Current through Register Vol. 56, No. 18, September 16, 2024
(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
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 (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.
