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New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

V

Health Services

Chapter:

A

Health Services

6-25-2012

Subchapter:

2

Medicaid

Issuance:

200

Medicaid Eligible Recipients

 

 

Eligible Individuals                                                            11-21-2011

 

Medical and health services are available to the following general groups of individuals, but are not all inclusive:

 

      Persons who are eligible to receive financial assistance as determined by the County Welfare Agency. Such persons are families with dependent children including children 18 through 21, families of the working poor, Cuban, Cuban/Haitian, and Indo-Chinese Refugees. Under certain circumstances, persons may receive extended Medicaid benefits for either four or 24 months following the month in which they are no longer eligible for WFNJ TANF and an additional 60 days of post-partum coverage for a mother and her newborn if applicable. See CP&P-V-A-1-600;

 

      Persons who are eligible to receive Supplemental Security Income (SSI) payments as determined by the Social Security Administration. Such persons are the aged (65 and over), the blind, and the disabled;

 

      Persons who qualify under the Supplemental Security Income (SSI) Program as an "ineligible spouse" of an SSI recipient as determined by the Social Security Administration;

 

•     Persons who meet the income standards of need applicable to their circumstances under one of the financial assistance programs referred to above but who are not receiving or do not apply for such cash assistance. Such persons are eligible for "Medicaid Only" under the New Jersey Medicaid Program;

 

•     Financially eligible children in resource care and under supervision of the Division of Child Protection and Permanency (CP&P), including those children who are temporarily placed out-of-state in resource care or residential placements;

 

•     Aliens who are under 18 may have access to Medicaid even if, under the Immigration Reform and Control Act of 1986, newly legalized aliens are barred from certain federally funded assistance programs;

 

•     Aliens 18 and older may have access to emergency and pregnancy related Medicaid services;

 

•     Certain persons in State and County Psychiatric Hospitals and/or State or private Intermediate Care Facilities/Mental Retardation are determined eligible by the Department of Human Services;

 

•     Persons 65 years of age and over who do not meet eligibility standards of the categorically-related assistance programs, but whose medical needs qualify under the New Jersey State Medical Assistance to the Aged Program (MAA); and

 

      Persons 18 through 20 years of age who are in a CP&P paid placement on their 18th birthday. See CP&P-V-A-3-500, Medicaid Extension for Young Adults (MEYA), Also Known as Chafee Medicaid.

 

      Children and pregnant women who are not eligible for the federally funded Medicaid Program may receive services through the New Jersey Care Program which authorizes optional coverage for pregnant women and children whose family income is equal to or less than certain income limits. See CP&P-V-A-4-100 and CP&P-V-A-1-600.

 

 

Newborn Eligibility                                                            9-29-89

 

Newborns are not automatically eligible for the Medicaid Program even though the child's mother is eligible for the program. The infant must be determined eligible for Medicaid in his or her own right and issued a Medicaid number if Medicaid coverage is to continue beyond the mother's hospital stay.

 

Providers may be reimbursed for services to the infant via the mother's Medicaid eligibility for in-hospital services until the mother is discharged from the hospital. See CP&P-V-A-1-600, Services to Pregnant Women.

 

Eligibility of Children in Detention Facilities               10-1-96

 

A Medicaid eligible child who is taken into custody and placed in a detention facility pending adjudication and/or release to parents or guardians will not be considered ineligible for Medicaid because of his temporary placement as long as all other criteria for Medicaid eligibility are satisfied.

 

Eligibility Through Other Agencies                               11-10-97

 

Children who are not eligible for Medicaid through CP&P may be determined eligible through the County Welfare Agency (CWA) or the Social Security Administration (SSA). Medicaid rules and regulations regarding eligibility, services provided to clients, and rates of reimbursement are uniform throughout the New Jersey Medicaid Program.

 

Other Programs Which May Qualify an Individual Eligible for Medicaid  11-21-2011

 

PROGRAM AGENCY*

ELIGIBILITY

Supplemental Security Income

 

SSA

Medicaid Only (including New Jersey Care-Special Medicaid Program for pregnant women and children)

 

CWA

Child in foster care through private adoption agency

 

Private adoption agency

Resident under 21 of state or county psychiatric hospital, or state or private intermediate care facility/mental retardation

 

Institutional Services Section

Medically Needy Program -

Certain individuals with incomes above the usual cut-off for Medicaid or with unusually high medical expenses

 

CWA

 

 

*SSA - Social Security Administration;

 CWA - County Welfare Agency;

 Institutional Services Section -

 Department of Public Welfare

 Bureau of Local Operations

 

Medicaid Eligibility Determination for CP&P Children

 

Legal Authority                                                                   11-21-2011

 

The New Jersey Medicaid Program in accordance with Federal Regulation (42 CFR 435.222) has elected to extend Medicaid coverage to individuals under age 21 for whom a public agency is assuming a full or partial financial responsibility and who meet the financial eligibility requirements for the AFDC payment standard that was in effect July 16, 1996 or who meet the financial requirements for New Jersey Care. Enabling legislation appears in N.J.S.A. 30:4D-31 (6) (Pl. 1968, c. 413), as amended in 1980.

 

Under the provisions of the New Jersey Medicaid State Plan, Medicaid coverage is extended to the above children provided that a child's available income and resources do not exceed the financial eligibility requirements for AFDC that were in effect July 16, 1996 or for New Jersey-Special Medicaid Program for Maternal and Child Health coverage.

 

Children Eligible for the Medicaid Code 60 Program Through CP&P      6-25-2012

 

Children who reside in substitute living arrangements paid for by CP&P and meet AFDC financial requirements or who meet the financial requirements for New Jersey Family Care are eligible for the Medicaid Code 60 Program. To be eligible for the Medicaid Program Code 60 through CP&P, a child must:

 

•     Be a legal United States citizen, residing in New Jersey with:

 

-   A valid birth certificate and

 

-  A valid Social Security number; or

 

•     Be a lawfully admitted immigrant with:

 

-   A permanent resident card (aka a green card) and

 

-    Five years permanency from the date the permanent resident card was issued; and

 

      Be under the supervision of CP&P and a resident of a resource home, subsidized adoption home, group home, institution or other approved CP&P paid living arrangement, including independent living;

 

      Children who have been court ordered into CP&P custody, have no other health insurance and who, for health reasons, must stay in a medical facility, such as a hospital or pediatric nursing facility, may also be eligible for the Medicaid Code 60 Program as long as all other eligibility conditions are met. Children who have been removed via a Dodd removal, CP&P-II-C-2-700, are eligible for Medicaid pending court ruling and further determination. Medicaid begins on the date of the Dodd removal;

 

•     Have all or part of his or her maintenance paid from public funds;

 

      Have a current photograph in the CP&P case record; and

 

      Meet the financial income requirements for AFDC or the financial requirements for New Jersey Family Care. See CP&P-V-A-4-100 for children not meeting eligibility requirements.

 

Inmates of public institutions are not eligible for Medicaid. However, children and adults who reside in some public institutions may be determined eligible for the Medicaid program. Children are not considered inmates if the institution in which they reside provides:

 

•     Medical care;

 

•     Inpatient psychiatric services;

 

•     Education or vocational training; or

 

•     A temporary placement while appropriate arrangements are being made for a child's care.

 

Children placed in correctional institutions or programs under the jurisdiction of the Juvenile Justice Commission (JJC) are not eligible for Code 60 (federally funded) Medicaid benefits. Through a cooperative arrangement between the Division of Medical Assistance and Health Services (DMAHS) and the JJC, Medicaid benefits are provided by a state-only funded Medicaid program designated by a Program 80 Medicaid number.

 

All CP&P children who are recipients of Supplemental Security Income benefits (SSI) are automatically eligible for Medicaid through Social Security. A determination of SSI/Medicaid benefits is completed by the Social Security Administration for all SSI recipients. See CP&P-III-C-2-400. SSI children residing in CP&P-supported placements have dual eligibility status in the Medicaid program, both Program Status Code 20 SSI and Program Status Code 60. When a child who is an SSI recipient enters a CP&P supported living arrangement, a formal determination for the Medicaid Code 60 Program by the Local Office is not made.

 

The child is enrolled in the Code 60 Medicaid program. As long as the child remains eligible for Medicaid through the SSI program, the child will continue to remain eligible for Code 60 Medicaid through CP&P. When a child is no longer eligible for SSI benefits and a child remains in a CP&P supported placement, formal determination for Medicaid Code 60 is made.

 

Policy                                                                                    10-1-96

 

CP&P determines the Medicaid eligibility of each child entering a substitute living arrangement e.g., resource care, residential care, independent living, at the time the child enters the substitute living arrangement. At the time of placement, Medicaid eligibility must be documented within 30 days. This is done by the Support Specialist at the same time as the support evaluation. A redetermination of eligibility for the Medicaid Code 60 program is made at six month intervals from the initial date of eligibility determination. A redetermination is also made when information is received indicating that there has been a change in circumstances, such as a change in finances.

 

Children determined ineligible for the Medicaid Code 60 program, but who must remain in CP&P supported substitute living arrangements, are enrolled in the Code 65 Medical Services Program, CP&P-V-A-4-100. A review of eligibility for the Code 65 program is made at three month intervals from the initial date of enrollment in the Code 65 Program.

 

In emergency situations, medical services are obtained and the medical providers are advised that appropriate medical coverage information will be provided as soon as Medicaid eligibility determination is made.

 

Medicaid cards are not issued for a child until a determination of Medicaid eligibility is made and the child is properly enrolled for medical services with the correct program status, Code 60 or 65.

 

Financial Eligibility Requirements for Medicaid         5-3-2003

 

To be eligible for medical assistance through the federally supported Medicaid Program an individual must meet the AFDC income standard in effect July 16, 1996.

 

Initial Eligibility for Code 60 Medicaid                           5-3-2003

 

Financial eligibility for the Code 60 Medicaid program is established when the available income of the eligible child does not exceed the AFDC income standard in effect July 16, 1996. When a child enters a substitute living arrangement, Medicaid eligibility is determined for an eligible unit of one, considering only the child's income and resources.

 

For Medicaid purposes, a child placed in a CP&P substitute living arrangement is considered separated from his parents at the time that the living situation is approved or arranged by CP&P. If a child's income exceeds the AFDC income standard in effect July 16, 1996, the child is not eligible for the Code 60 Medicaid program regardless of the maintenance cost incurred by CP&P.

 

A child in a substitute living arrangement found ineligible for the Code 60 Program is enrolled in Code 65 Medical Services Program. See CP&P-V-A-4-100. When initial determination of Medicaid eligibility is completed, the information is recorded in NJS.

 

Available Income and Resources                                  5-3-2003

 

Income is defined as cash or some other asset readily available to meet the needs of the eligible unit. Income may be earned, unearned, or in the form of contributions.

 

•     Earned Income - gross income earned by an eligible unit through receipt of wages, tips, and salaries. The earned income of any child who is a full-time student, or is a part-time student who is not a full-time employee, shall be exempt in determining Medicaid eligibility. A full time employee shall be any student whose average employment on a monthly basis equals 35 hours a week or more.

 

•     Unearned Income - income which is available to a child from dividends, interest, contributions from relatives, Social Security benefits, or benefits payable to the child under a parent's retirement program, or Veterans' Administration benefits. A child's SSI benefits are not included.

 

•     Contributions of Support - payments by parents to the support of the child. These are considered an available resource to the child. The financial contribution of a Legally Responsible Person (LRP) to the support of a child under CP&P care is considered available income to the child, if the LRP contribution is regular. Regular LRP contributions are defined as the average monthly payment received over the previous six month period.

 

•     Bank Accounts - saving deposits which are in the name of the child. These are regarded as available income. An individual may maintain a bank account and remain eligible for services.

 

When calculating available income, only that income which the child is actually receiving at the time of the determination of eligibility is considered. Income from Social Security benefits, Veteran's benefits, Railroad Retirement benefits, trust funds, or other funds is considered by CP&P in determining eligibility. CP&P takes action to obtain such benefits through the DCF Office of Revenue, Financial Reporting, and Title IV-E Operations (ORFR&IV-EO) when a child is placed out of home by CP&P.

 

At the time of initial determination of eligibility, if no resources in the form of financial benefits appear available to the child, but there is an absent, deceased, retired, or disabled parent in the family, or if the parent is a Veteran, the assigned Worker advises the Local Office Title IV-E Liaison, who applies for benefits in accordance with policy/procedures, CP&P-IX-F-1-250, Federal Benefits. Until such benefits are established and become available to the child, he or she is enrolled in the Code 60 Medicaid Program, provided all other eligibility criteria are met. When eligibility for Social Security benefits is established, the DCF Office of Revenue, Financial Reporting, and Title IV-E Operations takes action, as appropriate, to collect such benefits on behalf of the child. The child's Worker is notified by the ORFR&IV-EO concerning the receipt of benefits. The Worker re-determines Medicaid eligibility upon notification that benefits are received. See CP&P-IX-F-1-250.

 

Procedures for Determining Initial Eligibility              6-25-2012

 

RESPONSIBILITY

ACTION REQUIRED

Worker

1. Verify elements of eligibility:

•   A placement line or qualifying support service;

•   Age less than 21;

•   Valid Social Security number in NJ SPRIT or application for one in case record;

•   Citizen or five years of legal residency with green card, and

•   Income (wages, child support, Social Security) less than allowable amount.

 

2. Note: If any of the above qualifying elements is not in compliance, stop and see CP&P-V-A-4-100, Code 65 Medical Services.

 

3. Obtain child's current Medicaid card from the family, if at all possible, and give it to the new caregiver.

 

 

Procedures for Creating or Reopening Medicaid ID 6-25-2012

 

RESPONSIBILITY

ACTION REQUIRED

Worker or Medicaid Liaison

1.  Enter placement line or qualifying support service line.

 

2.  Review and verify eligibility and NJS entries.

 

3.  Note:  If any of the above qualifying elements are not in compliance, stop and advise the Worker to see CP&P-V-A-4-100, Code 65 Medical Services.

 

Medicaid Liaison

4.  Approve the Medicaid in NJS if appropriate.

 

5.  Research in Medicaid Eligibility File (MEF) to determine status of any other Medicaid/HMO or third party liability.

 

6.  Complete the Emergency Services Letter (ESL) and give it to the Worker for the new caregiver, with a copy to the Child Health Unit.

 

7.  Notify the appropriate party for further action, if the child has active Medicaid from another source.

 

8.  Send an e-mail to IT to have the HMO changed to CP&P Medicaid ID.

 

 

 

Six Month Eligibility Redetermination                          5-17-95

 

As long as a child remains in a CP&P supported living arrangement, eligibility for Medicaid is re-determined six months from the date of initial determination and every six months thereafter or sooner if the child's circumstances require a review. For children in placement enrolled in Code 65 due to excess income, the first redetermination is done three months from the date of placement.

 

The income available to the child is measured against the cost of maintaining the child in the substitute living arrangement. CP&P maintenance cost considerations include the monthly board payments and the clothing allowance. If a child's income at the time of redetermination remains below the cost to CP&P of maintaining the child in the substitute living arrangement, the child is eligible for Medicaid Code 60.

 

If a child's income exceeds the cost of CP&P maintenance, the child is no longer eligible for the Code 60 program. See CP&P-V-A-4-100. The child's Medicaid Program status is changed from 60 to 65. A review of the case is made at three month intervals to determine continued eligibility for Code 65. Eligibility for Code 60 is reviewed every 6 months as noted in CP&P-V-A-4-100.

 

IEVS Redetermination                                                      3-8-90

 

The Division of Medical Assistance and Health Services (DMAHS) is mandated by federal regulation to implement an Income and Eligibility Verification System (IEVS) which provides earned and unearned income information through computer match with Medicaid records. For the CP&P Medicaid population, information is obtained from IRS 1099 files of unearned income and New Jersey's Wage Reporting System and Verification of Income and Monitoring System (WRS/VIMS) of earned income.

 

The purpose of IEVS is to decrease federal, state and county agency expenditures for Medicaid by reducing ineligibility and overpayments, which result from unreported earned and unearned income.

 

On a monthly basis, with the exception of January, DMAHS forwards to the Office Of Telecommunication and Information Systems (OTIS) a tape containing records matched with the IRS unearned income file. Of the eleven monthly matches, one is a full file, and the remainder is new cases added to the Medicaid Eligibility File since the previous monthly match. OTIS runs the tape and produces several different types of reports, matching earned and unearned income with the CP&P Medicaid populations.

 

When there is a match, the Bureau of Revenue Development contacts the LO for follow-up action. Follow-up action must be completed within 30 days of the date of the IRS 1099 match or the WRS/VIMS match.

 

The LO Support Specialist may verify resources by writing to the savings institution or by contacting the person(s) who has authority to withdraw money from the account. If the savings information cannot be verified, the Support Specialist telephones BRD for the principal amount of the savings.

 

If the amount of the principal, combined with the amount of other countable resources, exceeds $1,000, the child becomes ineligible for Medicaid 60, and must be enrolled in Medicaid 65.

 

Procedures for Six Month Eligibility Redetermination          8-21-91

 

RESPONSIBILITY

ACTION REQUIRED

Support Specialist/ Worker

1. Review and  complete those portions relating to Medicaid redetermination:

•  When information is received indicating a change in the child's financial circumstances; or

•  No less frequently than six months after initial determination of Medicaid eligibility.

2. Contact the Bureau of Revenue  Development to determine income received on behalf of the child from:

•   Social Security benefits;

•   Trust funds, Railroad Retirement, pensions, V.A. benefits, etc., and

•   LRP contributions which are actually received by CP&P.

3. Calculate the income available to the child.

4. Change the child's Medicaid program status from 60 to 65.

5. Reevaluate the child's eligibility for Code 60 Medicaid every 6 months, or when a change in the child's circumstances requires a review.

 

Procedures for IEVS Redetermination             8-21-91

 

RESPONSIBILITY

ACTION REQUIRED

BRD

1. Telephone the LO Support Specialist when a CP&P Medicaid Program 60 child is matched with an IRS 1099 file or WRS/VIMS file. Advise Support Specialist of the match date.

Support Specialist/ Worker

 

2. Review child's case record to determine if BRD information (name of savings institution, account number and social security number) matches information in the case record.

3. If BRD financial information is in the   case record and the last eligibility determination was conducted within six months, no further action is required.

4. If the BRD financial information is not in the case record or the last eligibility determination or redetermination was not conducted within six months, determine or re-determine eligibility and verify financial information.

5. Terminate the child from Medicaid 60 if resources exceed $1,000 and enroll him in Medicaid 65.

6. File all verification documentation in the case record.

BRD

7. Complete the PA-925 response section and send the state copy to ISS Supervisor, DMAHS Bureau of Management Information Systems.

 

 

Medicaid Identification (HSP) Number                         11-10-97

 

Everyone who is eligible for Medicaid is identified in the Medicaid Program by a 12-digit Health Services Program (HSP) number. The eligible person's Medicaid number is used by medical care providers for billing purposes and by the Medicaid Program for purposes of client identification and tracking.

 

The first two positions designate the agency under which the case is supervised, i.e., either the County Welfare Agency, the CP&P County of supervision or the Institution Services code for State Bureau of Local Operations.

 

CP&P COUNTY OF SUPERVISION AND COUNTY WELFARE AGENCIES:

 

     01 - Atlantic

    08 - Gloucester

    15 - Ocean

     02 - Bergen

    09 - Hudson

    16 - Passaic

     03 - Burlington

    10 - Hunterdon

    17 - Salem

     04 - Camden

    11 - Mercer

    18 - Somerset

05 - Cape May

    12 - Middlesex

    19 - Sussex

06 - Cumberland

    13 - Monmouth

    20 - Union

07 - Essex

    14 - Morris

    21 - Warren

 

STATE and COUNTY INSTITUTIONS

 

Psychiatric    ICF/MR

Developmental Disabilities

 

31 - Greystone

41 - Vineland Developmental

32 - Trenton

42 - New Jersey Developmental

34 - Ancora

44 - Woodbine Developmental

37 - Bergen Pines

45 - New Lisbon Developmental

38 - Essex County Hospital

47 - Woodbridge Developmental

39 - Camden County Hospital

 

48 - Hunterdon Developmental

 

 

Other:

 

The third and fourth digits designate the program under which a person is determined eligible for the New Jersey Medicaid Program:

90 - Division of Developmental Disabilities

 

10 - Old Age Assistance

20 - Disability Assistance

30 - Aid to Families with Dependent    Children

50 – Blind Assistance

60 - CP&P

70 - County Juvenile Residential Facilities

80 - State Juvenile Residential Facilities

 

 

The next six digits designate the sequential case number of the recipient. The last two digits designate the person number assigned to each individual within the case.

01 - 09 Adult (any age)

 

10 - 19 Essential Person (any age)

 

20 - 49 Children under 21

 

 

 

Medicaid Eligibility File                                                     4-14-97

 

Upon establishing a child's eligibility for the Medicaid program at the time of placement in a substitute living arrangement, the child is enrolled in a Medicaid program.

 

The record of all active and inactive recipients of Medicaid benefits is known as the Medicaid Eligibility File. It is designed to maintain an up-to-date record of persons in the New Jersey Medicaid program. The file is also used to check the eligibility of Medicaid recipients for whom claims are submitted by providers.

 

Verification of Someone Covered by Medicaid          2-6-2012

 

Medicaid issues a plastic Health Benefit ID (HBID) card to all Medicaid recipients, including those deemed eligible by CP&P. The LO may be required to issue a temporary Emergency Service Letter (ESL) for any recipient deemed newly eligible and/or those not in possession of their HBID card.

 

A recipient's current eligibility status can be verified through a number of Medicaid systems.