N.J. Admin. Code § 10:71-5.6

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

Section 10:71-5.6 - Income eligibility standards

(a) Table B which follows shall be used to determine income eligibility for aged, blind, and disabled persons who make application for Medicaid Only benefits. The standard used for applicants/beneficiaries shall be determined in accordance with the following living arrangement categories. (For cases involving the deeming of income, this section shall be used in conjunction with 10:71-5.5) . The income eligibility standards in Table B which follows will be revised annually to reflect the annual cost-of-living adjustments to the SSI payment standards made by the Social Security Administration in accordance with 42 U.S.C. § 1382f. A notice of administrative changes containing the revisions will be published annually in the New Jersey Register.

(b) The income standard for Residential Health Care Facilities (RHCFs) (Table B, Figure I) shall be used for individuals/couples residing in such facilities which are licensed by the New Jersey Department of Health and Senior Services. Individuals in unlicensed facilities shall always be categorized as "living alone" (10:71-5.6(c) and Table B, II).

(c) The following provisions apply to non-institutional living arrangements:

1. The category "living alone" (Table B, Figure II) shall be used for individuals/couples who are:

i. Living physically alone;

ii. Living in a commercial establishment, such as a motel, hotel, rooming or boarding house (including type A, B and C, formerly known as unlicensed boarding homes) that holds itself open to the public as such;

iii. Living in a business-like arrangement;

iv. Purchasing or preparing food separately, which applies to persons living with others in a private dwelling, but separately purchasing or preparing their own food. The determination is based on the person's customary food purchase and preparation habits. Occasional joint purchase or preparation of food does not preclude a person from this classification;

v. Taking of all meals elsewhere, which applies to persons living with others in a private dwelling but taking all meals elsewhere; or

vi. Persons living as members of a household but having ownership or rental responsibility and paying more than their pro rata share of the household expenses (because other members are paying less) are considered to be living alone.

(1) It is assumed that a couple share rental or ownership responsibility. Therefore, the following steps are necessary to determine if the eligible individual with ineligible spouse and other household members is paying more than his or her pro rata share of household expenses.

(A) If the eligible individual's contributions (singly) are more than his or her pro rata share of household expenses, he or she will be considered living alone. If not, proceed to (c)1vi(1)(B) below.

(B) If the contributions of both the eligible individual and ineligible spouse to the household are more than their pro rata share, they shall be considered to be living alone. If their contribution is equal to or less than their pro rata share, the applicants/beneficiaries shall be considered to be living with others (see 10:71-5.6(c)3 ).

(C) Household expenses are limited to: food; mortgage or rental payments; real property taxes; heating fuel; gas; electricity; water; sewer; and garbage removal.

2. The category "living alone with ineligible spouse" (Table B, Figure III) applies when an individual lives with his or her ineligible spouse and there are no other persons who are part of the household. If any other persons, even minor children, are present in the same household, this category does not apply. Parents with minor children are always considered to be in the same household; therefore, the presence of minor children would result in the living arrangements described in either 10:71-5.6(c)3 or 4.

3. The category "living with others" (see Table B, Figure II) applies when the individual/couple resides with others and either:

i. Has ownership or rental liability and pays an amount equal to or less than pro rata share of household expenses (see 10:71-5.6(c)1 vi(1)(C)); or

ii. Does not have ownership or rental liability and is sharing household expenses with other members of the household. Sharing is defined as paying a pro rata share or more of household expenses (see 10:71-5.6(c)1 vi(1)(C)).

4. If the individual/couple lives in a household with adults other than a spouse and the living arrangement has not already been determined in 10:71-5.6(c)1, 2 or 3 above, the individual/couple may be considered to be living in the household of another (Table B, Figure IV). The specific criteria for categorization in this living arrangement is the receipt of both support and maintenance. That is, the individual/couple does not purchase either food or shelter separately in accordance with (c)4i below.

i. If meals are consumed by an individual/couple in the household and the individual/couple does not purchase either food or shelter separately, the individual/couple shall be considered living in the household of another.

(1) Separate purchase of food means that the individual/couple pays a pro rata share of the household's food or actually purchases food separately. An individual/couple receiving food stamps as a separate food stamp household shall be considered to be purchasing food separately.

(2) Separate purchase of shelter exists when the individual/couple contributes an amount equal to the pro rata share of the household's shelter expenses. Shelter expenses are limited to all items except "food" in 10:71-5.6(c)1 vi(1)(C).

ii. Persons determined to be living in the household of another shall not be considered to be receiving support and maintenance in-kind pursuant to 10:71-5.4(a)12 because such in-kind income has already been taken into account in the eligibility standards.

5. Table B follows:

Table B
Variations in Living Arrangements	Medicaid Eligibility Income Standards
Individual	Couple
I. Residential Health Care Facility	$ 931.05	$ 1,820.36
II. Living Alone or with Others	$ 752.25	$ 1,107.36
III. Living Alone or with Ineligible Spouse	$ 1,107.36
IV. Living in Household of Another	$ 524.98	$ 814.43
V. Title XIX Approved Facility: Includes persons in acute general hospitals, nursing facilities, intermediate care facilities/mental retardation (ICFMR) and licensed special hospitals (Class A, B, C) and Title XIX psychiatric hospitals (for persons under age 21 and age 65 and over) or a combination of such facilities	$ 2,163.00+

for a full calendar month.

+Gross income (that is, income prior to any income exclusions) is applied to this Medicaid "Cap."

(d) For the purpose of the Medicaid program, Title XIX approved facilities shall include acute care general hospitals, nursing facilities, intermediate care facilities for the mentally retarded (ICF/MR) and licensed special hospitals (Class A, B and C) and Title XIX psychiatric hospitals (for persons under age 21 and age 65 and over).

1. Persons are considered institutionalized if they enter a Title XIX approved facility and a physician has certified that the duration of stay in the Title XIX facility (or a combination of such facilities) is expected to be 30 consecutive days or more. Income eligibility shall be determined in accordance with the variations contained in 10:71-5.4(b). However, the income of the institutionalized individual shall not be reduced by any of the income exclusions found in 10:71-5.3.

2. Institutionalized individuals, identified in (d)1 above, who are found Program eligible will receive benefits as of the date of admission.

3. Persons in a facility which is not Title XIX approved or whose stay is expected to be a period of less than 30 consecutive days will have eligibility determined in accordance with the community living arrangement which existed prior to entering the facility.

4. Temporary absence from the institution: Any temporary absence, during which the individual remains a patient of the institution, does not interrupt a continuous stay in the institution.

5. Persons living in the community who do not otherwise qualify for Medicaid benefits and who elect to participate in the hospice program, or who are assigned a slot in the Global Options or other waiver programs, will have financial eligibility determined in the same manner as those who reside in an institution.

i. Such individuals who are found eligible will receive benefits on the date of the election of hospice benefits, or the date of assignment to a waiver slot, whichever is applicable.

(e) No portion of a cash reward provided to any individual by the Division for providing information about fraud and/or abuse in any program administered in whole or in part by the Division shall be included in the computation of income for financial eligibility purposes.

N.J. Admin. Code § 10:71-5.6

Administrative change, 47 N.J.R. 115(b).