N.J. Admin. Code § 10:71-3.14

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

Section 10:71-3.14 - Institutional eligibility

(a) Persons who are otherwise eligible for Medicaid Only receive medical coverage while receiving patient care in eligible medical institutions. Such coverage shall be provided through the appropriate payment mechanism of the Division of Medical Assistance and Health Services. The Medicaid Cap income standard is applied only to certain institutions.

(b) Individuals who are inmates of public institutions are not eligible for Medicaid coverage, unless they are receiving care in a Title XIX approved section of such facility.

(c) Individuals incarcerated in a Federal, State or local correctional facility (prison, jail, detention center, reformatory, etc.) are not eligible for Medicaid coverage. The needs of such individuals (inmates) are met through another agency of the Federal or State government or political subdivision thereof (see 10:71-1.6(a)3 ).

(d) An "institution" is any group living arrangement in which food, shelter and personal care (other than nursing care) are furnished on a continuous basis to four or more persons unrelated to the operator or in which food, shelter and personal care, including nursing care, are furnished on a continuous basis to four or more persons unrelated to the operator; or any establishment or facility licensed or approved by the State of New Jersey.

(e) Application of Medicaid Cap rules are:

1. General or Class A special hospitals: When a person is confined to such a hospital, the Medicaid Cap standard does not apply; eligibility will be determined according to the applicable living arrangement in Table B (see 10:71-5.6(c)5 ).

2. Long term care facilities (eligible private medical institutions): This may include licensed nursing homes, intermediate care facilities, or Class B and C special hospitals. These facilities must be licensed by the Department of Health and Senior Services licensing authority, and approved by the Department of Human Services for provider participation in the Title XIX Medicaid program. When a person is confined to a long term care facility, the Medicaid Cap standard is used.

3. Licensed boarding homes for sheltered care (including nonprofit incorporate homes for the aged): These homes must be licensed by the Department of Health and Senior Services in accordance with N.J.A.C. 8:43. When the person is in a facility of this type, the income standard for licensed boarding home is used.

(f) An "eligible medical institution" outside New Jersey is a public or voluntary medical institution which is licensed, certified or approved by the proper authority of the jurisdiction in which the institution is located, so that the costs of care and services provided therein may be paid. Evidence of such license, certification or approval shall be obtained from the Department of Welfare or similar authority of the jurisdiction in which the institution is located.

1. Use of out-of-state facilities shall be restricted to temporary emergency situations where it is established that there is no eligibility for coverage under a welfare or nonwelfare program in the other state.

N.J. Admin. Code § 10:71-3.14

Amended by R.1986 d.71, effective 3/17/1986.
See: 17 N.J.R. 2522(a), 18 N.J.R. 564(b).
New (b) and (c) added; old (b)-(d) now (d)-(f).
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).
In (e)2, deleted "(skilled nursing facilities)" following "homes".