N.J. Admin. Code § 10:69-3.15 - Deprivation of parental support or care (AFDC-C)

(a) The statutory definition of "dependent child" sets forth two eligibility factors: economic "need" and "deprivation of parental support or care." These two factors are not identical, and the law requires that both be demonstrated in each case.

(b) "Need" refers to financial eligibility and is determined in accordance with the provisions contained in this chapter.

(c) "Deprivation" is the result of death, physical or mental incapacity, or continued absence from the home of a natural or adoptive parent.

1. A child may be found to be deprived of parental support or care by reason of the documented death of either or both natural or adoptive parent(s).

2. A child may be found to be deprived of parental support or care by reason of the physical or mental incapacity of either or both natural or adoptive parent(s) whether such parent is in the home or is receiving treatment away from home.

(d) The determination of incapacity for persons other than those delineated in N.J.A.C. 10:69-2.9 is made by the Disability Review Section, Division of Medical Assistance and Health Services, on the basis of medical evidence provided by the eligibility worker. This is done in the following way:

1. Forms DRS-1 (or DRS-1A) and DRS-2 must be completed and forwarded with all pertinent medical and hospital records to the Disability Review Section, Division of Medical Assistance and Health Services. This should be done as quickly as possible and shall be completed within 30 days.

i. Give Form DRS-1 or DRS-1A to applicant to be filled in by his or her physician and returned to the welfare agency. If applicant prefers, the eligibility worker shall send the form with signed release to the doctor. The client should be warned that many physicians might not be as prompt in returning this form by mail as when filling it in the client's presence. When the form is returned, it shall be reviewed for completeness, including the physician's signature.

ii. Complete Form DRS-2 (Medical Social Information Report). This requires full and careful discussion with applicant of the relevant information and possibly a home visit.

(e) The existence of a physical or mental defect, illness, or impairment must be substantiated by current medical information (pertinent within the past three months):

1. This requires evidence of a defect, illness or impairment that is described by an examining physician in such a manner that another physician would reasonably accept the concept that incapacity exists without examining the client.

2. The unsupported opinion of the examining physician that an incapacity exists may, in itself, be accepted. However, material presented under the heading of Social Evaluation and Plan on Form DRS-2 or in other portions of the case record should also be evaluated in demonstrating that incapacity exists.

3.3 A specific diagnosis is not required.

4. Reports from attending physicians, recognized specialists, hospital or clinic reports or abstracts, photo copies of hospital discharge diagnoses or summaries, objective physical findings, diagnostic studies, and so forth, are all acceptable as supporting material.

(f) The following concern a parent incapacitated by mental defect, illness, or impairment:

1. A medical determination that a parent requires institutional care by reason of a diagnosis of mental incapacity does not affect the eligibility of the family. However, the extent of the "incapacity" and its relationship to the ability of the parent to provide "support or care" shall be determined.

2. It is not necessary for purposes of eligibility of the spouse and child to establish whether the incapacitated parent is competent to manage his or her own affairs since the spouse can be payee for the Health Benefits Identification (HBID) Card. It is probable that in an instance where the mental condition is of such degree as to raise these questions, the parent should apply for disability assistance under SSI.

3. Where the report of the examining physician, institutional or clinic records are available, and appear to provide current data adequate to a determination that "incapacity" exists, these shall be accepted. Whenever, in the judgment of the Disability Review Section, special psychiatric, neurological or psychological examination of testing is necessary or advisable, special consultants or facilities may be used.

(g) The following concern "incapacity" and its relation to employment:

1. When incapacity of a parent persists by reason of a permanent defect, illness or impairment but cannot be considered totally disabling because he or she can do some work, he or she may be considered "incapacitated" when there is evidence to demonstrate that his or her earning ability is limited by reason of the incapacity.

2. Thus, if because of his or her defect, illness, or impairment, he or she can engage only in part-time employment (that is, less than 30 hours per week), or his or her wages (or rate of pay) are less than those of other workers in the same type of work, he or she and any otherwise eligible dependents may be eligible for AFDC-related Medicaid. However, a parent who is found able to engage in full-time employment at normal rate of pay, but whose earnings are insufficient to adequately support his or her dependents, cannot be considered "incapacitated." In this situation, the CWA shall explore eligibility for AFDC-F.

3. When a parent has been determined "incapacitated" by reason of a temporary defect, illness, or impairment and no residual effects are anticipated upon recovery, such a parent shall be considered no longer "incapacitated" upon statement by the treating physician that he or she is able to resume full-time gainful employment in his or her previous or a similar occupation.

(h) The following concern refusal to undergo diagnostic evaluation, treatment, or related services:

1. In situations where a parent applicant claims to be "incapacitated" but refuses to undergo diagnostic evaluations considered by the Disability Review Section as essential to a determination of his or her "incapacity," the entire family is ineligible for the AFDC-C segment. However, refusal shall not affect the eligibility of his or her spouse and child for AFDC-F.

2. The CWA shall make every effort to establish the facts of eligibility on the basis of available evidence in spite of the refusal to undergo diagnostic evaluation.

3. If the family is eligible for Medicaid, the parent claiming incapacity shall be included if the incapacity can be established and the agency determines that the refusal is reasonable based on any of the following criteria:

i. The client is fearful of undergoing treatment, although such fear may appear to be unrealistic or emotional in origin or even irrational, if it is intense enough to adversely affect the result of treatment and a physician recommends against it;

ii. The client might suffer loss of a faculty, or the residual use of a remaining faculty, and he or she is unwilling to take the risk;

iii. The client has religious convictions that do not, in his or her judgment, permit him or her to undergo the recommended treatment; or

iv. The resistance to treatment is an element of the defect, illness or impairment itself.

4. An individual cannot be required to undergo treatment as a condition of eligibility.

(i) An incapacitated parent should be advised of services available through the social service unit and in the community.

(j) Payment for medical expenses incurred on behalf of an AFDC-C-related Medicaid (incapacitated) applicant in the determination of initial eligibility shall be the responsibility of the CWA and made from the administration account. The CWA shall advise the physician that payment of the fee will be at the applicable rate contained in the schedule of fees for professional and diagnostic services set forth at N.J.A.C. 10:54-9. Transportation for diagnostic evaluations shall be made available.

Notes

N.J. Admin. Code § 10:69-3.15

Amended by 49 N.J.R. 3729(a), effective 12/4/2017