Statutes, codes, and regulations
New Jersey Administrative Code
Title 10 - HUMAN SERVICESChapter 49 - ADMINISTRATION MANUAL
Subchapter 2 - NEW JERSEY MEDICAID BENEFICIARIES
Section 10:49-2.9 - Medicaid or NJ FamilyCare-Plan A retroactive eligibility

N.J. Admin. Code § 10:49-2.9

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Current through Register Vol. 56, No. 21, November 4, 2024
Section 10:49-2.9 - Medicaid or NJ FamilyCare-Plan A retroactive eligibility
(a) Any person applying for Medicaid or NJ FamilyCare-Plan A benefits shall be asked if he or she has unpaid medical bills incurred within the three-month period immediately prior to the month of application for Medicaid or NJ FamilyCare-Plan A.
1. Medically Needy applicants (see 10:49-2.3(f) ) shall be evaluated for retroactive eligibility by the county welfare agency (CWA) when they apply for the Medically Needy program.
2. An applicant for NJ FamilyCare-Plan A whose application was processed by the Statewide eligibility determination agency has his or her retroactive eligibility processed by that agency. The applicant must indicate on his or her NJ FamilyCare-Plan A application that unpaid medical bills exist in the retroactive period or shall contact the Statewide eligibility determination agency within six months of his or her application date for NJ FamilyCare-Plan A.
3. Applicants who applied for Medicaid or NJ FamilyCare-Plan A at a CWA shall have their retroactive eligibility evaluated and processed at that CWA when they apply for Medicaid or NJ FamilyCare-Plan A. If the applicant does not indicate to the CWA that unpaid medical bills exist at the time of application, the applicant shall provide that information to the CWA within six months of the date of application. If retroactive eligibility is not requested from the CWA within six months from the date of application, retroactive eligibility will not be established.
4. Medicaid or NJ FamilyCare-Plan A Applicants who applied for Supplemental Security Income (SSI) may complete an FD-74 Form, Application for Payment of Unpaid Medical Bills (see Appendix, N.J.A.C. 10:49) and forward the application with required verification and all outstanding unpaid medical bills to the Medicaid Retroactive Eligibility Unit, Division of Medical Assistance and Health Services, PO Box 712, Mail Code #10, Trenton, New Jersey 08625-0712. An application for retroactive eligibility may be obtained by the applicant, or his or her authorized agent, from the CWA, the Medical Assistance Customer Center (MACC), the Social Security Administration District Office, or from the Retroactive Eligibility Unit, Division of Medical Assistance and Health Services. The application shall be received by the Retroactive Eligibility Unit within six months from the date of application for public assistance.
5. Applications for retroactive unpaid medical bills cannot be processed for services rendered prior to the effective date of the program. For NJ FamilyCare-Plan A, children eligible under 10:79-3.4(b), the effective date is February 1, 1998. For NJ FamilyCare parents, the effective date is September 6, 2000.
(b) If the Division of Medical Assistance and Health Services Retroactive Eligibility Unit determines that the person was eligible for Supplemental Security Income (SSI)/Medicaid at the time the service was provided, providers shall be notified directly that the unpaid bills for any service covered by the New Jersey Medicaid program may be reimbursable in accordance with standard Medicaid reimbursement procedures.
1. The provider shall then complete the appropriate claim and submit it to the Fiscal Agent for consideration and authorization of payment within 90 days of the date the provider is notified in writing of the retroactive eligibility.
2. When the Retroactive Eligibility Unit approves retroactive eligibility more than one year after the date(s) of service, the Retroactive Eligibility Unit will send a special notification letter to the provider. The provider shall attach the original notification letter to the claim and shall manually submit the claim to the Medicaid fiscal agent at the address listed on the letter. The claim and the attached letter must be received by the Medicaid fiscal agent within 90 calendar days of the date on the special notification letter.
3. For any Medically Needy beneficiary, a retroactive eligibility determination shall be completed by the CWA (see 10:49-2.3, Persons eligible under the Medically Needy program).

N.J. Admin. Code § 10:49-2.9

Recodified from N.J.A.C. 10:49-2.7 and amended by R.1997 d.354, effective 9/2/1997.
See: 29 N.J.R. 2512(a), 29 N.J.R. 3856(a).
In (a) amended N.J.A.C reference and mailing address; in (a)1 and (b)2, substituted "CWA" for "county welfare agency"; and in (b)2, substituted "beneficiary" for "recipient". Former section recodified to N.J.A.C. 10:49-2.9.
Recodified from N.J.A.C 10:49-2.8 and amended by R.1998 d.116, effective 1/30/1998 (operative February 1, 1998; to expire July 31, 1998).
See: 30 N.J.R. 713(a).
Inserted references to NJ KidCare--Plan A throughout; in (a), inserted "and application processed by the Statewide eligibility determination agency" following "N.J.A.C. 10:492.3(f)" in the second sentence, and added 2 and 3; and in (b), inserted a reference to NJ KidCare reimbursement procedures in the first sentence, and deleted "Medicaid" following "appropriate" and substituted a reference to the Fiscal Agent for a reference to the Retroactive Eligibility Unit in 1. Former N.J.A.C. 10:49-2.9, Verification of eligibility for Medicaid/Pharmaceutical Assistance to the Aged and Disabled (PAAD) services, recodified to N.J.A.C. 10:49-2.10.
Amended by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Adopted concurrent proposal, R.1998 d.426, effective 7/24/1998.
See: 30 N.J.R. 713(a), 30 N.J.R. 3034(a).
Readopted provisions of R.1998 d.116 without change.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.2001 d.329, effective 9/17/2001.
See: 33 N.J.R. 1889(a), 33 N.J.R. 3334(a).
In (b)1, deleted "form" after "appropriate claim", and added "within 90 days of the date the provider is notified in writing of the retroactive eligibility".
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 N.J.R. 2650(a), 35 N.J.R. 1118(a).
Rewrote the section.
Amended by R.2008 d.230, effective 8/4/2008.
See: 40 N.J.R. 984(a), 40 N.J.R. 4531(a).
In the introductory paragraph of (a), substituted "three-month" for "three month"; in (a)1, substituted "welfare agency (CWA)" for "board of social services (CBOSS)"; in (a)3, substituted the first occurrence of "CWA" for "CBOSS other than Essex, Hunterdon or Warren Counties," and substituted "CWA" for "CBOSS" four times; in (a)4, deleted "who applied for benefits at the CBOSS in Essex, Hunterdon or Warren counties or" following "Applicants" and substituted "CWA" for "CBOSS"; in the introductory paragraph of (b), substituted "Supplemental Security Income (SSI)/Medicaid for "Medicaid or NJ FamilyCare-Plan A", deleted "or NJ FamilyCare-Plan A" preceding "may be reimbursable" and "and NJ FamilyCare" preceding "reimbursement"; and in (b)3, substituted "CWA" for "CBOSS" and inserted a comma preceding "Persons".