Form PA-1J for AFDC-related cases, as well as, any addenda to those forms as prescribed by the Division of Medical Assistance and Health Services.

1. Application for the Program shall be executed by:

i. A parent, caretaker relative, or guardian for cases with children under the age of 21 residing with a parent or caretaker relative;

ii. A child age 18 or older when not residing with a parent or caretaker relative;

iii. A pregnant woman age 18 or older;

iv. The parent or caretaker relative of a disabled or blind child;

v. The adult seeking benefits as aged, blind, or disabled.

2. For cases which, because of confinement, illness, incapacity, disability, or lack of competence of the person(s) required to execute the application, and for children who not yet attained the age of 18, the application may be executed on such person's behalf by:

i. A relative by blood or marriage;

ii. A staff member of a public or private welfare agency of which the person seeking program benefits is a client, who has been designated by the agency to so act;

iii. The attorney or physician of the person seeking program benefits;

iv. A staff member of an institution or facility in which the person is receiving care, who has been designated by the institutional facility to so act.

3. A legal guardian shall be recognized as an authorized agent to initiate an application for the Medically Needy Program.

(b) The county board of social services, under policies and procedures established by the Division of Medical Assistance and Health Services, has the direct responsibility in the application process to:

1. Inform applicants of the purpose and the eligibility requirements for the Medically Needy Program, their rights and responsibilities under the Program, and of their right to a fair hearing;

2. Receive applications and review them for completeness, consistency, and reasonableness;

3. Assist program applicants in exploring their eligibility for program benefits;

4. Make known to program applicants, the appropriate resources and services both within the agency and the community; and

5. Assure the prompt and accurate submission of eligibility data to the Medicaid Status File for eligible persons and prompt notification to ineligible persons of the reasons for their ineligibility.

(c) As part of the application process, the program applicant has the responsibility to:

1. Complete, with assistance from the county board of social services as needed, any forms required as part of the application process;

2. Assist the county board of social services in securing evidence that verifies his or her statements;

3. Report any change in circumstances that may affect program eligibility or amount of benefits;

4. Provide the county board of social services evidence, as requested, of incurred medical expenses and liability for payment; and

5. If applicable, submit to examinations or tests and provide such medical and other evidence as may be necessary to determine disability or blindness.

(d) With the exceptions noted below, disposition of an application for the Medically Needy Program must be accomplished within 30 days of the date of application (or the date of the inquiry form PA-1C, if applicable) for AFDC-related cases and for persons applying on the basis of being aged. The disposition standard for the disabled and blind is 60 days from the date of application (or the date of the inquiry form PA-1C, if applicable).

1. "Disposition of the application" means the official determination by the county board of social services of application approval or rejection.

2. Disposition of the application may exceed the applicable processing standards when substantially reliable evidence of eligibility or entitlement is lacking at the end of the processing period. In such circumstances, the application may be continued in pending status. The county board of social services shall document that the delay in application processing resulted from one of the following:

i. Circumstances wholly within the applicant's control;

ii. A determination to afford the applicant, whose evidence of eligibility or entitlement is inconclusive, additional time to provide sufficient evidence of eligibility before final action on his or her application;

iii. An administrative or other emergency that could not reasonably be avoided; or

iv. Circumstances wholly outside the control of both the applicant and the county board of social services.

3. When application processing is delayed beyond the processing standards, the county board of social services shall provide to the program applicant written notification prior to the expiration of the processing period setting forth the specific reasons for the delay.

4. Each county board of social services director shall establish appropriate operational controls to expedite the processing of applications and assure maximum compliance with the processing standards.

i. The county board of social services shall maintain control records which identify all pending applications which did not meet the processing standards and the reason therefor. That record shall be adequate to make possible the preparation of reports of such information as may be requested by the Division of Medical Assistance and Health Services.

(e) The following actions on an application qualify as disposition of an application for purposes of the processing standards:

1. Approved: The applicant(s) has been determined eligible for participation in the Medically Needy Program;

2. Denied: The applicant(s) has been determined ineligible for participation in the Medically Needy Program;

3. Eligible pending spend-down: The applicant(s) is eligible for participation in the Medically Needy Program in all respects except that the countable income of the budget unit exceeds the medically needy income levels. Eligibility for program benefits may be established through medical spend-downs (see subchapter 6);

4. Dismissed: A decision by the county board of social services that the application process need not be completed because:

i. The death of the applicant(s) (the application process must be completed if there are unpaid medical bills for covered services incurred in either the retroactive coverage period or subsequent to program application or inquiry);

ii. The applicant(s) cannot be located;

iii. The application was registered in error;

iv. The applicant(s) moved out of the State during the application process (see N.J.A.C. 10:70-2.4 for a move to another county within the State during the application process).

5. Withdrawn: The applicant(s) request that eligibility for the Medically Needy Program not be considered further.

(f) The county board of social services is required by law (N.J.S.A. 30:6-1.2) to report to the Department of Human Services, Commission for the Blind and Visually Impaired, every individual coming to its attention who is known to be, or is believed likely to become, permanently blind. Such information shall be reported on a form prescribed by the Commission.

N.J. Admin. Code § 10:70-2.1

Amended by R.1991 d.331, effective 7/1/1991.
See: 23 N.J.R. 964(a), 23 N.J.R. 2042(a).
Word "collaborates" deleted in (c)2.
Amended by R.2006 d.364, effective 10/16/2006.
See: 38 N.J.R. 2368(a), 38 N.J.R. 4480(c).
Substituted "board of social services" for "welfare agency" throughout; in (b)4 and (c)4, added "and" at the end; in (d)2, inserted "applicable"; in (d)4i, substituted "board of social services shall" for "welfare agency will" and deleted "will" preceding "identify"; and in (f), updated N.J.S.A. reference.