New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 69 - AFDC-RELATED MEDICAID
Subchapter 1 - AFDC-RELATED MEDICAID IN NEW JERSEY
Section 10:69-1.5 - Definitions
The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise.
"Adequate notice" means notice to a client of the county welfare agency (CWA) decision or action, which must state the nature, effective date, factual and legal basis of the decision or action, and the right to a fair hearing.
"Adjusted gross income" means, in self-employment, the net income as determined by subtracting the cost of producing the income from total gross earnings.
"AFDC" means the former Aid to Families with Dependent Children program.
"AFDC-related Medicaid" means medical assistance provided to families who would otherwise qualify for AFDC or deemed to qualify for AFDC if the program were still in existence.
"Agency" means the CWA.
"Applicant" means parent or parent-person who applies for AFDC-related Medicaid and whose application has not been officially acted upon by the CWA.
"Application process" means all activity performed by the eligibility staff until there is an official disposition of the application.
"Approved application" means an applicant has been determined to be eligible for AFDC-related Medicaid.
"Authorized representative" means an individual (or organization) whom a client designates orally or in writing to act on his or her behalf, or, in cases of incompetency, the person designated to act for the client.
"Beneficiary" means the family unit of parent(s) or parent-person(s) and child(ren) of eligible age who have been found eligible for AFDC-related Medicaid including any individual who is an eligible member of such family.
"Boarder, roomer, roomer-boarder" means a person, other than a member of an eligible unit, whose acceptance in the household is a business arrangement based upon payment in cash for board, room, or room and board.
"BQC" means the Bureau of Quality Control in the Division of Medical Assistance and Health Services.
"Calculated earned income" means amount of earned income remaining after applicable disregards and deductions have been subtracted from total gross earnings. This is the accountable amount to be used in determining the eligible unit's total income.
"Capacity of a legally responsible relative (LRR) to support" means the amount of contribution to be anticipated from an LRR.
"Caretaker relative" means the legally responsible adult or adults residing with the children for whom the application is being made.
"Carnegie unit" means the credit given for the successful completion of one year's study in one subject in a secondary school. Four Carnegie units per year represents full time attendance.
"Case record" means the official file of forms, chronological narrative, correspondence, and other documents pertinent to the application and eligibility of client case record. It constitutes a complete record which supports the decisions and actions of the CWA on a case.
"Categorical program" means a program established by the Federal Social Security Act for the purpose of enabling a state to furnish assistance to financially eligible individuals or families who meet specific eligibility requirements.
"CBOSS" means the county board of social services.
"CBOSS Director" means the county board of social services Director or staff member to whom he or she has delegated specified responsibility.
"Child born of unmarried parents" means a child born to a mother who is not married to the father of such child.
"Child of eligible age" means a child up to the age of 18 or a child up to the age of 19 if a full-time student in a secondary school, or in the equivalent level of vocational or technical training and reasonably expected to complete the program before reaching age 19.
"Client" means an all inclusive term including an applicant or beneficiary of Medicaid.
"Collateral investigations" means contacts with individuals other than members of the applicant's immediate household made with the knowledge and consent of the applicant(s).
"County board of social services" means the county agency designated to administer the AFDC-related Medicaid program.
"County residence" relates only to identification of the CWA charged by law with responsibility for the official receipt, registration, and processing of applications, and is not an eligibility requirement and does not limit the opportunity for any person residing in New Jersey to qualify for Medicaid.
"County welfare agency (CWA)" means that agency of county government, that is charged with the responsibility for determining eligibility for public assistance programs, including AFDC-related Medicaid, Temporary Assistance to Needy Families (TANF), the Supplemental Nutrition Assistance Program (SNAP), Medicaid and/or NJ FamilyCare. Depending on the county, the CWA might be identified as the board of social services, the welfare board, the division of welfare, or the division of social services.
"CSP" means Child Support and Paternity Program.
"CWA director" means the county welfare agency director or staff member to whom he or she has delegated a specified responsibility.
"DCP&P" means the Division of Child Protection and Permanency within DCF. This Division was formerly known as DYFS.
"DDD" means the Division of Developmental Disabilities in the Department of Human Services.
"Denied application" means a determination that, for a specific reason, the applicant is ineligible for AFDC-related Medicaid.
"Department of Children and Families (DCF)" means the New Jersey Department of Children and Families.
"Department of Human Services (DHS)" means the New Jersey Department of Human Services.
"Dependent child" means an eligible child, living in New Jersey with a parent or other enumerated relative.
"Deprivation" means where death, incapacity or continued absence of one or both natural or adoptive parents causes the loss of parental support.
"Desertion" denotes a willful abandonment of duty in violation of a legal obligation; failure to provide support and maintenance or to perform other duties owed to the family members, thus depriving them of care.
"DFD" means the Division of Family Development in the Department of Human Services.
"Dismissed application" means recognition that eligibility need not be considered further because the applicant moved to another state during the application process or cannot be located, or the application was registered in error.
"Disregards" means the amount discounted from income in the AFDC programs according to Federal and/or State regulations. (see N.J.A.C. 10:69-10)
"Division of Employment Services (DES)" means the office within the State Department of Labor responsible for administration of Unemployment Insurance and Temporary Disability Benefits programs.
"Division of Medical Assistance and Health Services" means office within the State Department of Human Services responsible for supervision of the administration of the AFDC-related Medicaid program.
"DMAHS" means Division of Medical Assistance and Health Services.
"DVRS" means the Division of Vocational and Rehabilitation Services in the Department of Human Services.
"DYFS" means the Division of Youth and Family Services in the Department of Human Services.
"Eligible medical institution" means a facility or specified section thereof certified as an approved institution for the purpose of treating acute illness (private or general hospitals) or providing care for the chronically ill (nursing homes or intermediate care facilities).
"Eligible unit" means those family members who apply for and are eligible to receive AFDC-related Medicaid.
"Emancipated" means a child released from the duty to serve and obey his or her parent(s) and having the right to his or her earnings. Emancipation may be expressed or implied from the circumstances.
"Family size" means, in an LRR's household, those persons identified in N.J.A.C. 10:69-3.31 (members of the eligible unit are not included).
"Financially eligible" means meeting the income standards in this chapter.
"Gross earned income" means the total earnings of members of the eligible unit before applicable disregards and deductions are subtracted.
"Head of household" means the individual who is recognized by other members of the household as having primary responsibility for financial control and direction of the household.
"Health Benefits Identification (HBID) Card" means a permanent, plastic identification card issued to each Medicaid beneficiary. The card is for identification purposes only; providers must verify eligibility in accordance with N.J.A.C. 10:49-2 before they provide services. The front of the card includes the beneficiary's name and a 16-digit card control number (CCN). The back of the card includes a magnetic strip that electronically stores the beneficiary's name and CCN.
"Health Benefits Identification (HBID) Emergency Services Letter" means a letter that contains pertinent information the provider will need to confirm eligibility and submit claims for services rendered to an eligible Medicaid beneficiary prior to the receipt of his or her HBID Card. The letter will include an expiration date indicating when the letter will no longer be acceptable as a substitute for the HBID Card.
"Incapacity" means physical or mental defect, illness or impairment, supported by competent medical testimony, of such a debilitating nature as to reduce substantially or eliminate the parent's ability to support or care for the otherwise eligible child, which is expected to last for a least 30 days.
"Incompetent (certified)" means certified by a court of law as incompetent.
"Inquiry" means any request for information about assistance programs which is not a request for application.
"Institution in New Jersey" means a total facility, or a designated part thereof, that include the following:
1. Hospital--general or special;
2. Nursing facility (NF);
3. Public psychiatric or tuberculosis hospital;
4. Certified section of State operated institution for the mentally retarded; or
5. Intermediate care facility for the mentally retarded (ICF/MR).
"Institution outside New Jersey" means a public or voluntary medical institution which is licensed, certified or approved by the proper authority of the jurisdiction in which the institution is located, so that the costs of care and services provided therein may be paid. Evidence of such license, certification or approval shall be obtained from the Division of Medical Assistance and Health Services.
"Legally responsible relative (LRR)" means a relative held to be legally responsible for the support and care of one or more relatives by the laws of this State, as identified in N.J.A.C. 10:69-3.31.
"LRR" means legally responsible relative.
"MACC" means a Medical Assistance Customer Center in the Division of Medical Assistance and Health Services.
"Mandatory payroll deductions" means deductions including, but not limited to, Federal, State, and city withholding taxes; Social Security; Medicare; unemployment compensation taxes; and garnishments as verified by legal document in possession of the employer.
"MDO" means Medicaid District Office in the Division of Medical Assistance and Health Services.
"Medicaid" means a Federal/State program administered by the Division of Medical Assistance and Health Services providing for payment of claims for and evaluation of health services.
"Medicaid Special" means Medicaid coverage available to any dependent child under 21 or an independent child under age 21, who meets the qualifications at N.J.A.C. 10:69-4.
"Needy person" means a person who lacks sufficient income and resources to maintain the AFDC-related Medicaid level of living.
"New application" means the filing of an application request for AFDC-related Medicaid from an individual/family who has never previously requested AFDC-related Medicaid in any county in the State under that program.
"N.J.A.C." means New Jersey Administrative Code.
"Noneligible person" means a person ineligible for AFDC-related Medicaid either due to age, relationship, or for incurring a penalty of ineligibility.
"Official discharge from an institution" means legal discharge of a patient from the institution in which he or she has been confined.
"Ownership of real or personal property" means any and all rights, title or interest, legal or equitable, to such property.
"Parent-minor" means a parent of a child or children who is himself or herself under the age of 18.
"Parent-person" means certain relatives of a child who, in the absence of a natural or adoptive parent, assume parental responsibility.
"Penalty of ineligibility" means when a member(s) of an eligible unit has incurred a penalty for not complying with program requirement(s) and such member(s) is excluded from the eligible unit.
"Pending application" is a general term for application, reapplication, reopened application, or transfer application prior to official disposition.
"Per capita" means an amount equal to one individual's share of the total (allowance, cost, income, etc.).
"Personal interview" means face-to-face discussion between individuals.
"Policy" means guidelines, limited by and consistent with law, which control CBOSS and DMAHS staff in carrying out AFDC-related Medicaid programs.
"Primary wage earner" means principal earner and shall be referred to as the principal earner in this chapter.
"Principal earner" means the parent who earned the greater amount of income in the 24-month period immediately preceding the month of application for AFDC-F.
"Reapplication" means a written request for AFDC-related Medicaid by an individual who has previously applied for, but never received, AFDC-related Medicaid under that program in any county in the State.
"Recovery" means the process whereby the CWA seeks the repayment of AFDC-related Medicaid improperly or properly obtained.
"Redetermination of eligibility" means investigation of all facts and circumstances relating to the beneficiary's application for continuation of AFDC-related Medicaid.
"Referral" means a request from an agency, institution, or individual on behalf of another individual who is interested in applying for AFDC-related Medicaid; or a request from the CWA to another agency.
"Registration" means the action of the CWA in creating an official record of and assigning a control number to an application.
"Rejected application" means an inclusive term covering applications which have been denied, dismissed, or withdrawn.
"Relatives, legally-responsible" means relatives held to be legally responsible by the laws of this State, as identified in N.J.A.C. 10:69-3.
"Release without discharge" means an arrangement under which a patient in an institution is, for a special purpose, permitted to reside outside the institution, and includes extended visit and convalescent leave.
"Reopened application" means a written request for Medicaid by an individual who has previously received AFDC-related Medicaid under that program in any county in the State.
"Request for local administrative review" means any clear expression (oral or written, by letter or otherwise) by a client or his or her authorized representative that he or she wishes to present his or her case in a proceeding before the CWA director or his or her delegated representative. This is not to be confused with a request for a fair hearing.
"Resident" means a person who is living in the State for other than a temporary purpose and who has no intention of moving from the State.
"Retirement, Survivors and Disability Insurance (RSDI)" means the Federal program administered by the Social Security Administration (SSA) which provides protection to workers and their families against loss or stoppage of earnings resulting from retirement at age 62 or older, death or disability.
"Return to state of origin" designates the desire of a family who has resided in New Jersey for a relatively short period to return to the state from which it came.
"RSDI" means Retirement, Survivors and Disability Insurance.
"Secondary school" means a traditional academic high school or a vocational/technical school of corresponding grade level, up to 12th grade, ranking between a primary school and a college or university.
"Social Security payment" means RSDI benefit.
"Sponsoring adult" means an individual 18 or older, including the applicant or the adult with whom the applicant resides, who may assist in making an application for presumptive eligibility. This definition is used for the application presumptive eligibility only (see N.J.A.C. 10:69-12).
"Spouse" means a husband or wife of a specified individual.
"SSA" means the Social Security Administration.
"SSI" means the Federal Supplemental Security Income Program, including State supplemental payments administered through this program for aged, blind or disabled of any age.
"State institution" means any institutional facility for the mentally ill or retarded, penal institution or veteran's hospital under the jurisdiction of the State of New Jersey.
"Total income" means the sum of all recognized income of the eligible unit, including unearned and calculated earned income.
"Transfer application" means a request for AFDC-related Medicaid for an individual who is presently receiving AFDC-related Medicaid under the same program in another county within the State.
"Vendor payment" means a check drawn to the order of a person or facility for providing goods or services to or for the client, representing payment for such goods or services.
"Withdrawn application" means an oral or written request by an applicant that the CWA terminate its activity on his or her application.
