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