reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 3 - ESTABLISHING PROGRAM ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-3.29 - Child or parent in an institution

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When a child
				who would be otherwise eligible for AFDC-related Medicaid is out of the home
				due to voluntary/involuntary placement in an institution, he or she shall be
				recognized as a member of the eligible unit so long as it is anticipated that
				he or she will return home within one year from the date of the placement.
				State only funds shall be used after the minor child has been absent from the
				home for more than 180 consecutive days.
1. A
				child whose placement is specified for a period longer than one year shall not
				be eligible during the entire period of placement. (See N.J.A.C. 10:69-11.5
				regarding visits home of seven or more days.)
2. Placement for an unspecified or
				indeterminate period shall be construed to be for less than one year. Should
				such period extend beyond one year, the child shall be deleted from the
				eligible unit at the end of the year.
3. In the case of a new application,
				eligibility of an institutionalized child shall be based on the specified
				length of the placement starting from the date the placement began.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 3 - ESTABLISHING PROGRAM ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-3.30 - Absence for reasons other than institutional

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Temporary absence of a child that has not lasted more than 30 consecutive days
				does not affect eligibility. When the absence of a child lasts longer than 30
				days or it appears that an absence will last longer than 30 days, the CWA shall
				review the situation.
1. If it is found that
				the parent or parent person lacks or will lack both physical custody and
				responsibility for day to day care of the child and the situation is likely to
				continue for more than 90 days, the child is no longer eligible for Medicaid
				coverage. In situations in which the whereabouts of the child is unknown, or
				the parent or parent-person is precluded from contact, or the time period is
				otherwise indefinite, the child is no longer eligible for Medicaid
				coverage.
2. If it is found there
				is reasonable expectation that the child will return to the home within 90
				days, the child remains eligible.
3. The child remains eligible during the time
				that the review under (a) above is in process, but not longer than 90
				days.
4. In unusual situations
				involving particular hardship, the CWA may consult with the Division of Medical
				Assistance and Health Services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 3 - ESTABLISHING PROGRAM ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-3.31 - Legally responsible relatives (LRRs)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Certain
				relatives are legally considered responsible to provide support if financially
				able and may be a source of income for an AFDC-related Medicaid applicant or
				beneficiary. The CWA shall determine the capacity of LRRs to contribute to the
				support of AFDC-related Medicaid applicants and beneficiaries.
(b) The CWA director is authorized under
				specified circumstances to apply to the appropriate court for a support order.
				In cases where a court order appears to be the only means of insuring
				consistent and actual support, the applicant/beneficiary may elect to receive
				from the CWA the grant for which he or she is eligible and request the CWA to
				collect the support payments (see
				N.J.A.C.
				10:69-3.36 ). The applicant shall be fully
				informed of these provisions and their impact:
1. The following chart identifies relatives
				who are recognized as legally responsible under AFDC-related Medicaid:
AFDC-related Medicaid
Legally Responsible Relative
Program
Spouse
X
Child under age 55
X
Parent of a child under 18 or of a
X
child over age 18 who is not an
AFDC-related Medicaid parent or
parent-person
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 3 - ESTABLISHING PROGRAM ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-3.32 - Support orders for legally responsible relatives

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The CWA
				director has authority, after due investigation, to direct a legally
				responsible relative to pay toward the support of an applicant for or
				beneficiary of AFDC-related Medicaid.
(b) Upon failure of such relative to comply,
				the director shall so certify in writing to the county court or to the court of
				juvenile and domestic relations of the county, whereupon such court may, after
				hearing, "order and adjudge the able relative or other persons responsible for
				the support of such applicant to pay such sum or to deliver to the court or to
				the CWA director such other pledge or guaranty as the circumstances may require
				in the discretion of the court for each such applicant."
(c) The CWA may also bring appropriate action
				in a court of competent jurisdiction to recover any sum of money due for
				Medicaid coverage given any person under this chapter against any person
				chargeable by law for the support of such persons.
(d) Where the relative from whom support is
				sought is a resident of another state and the CWA is unsuccessful in securing
				information and/or voluntary contributions commensurate with the evaluated
				capacity to support, either by direct correspondence or through an appropriate
				AFDC-related Medicaid agency, the procedures provided in the Uniform Interstate
				Family Support Act,
				N.J.S.A.
				2A:4-30.124 et seq., shall apply.
(e) When there is evidence that a relative is
				failing to comply with the order of the CWA director, the director shall follow
				the legal procedure as provided in (b) above. Where there is failure to comply
				with the order of a court, the CWA shall consult with the probation department
				or with the court that placed the order.
(f) With respect to AFDC-C segment, it shall
				be recognized that the presence of a stepparent in the home does not relieve
				either natural parent of duty to support a child.
(g) An order to support should not be sought
				against a reputed father of a child born of unmarried parents until paternity
				has been judicially established.
(h) The following concern the inability of a
				legally responsible relative to comply with an order:
1. Where there is evidence that a relative is
				not able or no longer able to comply with the order of the director, there
				shall be prompt reevaluation of capacity to support, and the order shall be
				voided or the amount adjusted, as appropriate.
2. Where such situation is found to exist in
				respect to a relative under court order to support, the terms of the order
				cannot be changed except by amendment by the court itself after review. The CWA
				will assist in initiating amendment proceedings in such cases.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 3 - ESTABLISHING PROGRAM ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-3.34 - Liquidation of all debts, claims, interests, settlements, and trust funds

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Members of the eligible family shall take
				all necessary and reasonable action to avail themselves of funds for support
				from others who owe or may owe money to them or who are holding funds for them.
				Any funds made available by such action shall be considered as income to the
				eligible family, except as provided in
				N.J.A.C.
				10:69-3.36(b).
1. When a trust fund exists for a member of
				the eligible family, the CWA shall determine whether or not the funds are
				currently accessible. If accessible, the funds represent a source of funds for
				support and shall be considered in determining eligibility.
i. When a trust fund is not currently
				accessible and it exists at the time of application, the client shall, as a
				condition of eligibility, make a bona fide presentation of a petition to the
				appropriate court for release of the funds for current and future support. The
				agency shall assist the client if necessary.
(1) When a trust fund is not currently
				accessible and came into being during the term of the assistance case, the
				agency shall present a petition to the appropriate court for release of funds
				for current and future support. The client shall, as a condition of continuing
				eligibility, provide whatever cooperation may be necessary in the presentation
				of the petition.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 3 - ESTABLISHING PROGRAM ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-3.35 - Repayment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The CWA shall, in all circumstances, take
				appropriate action to recover all AFDC-related Medicaid improperly granted. The
				action taken shall be in accordance with the appropriate sections of this
				chapter, N.J.A.C. 10:49, and any other applicable authority.
1. Recoveries of funds applicable to more
				than one CWA shall be divided according to the mutual agreement of the
				directors of the CWAs involved.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 3 - ESTABLISHING PROGRAM ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-3.36 - Action by CWA upon voluntary liquidation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon
				voluntary liquidation of a claim or interest, and the family is currently
				receiving AFDC-related Medicaid, the CWA shall evaluate the situation to
				determine the family's continued eligibility for Medicaid coverage.
(b) Rules on continued eligibility arising
				from sale of exempt resources (see
				N.J.A.C.
				10:69-11.1 for exempt resources) are as
				follows:
1. The CWA shall not terminate
				eligibility when the proceeds from the sale of an exempt resource are promptly
				reinvested in another exempt resource of the same type. Funds designated by the
				client as being reserved for such reinvestment, including any interest accrued
				during the period, may be held for up to three months, provided the funds are
				held in escrow or are otherwise unavailable for daily living expenses. The
				three-month period may be extended upon written approval of the Division of
				Medical Assistance and Health Services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 3 - ESTABLISHING PROGRAM ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-3.38 - Strikers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) AFDC-related
				Medicaid benefits shall not be payable for any month in which any caretaker
				relative with whom the child is living, is, on the last day of such month,
				participating in a strike. Additionally, no individual's needs shall be
				included in determining the amount of AFDC-related Medicaid payable for any
				month to a family if, on the last day of the month, such individual is
				participating in a strike.
1. The term
				"strike" includes any strike or other concerted stoppage of work by employees
				(including a stoppage by reason of expiration of a collective bargaining
				agreement) and any concerted interruption of operations by employees.
2. The term "participating in a strike" means
				an actual refusal in concert with others to provide services to one's
				employers.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 4 - MEDICAID SPECIAL › Section 10:69-4.1 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An individual under age 21, who would not
				have qualified as a dependent child for AFDC-related Medicaid, whether or not
				he or she lives with his or her parent(s), may be eligible for Medicaid
				Special.
(b) When the individual
				lives in the same household as his or her birth or adoptive parent(s),
				financial eligibility shall in all cases include the parent's(s') income. If
				applicable, the deemed income of the stepparent shall be included. For the
				determination of financial eligibility of an individual under the age of 21, he
				or she shall be considered to be in an eligible family consisting of the
				applicant, his or her parent(s) and the parent(s) dependent children.
(c) When an individual does not live with his
				or her birth or adoptive parent(s), eligibility shall be determined for an
				eligible family of one, considering only the individual's income (see
				10:69-4.2(c) 
				regarding LRRs).
1. An individual under age 21
				who would not have qualified as a dependent child for AFDC-related Medicaid
				shall be evaluated for Medicaid Special in accordance with this subchapter, but
				without regard to income or resources, if that individual was, at age 18, in
				foster placement under the supervision of the Division of Youth and Family
				Services with his or her maintenance paid in whole or in part from public
				funds. Such individual shall be eligible for medical coverage up to the age of
				21.
2. If the individual is married
				and living with his or her spouse, they shall be considered a family of two and
				the income of both parties shall be considered.
i. Medicaid coverage shall not be extended to
				a spouse age 21 or older, although his or her income shall be considered. If
				the spouse is under 21, both individuals shall be included.
3. College attendance shall be
				construed as a temporary absence from the home. College students shall be
				considered to be living with their parent(s), even if away from home during the
				school year. College students under age 21 who claim permanent residence apart
				from their parent(s) shall be evaluated in accordance with
				10:69-4.3.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 4 - MEDICAID SPECIAL › Section 10:69-4.2 - Determination of eligibility; Medicaid Special

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All
				appropriate rules in this chapter regarding income shall apply in determining
				financial eligibility. Requirements related to employment or training or job
				search activities, school attendance of a child, the birth of additional
				children, and parent minors not residing with specified
				applicants/beneficiaries are not applicable in the determination of eligibility
				for Medicaid Special. Sanctions relating to the Child Support and Paternity
				program shall not be imposed on applicants for Medicaid Special.
(b) Earned income shall be calculated in
				accordance with AFDC-C and -F procedures found in this chapter.
1. Work First New Jersey/GA payments whether
				in the form of cash, check or assistance order or a combination of the above
				shall be countable as income for purposes of determining eligibility for
				Medicaid Special. If the individual is ineligible for Medicaid Special due to
				this income, he or she shall be evaluated for the Medically Needy Program as a
				child or if disability is alleged, for New Jersey Care ... Special Medicaid
				Programs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 4 - MEDICAID SPECIAL › Section 10:69-4.3 - College students and Medicaid Special

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A student's
				permanent residence is considered to be with his or her parents even though he
				or she is temporarily absent to attend college. A student shall be determined
				"not living with parents" only when the CWA has verified that all of the
				following conditions exist:
1. The student
				lives apart from his or her parents for reasons other than convenience of
				attending school;
2. His or her
				parents do not provide one-half or more of his or her support; and
3. His or her parents did not claim the
				student as an exemption on their most recent Federal income tax return or they
				affirm that the student will not be claimed on their next return.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.1 - Continuing eligibility defined

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The eligibility
				of each case shall be redetermined at regular intervals.
(b) The eligibility worker shall be alert to
				indications of change in need for financial assistance or change in
				circumstances that may affect the eligible unit's continuing Medicaid
				eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.2 - Requirements for periodic redetermination

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Redetermination is a review of factors affecting AFDC-related Medicaid
				eligibility, including, but not limited to, continued parental deprivation, or
				changes in income. At the redetermination, the parent(s) shall complete an
				application for continuation for Medicaid. If a redetermination is not
				conducted and the CWA is responsible, the right of the client to continued
				Medicaid shall not be jeopardized.
(b) For beneficiaries of AFDC-related
				Medicaid, all factors of eligibility shall be redetermined at least every 12
				months. No case shall be terminated before evaluating eligibility, using data
				available from other sources, such as the Supplemental Nutrition Assistance
				Program (SNAP) or Work First programs. All cases determined ineligible for
				AFDC-Medicaid shall be screened for eligibility under all other program
				options. Referrals shall be coordinated to ensure that continuous coverage of
				benefits is available to the beneficiary, as applicable.
(c) Redeterminations shall be conducted in
				each case at least once every 12 months, but, at the beneficiary's option, the
				beneficiary may mail in the redetermination form to the CWA.
(d) It is the responsibility of the CWA to
				maintain a control file to assure that redeterminations are undertaken and
				acted upon at intervals as prescribed by this section. The redetermination time
				interval shall be contingent upon the month in which the beneficiary's
				permanent Health Benefits Identification (HBID) Card is issued, rather than on
				such factors as the date of application or final validation of
				eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.3 - Process of redetermination

Current through Register Vol. 56, No. 14, July 15, 2024
(a) At the option
				of the beneficiary, the face-to-face interview may be conducted. The
				eligibility worker shall assist the beneficiary in the completion of the
				application form, providing explanation as necessary. If the beneficiary cannot
				read, the contents of the form shall be read to him or her. Upon request, the
				client shall be given a copy of his or her executed application form, with any
				attachments. Signature requirements shall be the same as for initial
				application. The contact shall focus on discussion of the eligibility factors,
				which are subject to change and shall include information about any change in
				agency policy or procedure that affects the beneficiary's status. There shall
				also be a reevaluation of the family's need for social services. When the
				parent is represented by a protective payee or has a representative payee, such
				person shall also be interviewed. A summary report including all pertinent
				information shall be made for each contact with the parent(s), parent-person(s)
				or collateral sources.
(b) In each
				redetermination, it is the responsibility of the eligibility worker to complete
				the appropriate forms.
1. When there is a
				pending claim, the appropriate procedure in
				10:69-3.35 shall be
				followed.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.4 - Competency status in AFDC-related Medicaid

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				eligibility worker should be alert to the development of medical or mental
				problems that may affect the adequate functioning of the parent. Such evidence
				shall be submitted to the Disability Review Section for special
				review.
(b) If it is the finding of
				the CWA that the parent or parent-person has demonstrated such inability to
				manage the medical care of the child, the child's Health Benefits
				Identification (HBID) Card or HBID Emergency Services Letter can be issued to a
				third party. In such cases, the client shall be fully advised of his or her
				rights.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.6 - Requirements with respect to deprivation of parental support or care in AFDC-C

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Since eligibility in AFDC-C is based on
				the fact that the needy child has been deprived of parental support or care by
				reason of the death, continued absence from home, or mental or physical
				incapacity of a natural or adoptive parent, it is necessary to reevaluate these
				factors in determining continuing eligibility. A family may continue to be
				eligible for AFDC-C although the original reason for "deprivation" has changed.
				This may occur when an absent parent dies or, although returned to the home, is
				incapacitated. Such change in status shall be appropriately noted in the case
				record.
(b) When eligibility is
				based on deprivation of parental support or care by reason of the continued
				absence of a parent, the evaluation of continued eligibility shall include a
				determination that the absence still exists and, if not, whether there is
				another basis for eligibility.
(c)
				The following concern incapacity status for a natural or adoptive parent:
1. There shall be redetermination that
				"incapacity" exists in every case in which the eligibility of the family is
				based on the incapacity of a natural or adoptive parent.
2. The Disability Review Section, Division of
				Medical Assistance and Health Services shall designate the review date for the
				CWA. "Incapacity" shall be considered as continuing until the Disability Review
				Section officially determines that such incapacity no longer exists. The
				eligibility worker shall prepare Form DRS-2A, Interim Medical-Social Report,
				for the redetermination review. The CWA shall maintain controls on review dates
				so that any specific medical information or reports requested by the Disability
				Review Section may be obtained. In addition, the Disability Review Section
				shall maintain a control file in order to ensure appropriate and timely
				reevaluation by that Section. The Disability Review Section will notify CWAs
				one month in advance of cases scheduled for such review by means of Form
				DRS-5.
3. In any case in which,
				subsequent to a finding of "approved," the incapacitated parent becomes a
				beneficiary of Federal disability benefits or SSI benefits for reasons other
				than age, this of itself shall be considered conclusive proof of continuing
				incapacity, and the CWA shall disregard the "review date" for submittal to the
				Disability Review Section.
4. It is
				the responsibility of the eligibility worker to submit the record to the
				Disability Review Section for special review if available evidence raises
				question of continuing incapacity during the interval between redetermination
				review dates. The special review shall be requested through use of Form DRS-2A,
				Interim Medical-Social Report, together with all material previously
				submitted.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.7 - Marriage or remarriage

Current through Register Vol. 56, No. 14, July 15, 2024
In AFDC-C, when eligibility is based on the absence of one
				  parent and the remaining parent marries or remarries, such marriage or
				  remarriage does not in and of itself terminate eligibility but does require
				  prompt redetermination of financial need and eligible unit composition in
				  accordance with
				  N.J.A.C.
				  10:69-10.33.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.8 - Special conditions relating to parent(s) in AFDC-F

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When a
				parent becomes absent from the home and continuous absence is established
				(10:69-2.9(e) ),
				the AFDC-F case shall be transferred to the AFDC-C segment. No interruption of
				Medicaid shall result if AFDC-C eligibility begins with the absence.
(b) When a parent becomes hospitalized,
				incapacitated, committed to a mental institution, or incarcerated in a
				correctional facility and the CWA has evidence that this condition will
				continue beyond 30 days, the case shall be transferred to the AFDC-C segment.
				No interruption of Medicaid shall result if AFDC-related Medicaid eligibility
				begins with such aforementioned situation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.9 - Legally responsible relatives capacity to support

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each
				legally responsible relative's capacity to support shall be reevaluated at
				least once in each 12-month period and adjustments made as indicated (see
				10:69-3.31(d) 
				).
(b) Each legally responsible
				relative shall be contacted unless it can be verified that the relative:
1. Is receiving public or private financial
				assistance;
2. Has no source of
				support except fixed income, such as pension, retirement benefits or statutory
				benefits, and there was no capacity to support at time of last
				evaluation;
3. Is himself or
				herself dependent upon a relative (other than the client) for
				support;
4. Is receiving care in an
				institution for a mental or physical condition, or is in a penal institution
				and has no capacity to support; or
5. Cannot reasonably be anticipated to have
				experienced a change in income since the last evaluation that would affect his
				or her capacity to support. (The eligibility worker will consult with his or
				her supervisor when this appears to be the situation.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.10 - Recording and recommendation for changes in AFDC-related Medicaid eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
A complete summary report of pertinent information shall be
				  made for each contact with a beneficiary, which shall clearly state the basis
				  for any recommendation for termination of Medicaid. A new redetermination form
				  shall be completed for each redetermination.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.11 - Notice of agency decision

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each applicant
				shall receive timely and adequate written notice of any change in Medicaid
				eligibility status in accordance with N.J.A.C. 10:69-6.
(b) If the notice of intention to terminate
				Medicaid eligibility is related to identification of possible fraud,
				beneficiaries are entitled to timely notice as defined at
				N.J.A.C.
				10:69-6.1.
1. Seven days notice shall be considered
				timely when, in the judgment of the CWA director, there is substantiated
				evidence that the client is receiving Medicaid coverage through willful fraud
				(see N.J.A.C. 10:69-9.15 through
				9.18).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.12 - Periodic notice to client

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The client
				shall be informed periodically (at least once every 12 months) of his or her
				continuing obligation to furnish accurate and timely information to the CWA
				concerning changes in income or other circumstances that may affect the receipt
				of benefits. The applicant shall receive, and have explained if necessary, a
				copy of the pamphlet Medicaid Rights and Responsibilities. This pamphlet shall
				be given to the applicant at the time of application and at each
				redetermination if the beneficiary has not retained the copy previously
				provided. The client shall inform the CWA of any change as soon as possible but
				in no event later than two weeks after the change takes place. Failure of the
				client to so inform the CWA shall constitute willful withholding of
				information.
(b) The client, by the
				signing of an affidavit, agrees that he or she has received the pamphlet, has
				been informed of his or her rights and obligations as stated in the pamphlet,
				and understands them.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.13 - Extension of Medicaid benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Extended
				Medicaid benefits shall be provided to former AFDC-related Medicaid families in
				accordance with the provisions of this section for a period of 24 months
				beginning with the month in which the family no longer would have otherwise
				been eligible for AFDC-related Medicaid due to an increase in earned income.
1. When an AFDC-C or-F family loses
				eligibility for AFDC-related Medicaid due to the following reasons, Medicaid
				eligibility continues for a period of 24 months beginning with the month in
				which the family is no longer eligible for AFDC-related Medicaid:
i. Earnings or increased earnings from
				employment, including earnings from new employment;
ii. Increased hours of employment;
				or
iii. Receipt of New Jersey State
				unemployment or temporary disability insurance benefits.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 5 - CONTINUING ELIGIBILITY IN AFDC-RELATED MEDICAID › Section 10:69-5.14 - Change in eligible unit

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A newborn child
				shall be added to the AFDC-related Medicaid case effective with the date of
				birth, provided that the CWA is notified within one year of that
				date.
(b) The date of change for
				adding other members added to an eligible unit shall be the first day of the
				month the eligible unit reports to the CWA the addition of the
				member.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.1 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter,
				  shall have the following meanings unless the context clearly indicates
				  otherwise.
"Adequate notice" means a written notice that meets the
				  requirements of
				  N.J.A.C.
				  10:69-6.2(d).
"Administrative hearings" are hearings concerning either
				  contested cases or non-contested cases, which have been determined by the
				  Director of the Division of Medical Assistance and Health Services (DMAHS) in
				  accordance with N.J.A.C. 1:1-1, to be appropriately heard in the Office of
				  Administrative Law (see N.J.A.C. 10:6).
"Administrative law judge" (ALJ) means the person from the
				  Office of Administrative Law (OAL) who conducts the hearing and who writes an
				  initial decision which may be reviewed by the Director of the Division of
				  Medical Assistance and Health Services.
"Administrative review" means a review of a disputed matter
				  that has been determined by the Director of the Division of Medical Assistance
				  and Health Services not to constitute a contested case and therefore remains in
				  the Division for review. At the discretion of the Director, an administrative
				  review may be conducted as a procedure at which parties appear and are heard or
				  it may be a paper review (see
				  N.J.A.C.
				  10:69-6.6 ).
"Administrative review official" is a representative of the
				  State, Department of Human Services assigned to conduct an administrative
				  review.
"Adverse action" means any action by a CWA resulting in
				  denial of application for AFDC-related Medicaid. An adverse action is an action
				  to deny an application for Medicaid, or to terminate Medicaid (including
				  service, vendor payments, or Medicaid entitlement) or to deny payment to a
				  vendor for medical services required to be reimbursed by the CWA.
"CFR" is the acronym for Code of Federal Regulations.
"Contested case" means a dispute that is heard by an
				  Administrative Law Judge.
"Fair hearing" means a formal or informal procedure through
				  which an AFDC-related Medicaid client may protest an adverse action or decision
				  of the CWA regarding eligibility or manner of granting AFDC-related Medicaid.
				  Fair hearing is a general term that includes administrative hearing and
				  administrative review.
"Initial decision" means the decision of an administrative
				  law judge that is sent to the Director of the Division of Medical Assistance
				  and Health Services, who may accept, reject or modify it within 45 days.
"Timely notice" means that the notice is mailed at least 10
				  days before the effective date of agency action.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.2 - Right to fair hearing and administrative review

Current through Register Vol. 56, No. 14, July 15, 2024
(a) It is the
				right of every applicant or beneficiary adversely affected by an action by a
				CWA to be afforded a fair hearing in a manner established by the rules in this
				subchapter and by the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.
				These rules have been established pursuant to Federal regulations,
				45 CFR
				205.10, and the New Jersey Administrative
				Procedure Act,
				N.J.S.A.
				52:14B-1 et seq.
(b) The CWA shall promptly notify the
				beneficiary in writing of any agency decision affecting that client. The term
				"agency decision" refers to a decision made by the CWA and includes any
				decision made by the CWA. In the case of a client who cannot be located, notice
				shall be sent to his or her last known address.
(c) Agency action which adversely affects an
				applicant or beneficiary includes:
1. Any
				action, inaction, refusal of action, or unduly delayed action with respect to
				program eligibility, including, but not limited to, denial or termination of
				benefits; and
2. When the complete
				processing of an application is delayed beyond 30 days, the applicant is to be
				notified of this fact and the reason(s) for the delay on or before the
				expiration of such period (see
				10:69-2.14 and 2.15).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.3 - Responsibilities of the CWA in processing hearing requests

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon
				receipt of a timely request for a fair hearing, Medicaid coverage shall be
				continued until a written decision is rendered, unless:
1. A determination is made at the hearing by
				the ALJ that the sole issue is one of State or Federal law or policy, or change
				in State or Federal law, and not one of disputed facts; or
2. A change occurs which further affects
				beneficiary's eligibility while the first hearing decision is pending and the
				beneficiary fails to request an additional hearing after notice of this change
				within the time allowed.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.4 - Responsibilities of the Division of Medical Assistance and Health Services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each request for a fair hearing shall be
				registered by the Bureau of Administrative Review and Appeals (BARA) on the
				date the request is received.
(b)
				Requests initially received in BARA shall be transmitted by telephone to the
				CWA on the date received.
(c) BARA
				shall transmit each contested case to OAL within five work days of the receipt
				of the request.
(d) Written
				determination on entitlement to receive continuing Medicaid coverage shall be
				included in the OAL transmittal and sent to the applicant/beneficiary and the
				CWA.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.5 - Responsibilities of the Office of Administrative Law upon transmittal of a contested case from the DMAHS (45 CFR 205.10 and N.J.A.C 1:1-1 et seq.)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Office of
				Administrative Law shall schedule the hearing and shall send any necessary
				notices to the parties.
(b) The
				hearing shall be conducted by an administrative law judge who shall issue an
				initial decision.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.6 - Administrative hearings and administrative reviews

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Requests on
				matters which constitute a contested case (as defined by N.J.A.C. 1:1-1 and
				consistent with case law) shall be handled in accordance with the Department of
				Human Services (DHS) rules on "Administrative Hearings and Administrative
				Reviews" at N.J.A.C. 10:6.
(b)
				Requests on matters which do not constitute a contested case (as defined by
				N.J.A.C. 1:1-1 and consistent with case law) shall be handled in accordance
				with the DHS rules on "Administrative Hearings and Administrative Reviews" at
				N.J.A.C. 10:6.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.7 - Complaints and adjustment procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prompt and
				courteous attention shall be given to all complaints, whether or not such
				complaints constitute requests for fair hearing and whether or not they are
				directed to the CWA or the Division of Medical Assistance and Health Services.
				All complaints received shall be acknowledged promptly and, if it is not
				apparent from the complaint that a fair hearing request has been made, the
				acknowledgment shall inform the beneficiary of his or her right to a fair
				hearing.
(b) Informal efforts to
				effect a resolution may be made through field contacts, office interviews with
				supervisory personnel, or consultation with Division staff as needed. In no
				event, however, are such informal efforts to be considered as prerequisite to a
				fair hearing, and in no event do they delay, interfere with or otherwise impede
				the processing of a fair hearing whenever a request for such is made. Agency
				emphasis shall be on helping the client to prepare and submit his or her
				request for a fair hearing.
(c) Any
				clear expression (oral or written) by a beneficiary (or person acting for him
				or her, such as his or her legal representative or relative) to the effect that
				the beneficiary wants the opportunity to present his or her case to a higher
				authority constitutes a request for a fair hearing.
(d) A request for a fair hearing may be
				either oral or in writing and addressed to the CWA or to DMAHS. Oral requests
				for fair hearing shall be immediately reduced to a written record by the staff
				person to whom the request is made. No special form of statement or manner of
				expression is required so long as the request identifies the nature of the
				complaint and the relief sought. Requests made to the CWA shall be immediately
				transmitted to the BARA, and in no event later than one work day after receipt
				of the request.
(e) Upon receipt of
				any request for a fair hearing, a determination shall be made by DMAHS on the
				appropriateness of an administrative hearing or administrative review
				(N.J.A.C.
				10:69-6.6 ). If the matter is deemed
				contested, BARA will send an acknowledgment of the request to the client. All
				contested cases shall be promptly forwarded to the OAL for a hearing before an
				ALJ.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.8 - Time limitations on entitlement to fair hearings

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An applicant or
				beneficiary has a right to request a fair hearing which relates to an agency
				action or lack of action within 20 days of such action or lack of
				action.
(b) If the request for a
				fair hearing relates to an agency action or lack of action that occurred more
				than 20 days prior to the date of the request, there shall be no entitlement to
				a hearing on such action or lack of action, unless extraordinary and
				extenuating circumstances exist as determined by the Division of Medical
				Assistance and Health Services. Extraordinary or extenuating circumstances are
				defined as conditions beyond the applicant or beneficiary's control. This could
				include, but is not limited to, the beneficiary's receipt of notice after due
				date or personal illness or incapacity.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.9 - Eligibility for continued Medicaid coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When a
				request is made for a fair hearing within 15 days from the date of mailing of a
				notice of termination, Medicaid coverage shall be continued until the scheduled
				date of the administrative hearing or the date of the administrative review
				unless the beneficiary waives such entitlement or requests postponement of the
				scheduled hearing or review date. In the event the beneficiary elects to
				receive continued benefits, they will be continued pending a final decision if
				the ALJ or the administrative review official determines that the issue is one
				of fact rather than law or policy. (
				45 CFR
				205.10(a)(7) )
(b) An adjournment of a hearing at the
				request of a beneficiary shall not prolong continuation of Medicaid coverage,
				unless the adjournment is due to delay caused by DMAHS, OAL, or the CWA;
				unavoidable causes, such as an illness on the part of the
				applicant/beneficiary; or the failure of the CWA to provide assistance for
				transportation when such assistance is required by regulations. Adjournment at
				the request of the CWA or by the ALJ shall not affect continued
				benefits.
(c) The CWA shall
				promptly inform the beneficiary in writing whether or not Medicaid coverage
				shall be continued unreduced pending a final decision.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.10 - Access to discovery of information in contested cases

Current through Register Vol. 56, No. 14, July 15, 2024
The CWA shall provide the applicant/beneficiary and/or his or
				  her authorized representative opportunity to review the entire case file or
				  documents and records to be used in the administrative hearing. Such materials
				  shall be made available at a reasonable time before the scheduled hearing date
				  as well as during the hearing (see
				  45 CFR
				  205.10(a)(13)
				  ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.11 - Representation at hearings

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Representation
				shall be pursuant to
				1:10B-5.1.
(b) The CWA representative must have
				knowledge of the matter at issue and must be able to present the agency case,
				supplying the ALJ with that information needed to substantiate the agency
				action. If the CWA representative feels that he or she must be an advocate of
				the client and is unable to represent the agency, then another CWA staff person
				shall appear at the hearing to fulfill the above identified role.
(c) In hearings involving a determination by
				any component of the DMAHS, the matter at issue shall be presented by the
				appropriate staff representative(s) of the DMAHS.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.12 - Disposition of hearing request through withdrawal, abandonment, or settlement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prior to transmittal to OAL, if a party
				desires that a hearing request be withdrawn, that party shall notify the CWA or
				DMAHS in writing of the withdrawal request. DMAHS shall in turn acknowledge, in
				writing, receipt of the withdrawal request. No CWA shall deny or dismiss a
				request for a fair hearing. The determinations on the validity of each hearing
				request shall be made by the DMAHS including any determination on the
				appropriateness of processing hearing requests pursuant to this
				subchapter.
(b) The filing of a
				request for a fair hearing shall not of itself preclude continued effort to
				accomplish corrective action, settlement, or any other agreement through
				informal procedures. Any withdrawal or abandonment or any settlement or
				agreement reached, subsequent to the transmittal of the case to the OAL, shall
				be processed according to N.J.A.C. 1:1, including any Rules of Special
				Applicability which may apply to disposition by settlement or withdrawal.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.13 - Adjournments

Current through Register Vol. 56, No. 14, July 15, 2024
Any adjournment requested by an applicant or beneficiary and
				  granted by the OAL may not operate to extend the deadlines for a final decision
				  and final agency implementation of the final decision.