Current through Register Vol. 56, No. 18, September 16, 2024
(a)
Determination of continuing eligibility: The eligibility of each case shall be
redetermined at least once every 12 months. This redetermination provides an
opportunity to evaluate the total situation and enables the eligibility worker
to ascertain whether the individual's eligibility has changed.
1. It shall be the agency's responsibility to
review indications of ineligibility as they occur and to discontinue Medicaid
Only eligibility when appropriate and without delay. The agency shall notify
each applicant/beneficiary of any agency decision that relates to his or her
eligibility status in accordance with the provisions of (d) below and
8.3.
2. The individual, or his or
her authorized representative, shall execute a formal written application, Form
PA-1G, Application and Affidavit for Medical Assistance Only (Aged, Blind, or
Disabled), for continuance of assistance at least once every 12
months.
(b) Process of
redetermination:
1. Redeterminations of
eligibility require the completion of Form PA-1G-NJR2 (Redetermination Form).
The CWA may require that the form be completed during a face-to-face interview.
However, at the option of the CWA, and with the approval of the beneficiary,
the face-to-face interview may be eliminated. Form PA-1G-NJR2 (Redetermination
Form) may be mailed to and completed by the beneficiary and mailed to the CWA.
All factors of eligibility subject to change (with the exception of disability
and blindness factors) must be verified or reverified.
i. When a loss of assistance will result, the
face-to-face interview shall be required, unless the agency documents a clear
refusal by the beneficiary to have a face-to-face meeting. Before benefits are
terminated, a beneficiary shall be offered a face-to-face home visit. The visit
shall not be required to be in the office, but at the beneficiary's request, in
the home.
2.
Redetermination of financial and resource eligibility: The eligibility worker
shall review all eligibility factors in accordance with the provisions set
forth in N.J.A.C. 10:71-3, 4, and 5. Particular attention shall be directed to
identification of any changes in resources and income.
3. Completion of the Medicaid Eligibility
Worksheet: It is the responsibility of the eligibility worker to complete a new
Form PA-1E when eligibility is to be continued, or terminated. A PR-1 Statement
of Income Available for Long Term Care Facility Payment should be prepared for
persons in institutions only when there is a change with regard to the amount
of income available for medical reimbursement.
4. Need for institutional care: Official
review of this factor on a routine basis is not required, but when medical or
social evidence indicates that specific determination should be made, the CWA
shall institute such an investigation.
(c) Recording and recommendation: A Summary
Report, Form PA-2D, concerning all pertinent information shall be completed for
each contact with the individual, whenever it occurs. Whenever a change in
circumstances affects any facet of eligibility, a Medicaid Eligibility
Worksheet (Form PA-1E) shall be prepared. The summary shall clearly state the
basis for any termination of eligibility. Following each redetermination of
eligibility, it is the responsibility of the eligibility worker to recommend
that eligibility be continued or terminated.
(d) Notice of agency decision: Each
applicant/beneficiary shall receive written notice of any agency decision which
relates to his or her eligibility status at least 10 days prior to any change
in his or her eligibility status.
