Slovak Baron & Empey, LLP

By: Valerie A. Powers Smith, Esq.

Traditionally in New Jersey, Medicaid benefits are obtained through the State Medicaid Plan, whether it be under the fee-for-service or managed care model, for those with disabilities who meet categoric (e.g., disabled as determined by the Social Security Administration, low income families with dependent children, children under age 21, and individuals age 65 and older) and financial (vary by program) eligibility requirements. To be eligible, one must also be a resident of New Jersey and a United States citizen. This article briefly discusses the different programs under which New Jersey provides Medicaid services.

Medicaid Programs in New Jersey

The Supplemental Security Income (SSI) is administered through the Social Security Administration (SSA) and provides cash to individuals who meet the income (approximately $600/month for individuals & $800/month for couples) and resource (up to $2,000 for individuals & $3,000 for couples) limits. In New Jersey, those receiving SSI also receive Medicaid coverage.

Aid to Families with Dependent Children (AFDC Medicaid) provides full Medicaid coverage to low income families without regard to resources. Under AFDC Medicaid, a family of four can earn no greater than $507 per month.

The Early Periodic Screening, Diagnosis & Treatment (EPSDT) Program is Medicaid's comprehensive and preventive health program for children under age 21. To receive services under EPSDT, one must be under the age of 21 and the services must be medically necessary as recommended by the treating physician.

Work First New Jersey/General Assistance provides cash and medical assistance to single individuals who have a monthly income of less than $140 per month ($210/month for those unable to work); and to couples without minor dependent children with less than $193 gross income per month ($289/month for those medically certified as unable to work). Inpatient and outpatient hospital services are not covered under this program.

New Jersey Care Special Medicaid Program serves the aged, blind and disabled population and provides comprehensive medical coverage to those who meet the income ($798/month for individuals & $1,070/month for couples) and resource ($4,000 for individuals & $6,000 for couples) limits.

Medically Needy has two programs: Children & Pregnant Women and Aged, blind or Disabled (ABD). Both programs feature a send down provision in which documented medical expenses can be used to reduce one's monthly income to meet the program's limitations. The Children & Pregnant Women program provides limited medical coverage to children under 21 years, who are disqualified for eligibility under other Medicaid programs due to income and resources. The program limit for income is $367/month for individuals and up to $4,000 for resources. The ABD program is a Special Medicaid Program that provides limited coverage to aged or disabled individuals who are disqualified for other Medicaid programs due to their income and resources. The program limit for income is $367/month for individuals and $434/month for couples. The resource limit is up to $4,000 for individuals and $6,000 for couples.

Split Application Medicaid is for disabled children who are not income-eligible for Medicaid through SSI or otherwise because of their parents' income; and who have a non-disabled sibling. Parents must apply for both children under the Medically Needy program. Under the "split application" analysis, the parents' income is deemed to the child without a disability and the child with the disability is now considered on his/her own, so the child with the disability will now meet the income eligibility requirements. The disabled child must also meet the SSI disability requirements and the resource limit of $6,000.

Institutional Medicaid provides Medicaid payment for institutional stays (such as, nursing home care) for those who meet both financial criteria ($1,737/month in income & up to $2,000 in resources) and medical necessity requirements.

New Jersey WorkAbility Program is for individuals between 16 and 65 years of age, who have been determined to be permanently disabled by SSA or the Division of Medical Assistance & Health Services, and are employed. Income limits for individuals may be up to 250% of the Federal Poverty Level (that is, 250% of $9,080) and resources up to $20,000.

If a child under age 18 is ineligible for Medicaid because of parental income or resources, the New Jersey Division of Developmental Disabilities (DDD) offers to its clients a Medicaid-funded waiver program, the Community Care Waiver, that "waives" the consideration of parental income/resources. The income and resources of the child are still considered but eligibility can be obtained using a special needs trust. For those 18 years and older, while the resource limitation is still $2,000, the income limitation is higher (approximately $2,022/month).

The New Jersey Division of Disability Services administers the majority of Medicaid-funded waiver programs in New Jersey. Among those programs are the: (1) Community Resources to People with Disabilities (CRPD) - serves Medicaid beneficiaries with disabilities of all ages and provides services in addition to full Medicaid benefits to those who would otherwise be unable to live in the community and who meet the income ($1,737/month) and resource ($2,000) guidelines; (2) ABC Waiver - serves medically fragile children under the care and supervision of DYFS; (3) AIDS Community Care Alternatives Program (ACCAP) - serves any age with AIDS & children up to age 13 who are HIV positive, who meet the program income and resource limits; and (4) Traumatic Brain Injury (TBI) Waiver - serves people with TBI between the age of 18 and 64 and provides services in addition to full Medicaid coverage to those who meet the Institutional Medicaid financial requirements. All of the aforementioned waivers have individual medical necessity requirements and other program-specific requirements. For more information, contact DDS at (609) 588-2621.

The New Jersey Department of Health & Senior Services (DOHSS) administers the following Medicaid-funded waiver programs: (1) Enhanced Community Options - offers care alternatives to individuals who would otherwise qualify for placement in a nursing home and who are financially eligible for Institutional Medicaid; and (2) the Community Care Program for the Elderly and Disabled (CCPED) -provides assistance that allows individuals to remain in (or return to) the community, rather than being cared for in a nursing home or hospital to those who meet Institutional Medicaid financial requirements.

About Slovak Baron & Empey, LLP

© 2011, Valerie A. Powers Smith, Esq.

Valerie A. Powers Smith, Esq., Of Counsel, Slovak Baron & Empey, LLP, is licensed to practice in New Jersey, New York, Pennsylvania, and California and specializes in the following special needs and disability law subject areas: health care insurance, Medicaid, Medicare, special needs trust, trust administration, estate planning & administration, guardianships, and accessing federal and state government disability-based benefits. Valerie can be contacted at powers@sbelawyers.com, 609.655.3393 or 760.322.2275.