N.J. Admin. Code § 10:71-3.11

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:71-3.11 - Determination of disability and blindness eligibility; a State function

(a) The determination of disability and blindness eligibility for the Medicaid Only program is a direct responsibility of the Medical Review Team in the Division of Medical Assistance and Health Services. Determination of all other factors of eligibility is the responsibility of the CWAs. The medical review team is composed of a medical consultant; and a medical social work consultant; it reviews Medicaid Only applications submitted by the CWAs.

(b) In situations where an applicant's disability or blindness appears to meet the definition in 10:71-3.12, presumptive eligibility for either of these factors can be granted with the approval of the Medical Review Team.

(c) If an individual has been determined disabled for Social Security purposes (that is, he or she is currently receiving Disability Insurance Benefits), the CWA shall not refer the individual to the Medical Review Team for a determination of medical eligibility. The individual shall be considered automatically eligible, in this respect, for Medicaid Only benefits.

1. In the event the Social Security Administration determined within the 12 months prior to the application for Medicaid Only that the individual was not disabled, the Medical Review Team will not make an independent determination of the applicant's disability but will be bound by the determination of the Social Security Administration. If an individual whose Social Security or SSI disability claim was denied within the last 12 months presents new or additional evidence to support that claim, the CWA should refer the applicant to the Social Security Administration for a reevaluation of its determination.

2. When the denial by the Social Security Administration occurred more than 12 months prior to the application for Medicaid Only, the Medical Review Team will make an independent determination of disability.

N.J. Admin. Code § 10:71-3.11

As amended, R.1979 d.364, effective 11/1/1979.
See: 11 N.J.R. 379(b), 11 N.J.R. 519(e).
Amended by R.1995 d.651, effective 12/18/1995.
See: 27 N.J.R. 3543(a), 27 N.J.R. 5046(a).
Amended by R.2000 d.415, effective 10/16/2000.
See: 32 N.J.R. 2565(a), 32 N.J.R. 3844(a).
Substituted references to CBOSSs for references to CWAs and substituted references to the Medical Review Team for references to the Medical Review Team in the Disability Review Unit throughout.
Amended by R.2012 d.025, effective 2/6/2012.
See: 43 N.J.R. 804(a), 44 N.J.R. 230(a).
In (a), substituted "Medical Review Team" for "medical review team" once and "CWAs" for "CBOSSs" twice; in (b) and the introductory paragraph of (c), deleted "(MRT)" following "Team"; in (b), substituted "N.J.A.C. 10:71-3.12" for "section 12 of this subchapter"; in the introductory paragraph of (c) and in (c)1, substituted "CWA" for "CBOSS"; and in (c)1 and (c)2, substituted "Medical Review Team" for "(MRT)".