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Individuals seeking financial assistance from Medicaid for long-term care services must meet the program’s medical (clinical) and financial eligibility requirements.  The steps necessary to attain Medicaid approval are known as the Pre-Admission Screening (PAS) process.

The PAS process is administered statewide by Long Term Care Field Office (LTCFO)counselors.  Referrals are received in the LTCFO from a variety of sources, including:

  • Hospitals, including rehabilitation, psychiatric, acute care, and veterans;
  • Nursing Facilities, Special Care Nursing Facilities, and Intermediate Care Facilities – Mental Retardation (ICF/MR);
  • Assisted Living Residences, Comprehensive Personal Care Homes and agencies offering Adult Family Care and Assisted Living Programs; and
  • The community, from individuals in need of long-term care services or their caregivers, and community agencies including County Welfare Agencies and Boards of Social Services, Boarding Homes, Residential Health Care Facilities, the County Offices on Aging/Area Agencies on Aging, and Adult Protective Services.

Agencies making referrals for PAS are required to submit the following forms to the LTCFO:

  • Hospitals use Form LTC-4 (Word, PDF), the Hospital Pre-Admission Screening Referral. 
  • Nursing homes use Form LTC-2 (Word, PDF), the Notification from Long Term Care Facility of Admission or Termination of a Medicaid Client.
  • County Welfare Agencies and Boards of Social Services and County Office on Aging/Area Agencies on Aging care managers use Form CP-2 (formerly Form JCN-417) (Word, PDF).
  • Physicians referring people through County Welfare Agencies and Board of Social Services, and individuals referred from the community use Form PA-4 (Word, PDF), the Certification of Need for Patient Care in a Facility other than Public or Private General Hospital
  • Assisted Living waiver providers use Form AL-6 (Word, PDF), the Assisted Living/Adult Family Care (AF/AFC) Referral Form.
  • Individuals residing out-of-state who are seeking long-term care services in New Jersey use the Out-of-State referral packet available through the LTCFOs.

Note:  Approval for Medicaid Long Term Care Services is a two-fold process.  Waiver eligibility is contingent upon the financial eligibility determination for Medicaid by the County Welfare Agency or Board of Social Services.

Below is a table with the referral source, required referral documents and the critical information that needs to be completed to initiate the PAS.

 

Referral Source

Referral 
Documents Required

Critical Information

All Hospitals

 

 

Emergency Room

LTC-4

 

 

PA-4 or equivalent

LTC-4

Name of hospital, client’s name, date of birth, Social Security number (SSN), eligibility status, name of the social worker or discharge planner.

Same as above.

Nursing Facility

LTC-2

Client’s name, SSN, provider’s name, date of admission, client’s previous location and status:

  • Private to Medicaid
  • PAS Exempt

AL Waiver Providers

WPA-7

Client’s name, SSN, diagnosis, name of facility.

Community

County Welfare Agency or Board of Social Services

 

 

 

 

CP-2

 

If client receives Supplemental Security Income (SSI), no documents are required. The field office will confirm financial eligibility.

PA-4 (or its equivalent).

Client’s name, SSN, Medicaid number if available, address including county, telephone number, income if client wants a waiver, intake worker.

Client’s name, date of birth, current living situation, diagnosis, ADL needs, #10 must be “yes,” MD signature, date.

ADRC/AAA

JCN-417

 

 




PA-4 (or its equivalent).

 

 

 

Letter of eligibility.

Client’s name, SSN, Medicaid number if available, address including county, telephone number, income if client wants a waiver, intake worker.

Client’s name, date of birth, current living situation, diagnosis, ADL needs, #10 must be “yes,” MD signature, date

Client’s name and effective date

Adult Protective Services (APS)

PA-4 (or its equivalent)

Client’s name, date of birth, current living situation, diagnosis, ADL needs, #10 must be “yes,” MD signature, date.

AL Waiver Providers

AF/AFC Referral Form.

Client’s name, SSN, diagnosis, name of facility.

LTCFO request for referral from family

Field office cover letter for the PA-4, if needed.

 

Client’s name, address, SSN, contact person with phone number.

Out-of-State Referral

Out-of-State packet which must include letter from family requesting placement.

 

Client’s name, address, SSN, contact person with phone number.


 
 
 
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