SI NY01730.002 (New Jersey) Determination of Medicaid Eligibility

A. Unpaid Medical Expenses in the Three Months Prior to SSI Application

1. Non-deferred Cases

SSA has agreed to obtain supplemental information to assist the State in determining retroactive Medicaid eligibility for the three months prior to the date of application for SSI. If the applicant answers "yes" to the question regarding prior medical expenses on the SSI application, date stamp Form FD-74 (Application for Payment of Unpaid Medical Bills, New Jersey Health Services Program). Advise the applicant to complete the application requesting consideration of Medicaid payment; local Medicaid offices will assist the applicant in completing the form.

The applicant should be advised to submit the FD-74 with copies of unpaid medical bills for medical care and services to:

Department of Human Services
Division of Medical Assistance and Health Services
Retroactive Eligibility Unit
PO Box 712
Quackerbridge Plaza, Room 202
Trenton, New Jersey 08625-0712

The State will take action on the unpaid medical expenses. Any further inquiries regarding these claims should be addressed to the above-mentioned unit. FD-74s are available at the above mentioned unit and field offices (FO) may call there at (609) 588-2837.

2. Deferred Cases

In New Jersey an SSI applicant has six months from the date of his/her SSI application in which to file a claim for any unpaid medical expenses which occurred within the three months prior to the date of the SSI application. In order to take into consideration deferred cases; the following procedure has been adopted for all FO's in New Jersey. When a disability case is allowed and the FO develops the pre-effectuation review contact (PERC), the FO should also complete the following items on the FD-74:

a. Complete Question Number 5

Indicate the: Initial application date, the date of the PERC and write: Deferred Development. Have the claims representative initial the item.

b. Complete Question Number 6

Indicate the FO address. The applicant should be advised to submit the FD-74 with copies of unpaid medical bills for medical care and services to:

Department of Human Services
Division of Medical Assistance and Health Services
Retroactive Eligibility Unit
PO Box 712
Quackerbridge Plaza, Room 202
Trenton, New Jersey 08625-0712

The State will take action on the unpaid medical expenses. Any further inquiries regarding these claims should be addressed to the above-mentioned unit. FD-74s are available at the above mentioned unit and FO's may call there at (609) 588-2837.

B. Medicaid Referrals

1. Emergency Medical Authorization

If a blind/disabled claimant needs an emergency authorization for medical assistance before a determination is made on his/her SSI application, refer him/her to the appropriate Medicaid District Office (MDO).

Complete the Division of Youth and Family Services' form DYFS 12-49 (SSA/CWB Referral and Notification). Give one copy to the applicant and advise him/her to go to the MDO. Mail the other copy to the MDO.

There is no provision for emergency authorization for aged applicants whose claims are pending.

2. Medical Assistance Only

Individuals who are found ineligible for SSI because they exceed SSA's income and resource limitations can be referred to the MDO to make an application for the State's Medically Needy Program. Complete form DYFS 12-49, in duplicate, when an individual requires medical assistance only. Give one copy to the individual and advise him/her to go to the MDO. Mail the second copy to the appropriate MDO.

3. Non-Receipt of Medicaid Cards

If an eligible individual who has not received a Medicaid card needs an emergency authorization for medical assistance, refer him/her to the appropriate local MDO.

Complete form DYFS 12-49, in duplicate. Give one copy to the individual and advise him/her to go the local MDO. Mail the other form to the local MDO.

4. Medicaid and the Ineligible Spouse

In New Jersey an ineligible spouse living alone (optional State supplement code "C") with an eligible individual, is covered for Medicaid, but solely at State expense. Based on the State Data Exchange (SDX), the State will extract these cases and send the form LD-70 to the ineligible for additional information. A Medicaid card is usually sent to the ineligible spouse within thirty days after the LD-70 has been completed and returned to the appropriate local MDO. If a Medicaid card is not received within thirty days, complete form DYFS 12-49 in duplicate. Give one copy to the individual and advise him/her to contact the local MDO. Mail the other one to the local MDO.

5. Establishing Retroactive Medicaid Eligibility After Death

SSA has agreed to make a medical eligibility determination in blind/disability cases where the claimant dies after filing and there are unpaid medical expenses. New Jersey has requested that we make a determination in all such cases. SSA will make only a medical determination; do not pursue non-medical issues.

When an aged claimant dies after filing, and has unpaid medical expenses in the retroactive period, the State will make the Medicaid determination. The state may contact the FO to determine if an SSI application was filed.

a. Notice of Death Received

If the FO is notified by mail, associate the notice with the file and review the application to see if there were any unpaid medical expenses. If none are shown contact the surviving spouse or other relative to learn if there are medical expenses that were incurred and still unpaid. If there were, take action to have the Disability Determination Service (DDS) make a disability decision.

If the FO is notified in person or telephone, ask whether there were any unpaid medical expenses. Record on a report of contact (RC) the name, relationship, telephone number and whether he/she is aware of any unpaid expenses. Associate this with the file. Review the application to see if there were any unpaid medical expenses. If there were, take action to have the Disability Determination Service (DDS) make a disability decision.

b. Informing the State

When a final disability determination is made, or, if the individual is aged, send the information to the supervisor of the Retroactive Eligibility Unit (the address is in POMS SI NY01730.010A). The notification should be on an RC, a copy of which is retained in the file. It should contain the following:

  1. Subject: Manual Medicaid Eligibility Determination, SSI, SSI Claimant Deceased.

  2. Name.

  3. SSN.

  4. Welfare Identification Number (if known).

  5. Title XVI disability determination.

  6. Effective date of the determination.

  7. Date of death.

  8. Applicant's last known address.

  9. Name and telephone number of the informant.

    6. E02 Month
    Under the 1634 agreement, an SSI application serves as an application for Medicaid benefits. Accordingly under SSI regulations, SSA may determine an individual eligible for Medicaid benefits under SSI during the month of application without receiving payment until the subsequent month.

    EXAMPLE: A 67 year old individual contacts SSA and files an application for SSI on July 10, 2005. Assuming he meets all other factors of eligibility, his SSI/Medicaid would begin July 10, 2005, but the individual cannot be paid any benefits prior to August 2005. The SDX will reflect a payment status code of E02 for July 2005, followed by a C01 for August 2005.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0501730002NY
SI NY01730.002 - (New Jersey) Determination of Medicaid Eligibility - 10/12/2005
Batch run: 01/27/2009
Rev:10/12/2005