New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 49 - ADMINISTRATION MANUAL
Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES
Section 10:49-2.19 - Medicaid or NJ FamilyCare eligibility-aliens

For any alien who does not qualify for Medicaid or NJ FamilyCare-Plan A based on his or her alien status, and thus is potentially eligible for Medicaid or NJ FamilyCare-Plan A payment for emergency services only (see 10:49-5.4, Medicaid or NJ FamilyCare-Plan A Emergency Services for Aliens) the provider of service shall complete a Form PA-1C and submit it with Certification of Treatment of Emergency Medical Condition (if necessary) to the eligibility determination agency in the county in which the individual lives. The provider shall inform the individual that a Form PA-1C does not establish Medicaid eligibility or NJ FamilyCare-Plan A eligibility but serves only to protect the date of inquiry as an application date for Medicaid, or NJ FamilyCare-Plan A if an application is filed within three months of the date that the Form PA-1C is signed. The individual should be advised to file an application with the eligibility determination agency as soon as possible.