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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 use Form CP-2
(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
- County Offices on Aging/Area Agencies on Aging case managers use Form
JCN-417 (Word, PDF).
- Assisted Living waiver providers use Form WPA-7 (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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