N.J.S.A. 30:4D-3 — Definitions.

30:4D-3 Definitions. 3. Definitions. As used in P.L.1968, c.413 (C.30:4D-1 et seq.), and unless the context otherwise requires: a. "Applicant" means any person who has made application for purposes of becoming a "qualified applicant." b. "Commissioner" means the Commissioner of Human Services. c. "Department" means the Department of Human Services, which is herein designated as the single State agency to administer the provisions of this act. d. "Director" means the Director of the Division of Medical Assistance and Health Services. e. "Division" means the Division of Medical Assistance and Health Services. f. "Medicaid" means the New Jersey Medical Assistance and Health Services Program. g. "Medical assistance" means payments on behalf of recipients to providers for medical care and services authorized under P.L.1968, c.413. h. "Provider" means any person, public or private institution, agency, or business concern approved by the division lawfully providing medical care, services, goods, and supplies authorized under P.L.1968, c.413, holding, where applicable, a current valid license to provide such services or to dispense such goods or supplies. i. "Qualified applicant" means a person who is a resident of this State, and either a citizen of the United States or an eligible alien, and is determined to need medical care and services as provided under P.L.1968, c.413, with respect to whom the period for which eligibility to be a recipient is determined shall be the maximum period permitted under federal law, and who: (1) Is a dependent child or parent or caretaker relative of a dependent child who would be, except for resources, eligible for the aid to families with dependent children program under the State Plan for Title IV-A of the federal Social Security Act as of July 16, 1996; (2) Is a recipient of Supplemental Security Income for the Aged, Blind and Disabled under Title XVI of the Social Security Act; (3) Is an "ineligible spouse" of a recipient of Supplemental Security Income for the Aged, Blind and Disabled under Title XVI of the Social Security Act, as defined by the federal Social Security Administration; (4) Would be eligible to receive Supplemental Security Income under Title XVI of the federal Social Security Act or, without regard to resources, would be eligible for the aid to families with dependent children program under the State Plan for Title IV-A of the federal Social Security Act as of July 16, 1996, except for failure to meet an eligibility condition or requirement imposed under such State program which is prohibited under Title XIX of the federal Social Security Act such as a durational residency requirement, relative responsibility, consent to imposition of a lien; (5) (Deleted by amendment, P.L.2000, c.71). (6) Is an individual under 21 years of age who, without regard to resources, would be, except for dependent child requirements, eligible for the aid to families with dependent children program under the State Plan for Title IV-A of the federal Social Security Act as of July 16, 1996, or groups of such individuals, including but not limited to, children in resource family placement under supervision of the Division of Child Protection and Permanency in the Department of Children and Families whose maintenance is being paid in whole or in part from public funds, children placed in a resource family home or institution by a private adoption agency in New Jersey or children in intermediate care facilities, including developmental centers for the developmentally disabled, or in psychiatric hospitals; (7) Would be eligible for the Supplemental Security Income program, but is not receiving such assistance and applies for medical assistance only; (8) Is determined to be medically needy and meets all the eligibility requirements described below: (a) The following individuals are eligible for services, if they are determined to be medically needy: (i) Pregnant women; (ii) Dependent children under the age of 21; (iii) Individuals who are 65 years of age and older; and (iv) Individuals who are blind or disabled pursuant to either 42 C.F.R.435.530 et seq. or 42 C.F.R.435.540 et seq., respectively. (b) The following income standard shall be used to determine medically needy eligibility: (i) For one person and two person households, the income standard shall be the maximum allowable under federal law, but shall not exceed 133 1/3% of the State's payment level to two person households under the aid to families with dependent children program under the State Plan for Title IV-A of the federal Social Security Act in effect as of July 16, 1996; and (ii) For households of three or more persons, the income standard shall be set at 133 1/3% of the State's payment level to similar size households under the aid to families with dependent children program under the State Plan for Title IV-A of the federal Social Security Act in effect as of July 16, 1996. (c) The following resource standard shall be used to determine medically needy eligibility: (i) For one person households, the resource standard shall be 200% of the resource standard for recipients of Supplemental Security Income pursuant to 42 U.S.C. s.1382(1)(B); (ii) For two person households, the resource standard shall be 200% of the resource standard for recipients of Supplemental Security Income pursuant to 42 U.S.C. s.1382(2)(B); (iii) For households of three or more persons, the resource standard in subparagraph (c)(ii) above shall be increased by $100.00 for each additional person; and (iv) The resource standards established in (i), (ii), and (iii) are subject to federal approval and the resource standard may be lower if required by the federal Department of Health and Human Services. (d) Individuals whose income exceeds those established in subparagraph (b) of paragraph (8) of this subsection may become medically needy by incurring medical expenses as defined in 42 C.F.R.435.831(c) which will reduce their income to the applicable medically needy income established in subparagraph (b) of paragraph (8) of this subsection. (e) A six-month period shall be used to determine whether an individual is medically needy. (f) Eligibility determinations for the medically needy program shall be administered as follows: (i) County welfare agencies and other entities designated by the commissioner are responsible for determining and certifying the eligibility of pregnant women and dependent children. The division shall reimburse county welfare agencies for 100% of the reasonable costs of administration which are not reimbursed by the federal government for the first 12 months of this program's operation. Thereafter, 75% of the administrative costs incurred by county welfare agencies which are not reimbursed by the federal government shall be reimbursed by the division; (ii) The division is responsible for certifying the eligibility of individuals who are 65 years of age and older and individuals who are blind or disabled. The division may enter into contracts with county welfare agencies to determine certain aspects of eligibility. In such instances the division shall provide county welfare agencies with all information the division may have available on the individual. The division shall notify all eligible recipients of the Pharmaceutical Assistance to the Aged and Disabled program, P.L.1975, c.194 (C.30:4D-20 et seq.) on an annual basis of the medically needy program and the program's general requirements. The division shall take all reasonable administrative actions to ensure that Pharmaceutical Assistance to the Aged and Disabled recipients, who notify the division that they may be eligible for the program, have their applications processed expeditiously, at times and locations convenient to the recipients; and (iii) The division is responsible for certifying incurred medical expenses for all eligible persons who attempt to qualify for the program pursuant to subparagraph (d) of paragraph (8) of this subsection; (9) (a) Is a child who is at least one year of age and under 19 years of age and, if older than six years of age but under 19 years of age, is uninsured; and (b) Is a member of a family whose income does not exceed 133% of the poverty level and who meets the federal Medicaid eligibility requirements set forth in section 9401 of Pub.L.99-509 (42 U.S.C. s.1396a); (10) Is a pregnant woman who is determined by a provider to be presumptively eligible for medical assistance based on criteria established by the commissioner, pursuant to section 9407 of Pub.L.99-509 (42 U.S.C. s.1396a(a)); (11) Is an individual 65 years of age and older, or an individual who is blind or disabled pursuant to section 301 of Pub.L.92-603 (42 U.S.C. s.1382c), whose income does not exceed 100% of the poverty level, adjusted for family size, and whose resources do not exceed 100% of the resource standard used to determine medically needy eligibility pursuant to paragraph (8) of this subsection; (12) Is a qualified disabled and working individual pursuant to section 6408 of Pub.L.101-239 (42 U.S.C. s.1396d) whose income does not exceed 200% of the poverty level and whose resources do not exceed 200% of the resource standard used to determine eligibility under the Supplemental Security Income Program, P.L.1973, c.256 (C.44:7-85 et seq.); (13) Is a pregnant woman or is a child who is under one year of age and is a member of a family whose income does not exceed 185% of the poverty level and who meets the federal Medicaid eligibility requirements set forth in section 9401 of Pub.L.99-509 (42 U.S.C. s.1396a), except that a pregnant woman who is determined to be a qualified applicant shall, notwithstanding any change in the income of the family of which she is a member, continue to be deemed a qualified applicant until the end of the 60-day period beginning on the last day of her pregnancy; (14) (Deleted by amendment, P.L.1997, c.272). (15) (a) Is a specified low-income Medicare beneficiary pursuant to 42 U.S.C. s.1396a(a)10(E)iii whose resources beginning January 1, 1993 do not exceed 200% of the resource standard used to determine eligibility under the Supplemental Security Income program, P.L.1973, c.256 (C.44:7-85 et seq.) and whose income beginning January 1, 1993 does not exceed 110% of the poverty level, and beginning January 1, 1995 does not exceed 120% of the poverty level. (b) An individual who has, within 36 months, or within 60 months in the case of funds transferred into a trust, of applying to be a qualified applicant for Medicaid services in a nursing facility or a medical institution, or for home or community-based services under section 1915(c) of the federal Social Security Act (42 U.S.C. s.1396n(c)), disposed of resources or income for less than fair market value shall be ineligible for assistance for nursing facility services, an equivalent level of services in a medical institution, or home or community-based services under section 1915(c) of the federal Social Security Act (42 U.S.C. s.1396n(c)). The period of the ineligibility shall be the number of months resulting from dividing the uncompensated value of the transferred resources or income by the average monthly private payment rate for nursing facility services in the State as determined annually by the commissioner. In the case of multiple resource or income transfers, the resulting penalty periods shall be imposed sequentially. Application of this requirement shall be governed by 42 U.S.C. s.1396p(c). In accordance with federal law, this provision is effective for all transfers of resources or income made on or after August 11, 1993. Notwithstanding the provisions of this subsection to the contrary, the State eligibility requirements concerning resource or income transfers shall not be more restrictive than those enacted pursuant to 42 U.S.C. s.1396p(c). (c) An individual seeking nursing facility services or home or community-based services and who has a community spouse shall be required to expend those resources which are not protected for the needs of the community spouse in accordance with section 1924(c) of the federal Social Security Act (42 U.S.C. s.1396r-5(c)) on the costs of long-term care, burial arrangements, and any other expense deemed appropriate and authorized by the commissioner. An individual shall be ineligible for Medicaid services in a nursing facility or for home or community-based services under section 1915(c) of the federal Social Security Act (42 U.S.C. s.1396n(c)) if the individual expends funds in violation of this subparagraph. The period of ineligibility shall be the number of months resulting from dividing the uncompensated value of transferred resources and income by the average monthly private payment rate for nursing facility services in the State as determined by the commissioner. The period of ineligibility shall begin with the month that the individual would otherwise be eligible for Medicaid coverage for nursing facility services or home or community-based services. This subparagraph shall be operative only if all necessary approvals are received from the federal government including, but not limited to, approval of necessary State plan amendments and approval of any waivers; (16) Subject to federal approval under Title XIX of the federal Social Security Act, is a dependent child, parent or specified caretaker relative of a child who is a qualified applicant, who would be eligible, without regard to resources, for the aid to families with dependent children program under the State Plan for Title IV-A of the federal Social Security Act as of July 16, 1996, except for the income eligibility requirements of that program, and whose family earned income, (a) if a dependent child, does not exceed 133% of the poverty level; and (b) if a parent or specified caretaker relative, beginning September 1, 2005 does not exceed 100% of the poverty level, beginning September 1, 2006 does not exceed 115% of the poverty level and beginning September 1, 2007 does not exceed 133% of the poverty level, plus such earned income disregards as shall be determined according to a methodology to be established by regulation of the commissioner; The commissioner may increase the income eligibility limits for children and parents and specified caretaker relatives, as funding permits; (17) Is an individual from 18 through 20 years of age who is not a dependent child and would be eligible for medical assistance pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), without regard to income or resources, who, on the individual's 18th birthday was in resource family care under the care and custody of the Division of Child Protection and Permanency in the Department of Children and Families and whose maintenance was being paid in whole or in part from public funds; (18) Is a person 16 years of age or older and who is permanently disabled and working, and who pays the premium contribution and other cost sharing as established by the commissioner based solely on the applicant's earned and unearned income, subject to the limits and conditions of federal law. A qualified applicant pursuant to this paragraph shall: (a) not be subject to any eligibility requirements regarding the earned or unearned income of the applicant or the applicant's spouse; and (b) remain eligible for medical care and services as provided under P.L.1968, c.413 for up to a period of one year if, through no fault of the applicant, a job loss occurs; (19) Is an uninsured individual under 65 years of age who: (a) has been screened for breast or cervical cancer under the federal Centers for Disease Control and Prevention breast and cervical cancer early detection program; (b) requires treatment for breast or cervical cancer based upon criteria established by the commissioner; (c) has an income that does not exceed the income standard established by the commissioner pursuant to federal guidelines; (d) meets all other Medicaid eligibility requirements; and (e) in accordance with Pub.L.106-354, is determined by a qualified entity to be presumptively eligible for medical assistance pursuant to 42 U.S.C. s.1396a(aa), based upon criteria established by the commissioner pursuant to section 1920B of the federal Social Security Act (42 U.S.C. s.1396r-1b); (20) Subject to federal approval under Title XIX of the federal Social Security Act, is a single adult or couple, without dependent children, whose income in 2006 does not exceed 50% of the poverty level, in 2007 does not exceed 75% of the poverty level and in 2008 and each year thereafter does not exceed 100% of the poverty level; except that a person who is a recipient of Work First New Jersey general public assistance, pursuant to P.L.1947, c.156 (C.44:8-107 et seq.), shall not be a qualified applicant; or (21) is an individual who: (a) has an income that does not exceed the highest income eligibility level for pregnant women established under the State plan under Title XIX or Title XXI of the federal Social Security Act; (b) is not pregnant; and (c) is eligible to receive family planning services provided under the Medicaid program pursuant to subsection k. of section 6 of P.L.1968, c.413 (C.30:4D-6) and in accordance with 42 U.S.C. s.1396a(ii). j. "Recipient" means any qualified applicant receiving benefits under this act. k. "Resident" means a person who is living in the State voluntarily with the intention of making his home here and not for a temporary purpose. Temporary absences from the State, with subsequent returns to the State or intent to return when the purposes of the absences have been accomplished, do not interrupt continuity of residence. l. "State Medicaid Commission" means the Governor, the Commissioner of Human Services, the President of the Senate and the Speaker of the General Assembly, hereby constituted a commission to approve and direct the means and method for the payment of claims pursuant to P.L.1968, c.413. m. "Third party" means any person, institution, corporation, insurance company, group health plan as defined in section 607(1) of the federal "Employee Retirement and Income Security Act of 1974," 29 U.S.C. s.1167(1), service benefit plan, health maintenance organization, or other prepaid health plan, or public, private or governmental entity who is or may be liable in contract, tort, or otherwise by law or equity to pay all or part of the medical cost of injury, disease or disability of an applicant for or recipient of medical assistance payable under P.L.1968, c.413. n. "Governmental peer grouping system" means a separate class of skilled nursing and intermediate care facilities administered by the State or county governments, established for the purpose of screening their reported costs and setting reimbursement rates under the Medicaid program that are reasonable and adequate to meet the costs that must be incurred by efficiently and economically operated State or county skilled nursing and intermediate care facilities. o. "Comprehensive maternity or pediatric care provider" means any person or public or private health care facility that is a provider and that is approved by the commissioner to provide comprehensive maternity care or comprehensive pediatric care as defined in subsection b. (18) and (19) of section 6 of P.L.1968, c.413 (C.30:4D-6). p. "Poverty level" means the official poverty level based on family size established and adjusted under Section 673(2) of Subtitle B, the "Community Services Block Grant Act," of Pub.L.97-35 (42 U.S.C. s.9902(2)). q. "Eligible alien" means one of the following: (1) an alien present in the United States prior to August 22, 1996, who is: (a) a lawful permanent resident; (b) a refugee pursuant to section 207 of the federal "Immigration and Nationality Act" (8 U.S.C. s.1157); (c) an asylee pursuant to section 208 of the federal "Immigration and Nationality Act" (8 U.S.C. s.1158); (d) an alien who has had deportation withheld pursuant to section 243(h) of the federal "Immigration and Nationality Act" (8 U.S.C. s.1253 (h)); (e) an alien who has been granted parole for less than one year by the U.S. Citizenship and Immigration Services pursuant to section 212(d)(5) of the federal "Immigration and Nationality Act" (8 U.S.C. s.1182(d)(5)); (f) an alien granted conditional entry pursuant to section 203(a)(7) of the federal "Immigration and Nationality Act" (8 U.S.C. s.1153(a)(7)) in effect prior to April 1, 1980; or (g) an alien who is honorably discharged from or on active duty in the United States armed forces and the alien's spouse and unmarried dependent child. (2) An alien who entered the United States on or after August 22, 1996, who is: (a) an alien as described in paragraph (1)(b), (c), (d) or (g) of this subsection; or (b) an alien as described in paragraph (1)(a), (e) or (f) of this subsection who entered the United States at least five years ago. (3) A legal alien who is a victim of domestic violence in accordance with criteria specified for eligibility for public benefits as provided in Title V of the federal "Illegal Immigration Reform and Immigrant Responsibility Act of 1996" (8 U.S.C. s.1641). L.1968, c.413, s.3; amended 1969, c.225; 1971, c.209, s.13; 1972, c.152; 1979, c.365, s.2; 1985, c.303, s.4; 1985, c.371, s.1; 1985, c.474, s.1, 1985, c.371, s.5 amended 1985, c.510; 1987, c.115, s.2; 1987, c.349; 1991, c.20, s.1; 1991, c.187, s.41; 1991, c.328; 1992, c.208, s.1; 1994, c.65; 1995, c.153, s.1; 1995, c.292, s.1; 1997, c.13, s.10; 1997, c.272, s.5; 1997, c.352, s.1; 2000, c.71, s.7; 2000, c.116, s.1; 2001, c.122, s.1; 2001, c.186, s.1; 2004, c.130, s.93; 2005, c.156, s.8; 2005, c.169, s.17; 2006, c.47, s.159; 2012, c.16, s.114; 2018, c.1, s.1; 2021, c.344, s.1. 30:4D-3a. "Invalid coach service" deemed to mean "mobility assistance vehicle service" 4. Whenever the term "invalid coach service" occurs or any reference is made thereto in any law, contract or document which pertains to the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), the same shall be deemed to mean or refer to "mobility assistance vehicle service." L.1997,c.102,s.4. 30:4D-3b Establishment of enrollment simplification practices. 9. No later than January 1, 2006, the Commissioner of Human Services shall, at a minimum, establish the following enrollment simplification practices for dependent children and their parents or specified caretaker relatives who are applicants for or recipients of the Medicaid program: a. A streamlined application form as established pursuant to subsection k. of section 5 of P.L.2005, c.156 (C.30:4J-12); b. Require new applicants to submit one recent pay stub from the applicant's employer, or, if the applicant has more than one employer, one from each of the applicant's employers, to verify income. In the event the applicant cannot provide a recent pay stub, the applicant may submit another form of income verification as deemed appropriate by the commissioner. If an applicant does not submit income verification in a timely manner, before determining the applicant ineligible for the program, the commissioner shall seek to verify the applicant's income by reviewing available Department of the Treasury and Department of Labor and Workforce Development records concerning the applicant and such other records as the commissioner determines appropriate. The commissioner shall establish retrospective auditing or income verification procedures, such as sample auditing and matching reported income with records of the Department of the Treasury and the Department of Labor and Workforce Development and such other records as the commissioner determines appropriate. In matching reported income with confidential records of the Department of the Treasury, the commissioner shall require an applicant to provide written authorization for the Division of Taxation in the Department of the Treasury to release applicable tax information to the commissioner for the purposes of establishing income eligibility for the program. The authorization, which shall be included on the program application form, shall be developed by the commissioner, in consultation with the State Treasurer; c. Online enrollment and renewal, in addition to enrollment and renewal by mail. The online enrollment and renewal forms shall include electronic links to other State and federal health and social services programs; d. Continuous enrollment; e. Simplified renewal by sending a recipient a preprinted renewal form and requiring the recipient to sign and return the form, with any applicable changes in the information provided in the form, prior to the date the recipient's annual eligibility expires. The commissioner shall establish such auditing or income verification procedures as provided in subsection b. of this section; and f. Provision of program eligibility-identification cards that are issued no more frequently than once a year. L.2005, c.156, s.9; amended 2008, c.53, s.1. 30:4D-3b1 Permanent change of station order, residency requirement, Division of Medical Assistance and Health Services; definitions. 1. a. Notwithstanding any other law to the contrary, the Division of Medical Assistance and Health Services within the Department of Human Services shall accept a permanent change of station order to a duty location located in New Jersey, issued by any branch of the United States military to the parent or legal guardian of an applicant, for the purposes of satisfying the residency requirement for the provision of home and community based services reimbursed by the Medicaid program. b. For the purpose of this section: "Legal guardian" means a person who exercises continuing control over the person or property, or both, of an individual, pursuant to a court order. "Medicaid program" means the program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "Permanent change of station order" means the official documentation issued by a branch of the United States military to an active duty member requiring the member's relocation, along with the relocation of any dependents living with the member, from one duty location to another. L.2022, c.84, s.1. 30:4D-3c Information technology platform relative to eligibility determination for Medicaid, NJ FamilyCare. 1. a. The Commissioner of Human Services shall develop an information technology platform for use by the State, county welfare agencies, and State contractors for the purpose of intake, processing, and tracking of applications for benefits under the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) and the NJ FamilyCare program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.). The goals of the system shall be: to simplify the applications and eligibility determination processes for both applicants and eligibility determination staff; to standardize the application of eligibility policy across the various agencies responsible for eligibility determination; to allow for real-time tracking of the status of applications; to allow the rapid exchange of data relevant to applications among various State and county agencies and contractors; and to provide a platform to expand the system to encompass other social service program applications and eligibility determinations as the technology permits. b. The Commissioner of Human Services shall establish a system to evaluate the performance of all entities responsible for intake and processing of applications for the Medicaid and NJ FamilyCare programs, including all county welfare agencies and the State's contracted health benefits coordinator. The system shall allow for the measurement of a set of relevant common metrics, including but not limited to: the number of complete and incomplete applications of each type received; the time between receipt of completed applications and the completion of the eligibility determination; the time between receipt of an application and the request for supporting documentation sent to the applicant; the number of applicants granted extensions; and the accuracy of eligibility determinations. Nothing in this section shall be construed to permit a county welfare agency to deny an application for which an applicant requires additional time to provide information or documentation to a county welfare agency, and a county welfare agency shall grant extensions, as appropriate,when needed. The Commissioner shall annually publish on the Department of Human Services website, the results, including those for each of the common metrics and by individual entity, of the performance evaluation system to be established pursuant to this section. c. The Commissioner of Human Services shall establish a system of rewards and penalties for all entities responsible for intake, processing of applications, and processing of redetermination applications that provides incentives for performance on the metrics established pursuant to subsection b. of this section. This system shall include incentives for county welfare agencies to streamline their processes and utilize the information technology platform required by subsection a. of this section. d. The Commissioner of Human Services shall designate a customer service liaison team, which shall be composed of employees of the Department of Human Services, to receive complaints that result from the eligibility application process. The customer service liaison team shall have authority to review all records of the cases about which complaints are submitted; to interview individuals who submit complaints, the individuals who have assisted with their applications, and the State and county staff who have worked on their cases; and to recommend corrective actions to State and county agencies to address specific complaints and reduce future complaints. L.2019, c.246, s.1. 30:4D-3d Definitions, Medicaid eligibility redetermination. 1. a. As used in this section: "Beneficiary" means an individual eligible for medical assistance through Medicaid or NJ FamilyCare. "Commissioner" means the Commissioner of Human Services. "Division" means the Division of Medical Assistance and Health Services in the Department of Human Services. "Eligibility redetermination" means the administrative process by which the division or a county welfare agency reviews a beneficiary's income, financial resources, and circumstances relating to the beneficiary's application for continuation of benefits received under Medicaid or NJ FamilyCare. "Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "NJ FamilyCare" means the NJ FamilyCare program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.). b. No later than the first day of the fourteenth month next following the expiration of the federal public health emergency declared in response to the SARS-CoV-2 pandemic, the commissioner shall direct the division or a county welfare agency to conduct an eligibility redetermination for a beneficiary no less than 365 days following the date of the beneficiary's initial enrollment in, or the date of the beneficiary's last eligibility redetermination for, Medicaid or NJ FamilyCare. The commissioner shall determine the means and method by which an eligibility redetermination shall be conducted. c. To the extent permitted under federal law and regulation, the commissioner, not later than the first day of the fourteenth month next following the expiration of the federal public health emergency declared in response to the SARS-CoV-2 pandemic, shall provide for at least 12 months of continuous Medicaid eligibility for adult eligibility groups without imposing any reporting requirements regarding changes of income or resources and regardless of the delivery system through which the beneficiary receives benefits. d. The commissioner shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this act and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program. L.2022, c.123, s.1. 30:4D-3d1 Presumptive eligibility, Medicaid, home, community-based services, long-term services, supports program; definitions. 1. a. Within 30 months of enactment of P.L.2023, c.306 (C.30:4D-3d1), and conditional on the receipt of all necessary approvals and the securing of federal financial participation pursuant to subsection g. of this section, the Department of Human Services shall provide presumptive eligibility for Medicaid, including, where appropriate, eligibility for the managed long-term services and supports program, for an individual who is: seeking home and community-based services or PACE enrollment; awaiting an eligibility determination for Medicaid or for the managed long-term services and supports program or services provided through PACE; and likely to be financially and clinically eligible for Medicaid and where necessary the managed long-term services and supports program or services provided through PACE, as determined by the department. b. Conditional on federal financial participation, the department shall provide Medicaid coverage for eligible home and community-based services or services provided through PACE to an individual who is granted presumptive eligibility pursuant to this section. Coverage provided under this subsection shall begin upon the receipt of an individual's request for services, pursuant to subsection c. of this section, and shall be terminated if the individual is determined clinically or financially ineligible for home and community-based services or services provided through PACE under Medicaid during the eligibility determination process. c. An individual seeking presumptive eligibility for home and community-based services or services provided through PACE under Medicaid shall submit a request to the department in a manner and form as determined by the commissioner. d. An individual granted presumptive eligibility pursuant to this section shall be required to submit a completed application for Medicaid and any applicable Medicaid waiver program offering home and community-based services or services provided through PACE no later than the end of the month following the month in which presumptive eligibility is granted. e. Conditional on federal financial participation, a home and community-based services provider or PACE center shall be reimbursed for all Medicaid-eligible services rendered to an individual who has been granted presumptive eligibility pursuant to this section, regardless of whether the individual granted presumptive eligibility is determined clinically or financially ineligible for home and community-based services or services provided through PACE under Medicaid during the eligibility determination process. f. The department shall provide each individual granted presumptive eligibility pursuant to this section a written notice explaining the terms and conditions of presumptive eligibility and the home and community-based services or services provided through PACE the individual will be eligible to receive. g. The commissioner shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this section and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program. The provision of presumptive eligibility pursuant to this section shall be contingent on securing all necessary federal approvals and federal financial participation as may be necessary to implement the provisions of this section. h. In designing the program required pursuant to subsection a. of this section, the Department shall assess the success of other jurisdictions in providing for presumptive eligibility for home and community-based services and related services for Medicaid recipients; consider methods for minimizing costs due to determinations of clinical or financial ineligibility; and engage with relevant stakeholders to determine how to best tailor the benefit to the needs of the Medicaid population. i. As used in this section: "Commissioner" means the Commissioner of Human Services. "Department" means Department of Human Services. "Eligibility determination" means the administrative process by which the Division of Medical Assistance and Health Services in the Department of Human Services or a county welfare agency reviews a beneficiary's income, financial resources, and circumstances relating to the beneficiary's application for benefits received under Medicaid or any applicable Medicaid waiver program offering home and community-based services or services provided through PACE. "Home and community-based services" means community-based services provided under the managed long term services and supports program or personal care assistant services provided in the home under New Jersey's Medicaid State Plan. "Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "PACE" means the program of all-inclusive care for the elderly as defined in section 1 of P.L.1997, c.296 (C.26:2H-88). L.2023, c.306. 30:4D-3e Rules, regulations. 2. The Commissioner of Human Services shall adopt rules and regulations as shall be necessary to implement the provisions of this act, which rules and regulations shall be effective immediately upon filing with the Office of Administrative Law for a period not to exceed 18 months and may, thereafter, be amended, adopted, or readopted in accordance with the "Administrative Procedure Act" P.L.1968, c.410 (C.52:14B-1 et seq.). L.2022, c.123, s.2.

This is the verbatim text of N.J.S.A. 30:4D-3, retrieved from the New Jersey Legislature's public statute corpus. Statutes are amended periodically — for the most current version, check the external source link above. Kyzer is not a law firm and this page is not legal advice.