New Jersey § 30:4d-3

§ 30:4d-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. 1 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 (2) Is a recipient of Supplemental Security Income for the Aged, Blind and Disabled

under Title XVI of the Social Security Act; 3 (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 4 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; 5 (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 ). 1

N.J.S.A. § 30:4D-1 et seq. 2

42 U.S.C.A. § 601 et seq. 3

42 U.S.C.A. § 1381 et seq. 4

42 U.S.C.A. § 1396 et seq. 5

42 U.S.C.A. § 1396 et seq. or 42 U.S.C.A. § 1397aa et seq.