reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.14 - Hearings involving medical issues

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If the hearing
				involves medical issues, requiring a diagnosis or a report from an examining
				physician, or concerning a determination by the DMAHS Disability Review Unit,
				the ALJ may issue an order requiring a medical assessment by someone other than
				the person who made the original medical determination.
(b) The CWA shall pay for this medical
				assessment which shall be obtained at reasonable expense.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 6 - COMPLAINTS, HEARINGS AND ADMINISTRATIVE REVIEWS › Section 10:69-6.15 - Decision by Director, Division of Medical Assistance and Health Services

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				A final administrative hearing decision shall be rendered by the Director of
				the DMAHS. The applicant/beneficiary, his or her representative, and the CWA
				shall be notified by mail of any decision or order.
1. Unless otherwise indicated, the decision
				shall be effective on the date of issuance.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 7 - CASE RECORDS AND FILES › Section 10:69-7.1 - Purpose of case records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The case record
				is the official file of forms, chronological narrative, correspondence, and
				other documents pertinent to the application and eligibility of the client. It
				constitutes a complete record of the CWA's decisions and actions about
				eligibility for each case. Since it is the record of information on which
				decisions to grant, deny, or continue Medicaid coverage in accordance with law
				and regulations are made, it is mandatory that a case record be established for
				every individual who applies for and/or receives Medicaid.
(b) The case record shall be kept absolutely
				confidential.
(c) The case record
				also serves:
1. To provide the information
				necessary for action in conformity with all relevant legal requirements in the
				CWA's relationship with the client;
2. To provide an adequate and accurate source
				of information for the DMAHS and Federal staff for statistical studies or other
				research purposes that will be statistical in nature and include no
				beneficiary's names; and
3. As an
				essential tool in supervision.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 7 - CASE RECORDS AND FILES › Section 10:69-7.2 - Contents of the case record

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The validity of
				all case action rests primarily on the significance of the data in the case
				record. The following items shall be part of the case record:
1. All completed forms necessary for the
				appropriate AFDC-related Medicaid programs;
2. Any pertinent narrative
				recording;
3. A log of each contact
				with client and summary of substance;
4. All medical reports, as appropriate;
				and
5. All case-related referrals,
				correspondence, memorandums and documents except those that are required by law
				or regulation to be maintained in some other files.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 7 - CASE RECORDS AND FILES › Section 10:69-7.3 - Documentation of verification of factors of eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) It is
				essential that the CWA carefully document its verification of all eligibility
				requirements. It is extremely important that when reference is made to a
				document or source of verification, sufficient information be provided so that
				the document or source can be readily identified.
(b) The preferred method of documentation is
				inclusion in the case record of the original document, or photocopy of such
				document verifying a factor of eligibility.
1. If the eligibility worker has reviewed but
				not obtained a copy of a document, a description of the document and its
				location shall be included in the case record to facilitate review of the
				material, where necessary, by the Division of Medical Assistance and Health
				Services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 7 - CASE RECORDS AND FILES › Section 10:69-7.4 - Maintenance and custody of case records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All
				financial eligibility record material relevant to each client or client group
				shall be maintained in a folder, jacket, or envelope bearing the appropriate
				registration number, separate and apart from material relevant to social
				services.
(b) All records shall be
				filed in a secure and fire-resistant room. A separate file shall be maintained
				for each program. The CWA director may further subclassify the case records in
				whatever manner is best suited to local administrative use and control,
				provided that all such classifications are cross-indexed so that it shall be
				possible to locate immediately the whole of any case record either by name or
				registration number.
(c) All
				records shall be maintained in accordance with the New Jersey Division of
				Revenue and Enterprise Services (DORES) Records Management Services (RMS)
				policy (see N.J.A.C. 15:3). The RMS website is:
http://www.nj.gov/treasury/revenue/rms/index.shtml
.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 7 - CASE RECORDS AND FILES › Section 10:69-7.5 - Movement of case records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No case record
				or official part of such record shall be removed from its designated filing
				cabinet without an identifying record of the person who has custody of
				it.
(b) Any case record or official
				part that has been removed from its designated filing cabinet shall be placed
				in some similar storage arrangement at the close of each business
				day.
(c) No case record or official
				part shall be removed from the offices of the CWA except at the specific
				authorization of the director, deputy director, or other person specifically
				designated by the agency director to authorize such removal.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 7 - CASE RECORDS AND FILES › Section 10:69-7.6 - Transfer of case records

Current through Register Vol. 56, No. 14, July 15, 2024
No case record or official part of such record shall be
				  permanently removed from its designated filing cabinet unless and until it is
				  transferred in its entirety to the custody of some other CWA or it comes under
				  the provisions of
				  N.J.A.C.
				  10:69-7.7.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 7 - CASE RECORDS AND FILES › Section 10:69-7.7 - Retention and destruction of case records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each
				CWA shall retain all material normally kept in the "case folder" for the time
				periods indicated in (b) below. At the expiration of such time period the CWA
				may, at its option, destroy records in accordance with (c) and (d) below,
				continuing to retain those portions indicated. In permanent available archives,
				the CWA shall retain information showing the date and manner of destruction of
				each "case folder" destroyed.
1. "Case
				folder" shall be construed to mean the entire set of financial eligibility
				records related to eligibility determinations for one person or household. Each
				such case folder may be reviewed as a single unit without reference to the fact
				that the person(s) involved may have received Medicaid or may be receiving
				Medicaid under another program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 7 - CASE RECORDS AND FILES › Section 10:69-7.8 - Agency controls for other operational procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each
				CWA director shall establish operational procedures and appropriate controls
				for the staff that will expedite the processing of applications and ensure
				maximum compliance with policy and regulations.
(b) Control records shall include
				identification of pending cases upon which action must be taken within 30 days
				of application, and shall indicate any case about which decision has not been
				made within the 30-day limitation.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 7 - CASE RECORDS AND FILES › Section 10:69-7.9 - Disclosure of records or information for formal proceedings

Current through Register Vol. 56, No. 14, July 15, 2024
Pertinent information and records shall be released to the
				  participants only, in the course of any fair hearing or in the course of any
				  other formal proceeding provided for in Titles 30 and 44, New Jersey Statutes
				  Annotated, and in the Federal Social Security Act.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 7 - CASE RECORDS AND FILES › Section 10:69-7.10 - Release of information for statistical purpose

Current through Register Vol. 56, No. 14, July 15, 2024
Any statistical data or other information not including any
				  names or personal information may be released.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 8 - OTHER GOVERNMENTAL PROGRAMS › Section 10:69-8.1 - Retirement, Survivors and Disability Insurance

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Retirement,
				Survivors and Disability Insurance (RSDI) is a Federal program administered by
				the Social Security Administration (SSA) which provides protection to workers
				and their families against loss or stoppage of earnings resulting from
				retirement at age 62 or older, death and disability. The possibility of
				entitlement to Social Security benefits shall be explored with every applicant
				and beneficiary.
(b) Substantially
				all workers and self-employed persons, including military servicemen, are
				protected by Social Security coverage or are under another governmental
				retirement system (Civil Service or Railroad Retirement).
(c) Since Social Security benefits are an
				available resource, a beneficiary or applicant who has potential eligibility
				for such benefits, even at a "reduced" rate, shall apply for them.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 8 - OTHER GOVERNMENTAL PROGRAMS › Section 10:69-8.2 - Procedures for securing information from the Social Security Administration

Current through Register Vol. 56, No. 14, July 15, 2024
(a) CWAs are required to use the Automated
				Benefit Information Exchange (ABIE)/Beneficiary Earnings and Data Exchange
				(BENDEX) and the State Data Exchange (SDX) as the primary source of
				verification of Social Security (RSDI) and Supplemental Security Income (SSI)
				benefit information.
(b) The State
				Verification and Exchange System (SVES) is to be used to obtain RSDI and SSI
				data for AFDC-related applicants and beneficiaries when ABIE/BENDEX and SDX
				information is not available.
(c)
				The SVES may be supplemented through use of Form SSA-1610-U2 (Social
				Security-Public Assistance Agency Request for Information) to resolve conflicts
				between other evidence and data shown in the ABIE/BENDEX, SDX and SVES files,
				for example, an identification problem.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 8 - OTHER GOVERNMENTAL PROGRAMS › Section 10:69-8.3 - Release of information by CWA to Social Security Administration (SSA)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When the SSA requests information to
				assist in determining an applicant's eligibility for any benefits, the CWA is
				authorized to release such information from its records.
(b) Medical information when requested shall
				be provided since this information will be used by professional medical
				personnel in determining disability status for disability benefits.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 8 - OTHER GOVERNMENTAL PROGRAMS › Section 10:69-8.4 - Entitlement of child born of unmarried parents

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A child born of
				unmarried parents may be entitled to RSDI benefits based on the earnings record
				of the birth mother or birth father subject to the conditions and proofs in
				this section.
(b) In New Jersey, a
				child born of unmarried parents has the requisite status for entitlement to
				RSDI benefits based upon the earnings record of the birth mother without
				meeting any special requirements beyond proof of the relationship.
(c) In New Jersey, a child born of unmarried
				parents may be entitled to RSDI benefits based upon the earnings record of the
				birth father under any of the following circumstances:
1. When the wage earner is the birth father
				and marries the mother;
2. When the
				wage earner has acknowledged in writing that the child is his. The
				acknowledgment need not be in any special form, but must identify the child in
				question and further identify such child as his own. Examples of an acceptable
				written statement include income tax return, a serviceman's application for
				allotment, a will, an application for insurance, or a letter:
i. The written statement should be signed by
				the wage earner, but an unsigned statement may have value if there is evidence
				that it was prepared by the wage earner;
3. When the wage earner has been determined
				to be the father under the provisions of N.J.S.A. 9:16-1 et seq. or 9:17-1 et
				seq., or he has been ordered to contribute to the support of the child on the
				basis of a determination that such child is his, at a point in time which is:
i. Not less than one year before the time he
				became entitled to retirement benefits or attained age 65, whichever is
				earlier;
ii. Before the beginning
				of his most recent period of disability on which his claim for disability
				benefits is based; or
iii. Before
				his death;
4. The
				adjudication of paternity or order of support must identify the child in
				question and further identify such child as the son or daughter of the wage
				earner. The amount directed to be paid for the support of the child, or whether
				support payments are actually made, is immaterial; or
5. When there is satisfactory evidence of
				paternity and the birth father was living with or contributing to the support
				of the child as of the time:
i. The birth
				father became entitled to retirement benefits or attained age 65, whichever is
				earlier;
ii. The birth father's
				most recent period of disability began; or
iii. The birth father died.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 8 - OTHER GOVERNMENTAL PROGRAMS › Section 10:69-8.5 - Department of Labor and Workforce Development

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				Department of Labor and Workforce Development is responsible for the
				administration of Unemployment Insurance and Temporary Disability
				Benefits.
(b) The Department of
				Labor and Workforce Development maintains local offices and provides itinerant
				services at necessary points, which vary from time to time with economic
				conditions, on specified days or during specified seasons of the year. The CWA
				may obtain copies of a published list of the local and itinerant offices from
				the Department of Labor and Workforce Development, PO Box 110, Trenton, New
				Jersey 08625-0110.
(c) It is
				essential that the CWA staffs familiarize themselves with the general rules of
				eligibility for receipt of unemployment insurance and temporary disability
				benefits, payment provisions, and duration of weekly payments for persons who
				have been engaged in "covered" employment.
(d) The following concern the verification of
				the status of a claim for unemployment insurance:
1. Claims for unemployment insurance benefits
				are filed at the appropriate local Reemployment Call Center or online at
www.njuifile.net
.
2. It should be possible for the agency to
				secure from the client all the necessary information about his or her
				eligibility for and the receipt of unemployment insurance benefits.
3. The CWA shall obtain unemployment status
				verifications via access to the Department of Labor and Workforce Development's
				Local Office Online Payment System (LOOPS).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 8 - OTHER GOVERNMENTAL PROGRAMS › Section 10:69-8.6 - Functions of the Department of Veterans Affairs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				Department of Veterans Affairs operates the Federal program of benefit payments
				and health and welfare services to veterans and to certain of their dependents
				or survivors. To be eligible for these benefits and services, the veteran,
				serving in either war or peacetime service, shall have been released with other
				than a dishonorable discharge.
(b)
				Exploration of veterans benefits is a condition of eligibility for AFDC-related
				Medicaid provisions as follows:
1. Veterans
				benefits are a resource for a number of AFDC-related Medicaid beneficiaries,
				and shall be carefully explored in the process of determining need.
2. In the case of a person who is a veteran
				(or a dependent or survivor of a veteran) and presumptively eligible for any
				form of veterans benefits, it shall be required as a condition of eligibility
				for AFDC-related Medicaid that application for such benefits be made and fully
				processed.
i. The exception to this
				requirement are certain persons who had been receiving Veterans Administration
				(VA) pensions prior to December 1978 and elected to continue receiving "lower"
				pension amounts in order to retain AFDC-related Medicaid eligibility. Those
				individuals shall not, as a condition of eligibility for AFDC-related Medicaid,
				be required to apply for "improved" or higher pension amounts to which they may
				be entitled.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 8 - OTHER GOVERNMENTAL PROGRAMS › Section 10:69-8.7 - Availability of Work First New Jersey

Current through Register Vol. 56, No. 14, July 15, 2024
It is the responsibility of the county board of social
				  services staff to inform clients and members of their immediate families of the
				  availability of general assistance, if appropriate.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.1 - Adherence to law and regulations

Current through Register Vol. 56, No. 14, July 15, 2024
There must be strict adherence to Federal and State law and
				  regulations. Requirements other than those established pursuant to Federal and
				  State law and regulations shall not be imposed as a condition of receiving
				  AFDC-related Medicaid.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.2 - Issuance of manual

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Rules concerning assignment and
				responsibility are as follows:
1. The
				director of the CWA shall assign copies of this chapter as an eligibility
				manual to administrative staff and all other income maintenance staff members
				working with applicants and beneficiaries and to social services staff as
				appropriate and shall ensure that each staff member is thoroughly familiar with
				its contents and applies the required policy and procedures
				consistently.
2. The Division of
				Medical Assistance and Health Services (DMAHS) shall issue updates to this
				chapter with revisions duly promulgated in accordance with the Administrative
				Procedure Act,
				N.J.S.A.
				52:14B-1 et seq., as well as informational
				materials, as necessary. It is the responsibility of each holder of the manual
				to maintain its accuracy by accessing updated copies of the manual in
				accordance with (b) below.
3. One
				administrative copy of obsolete material related to this manual shall be kept
				by the CWA.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.3 - CWA reporting requirements

Current through Register Vol. 56, No. 14, July 15, 2024
The CWA shall provide all reports as requested by the
				  Division of Medical Assistance and Health Services (DMAHS).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.4 - Issuance of identification cards (validation of eligibility)

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Each individual eligible for AFDC-related Medicaid will be issued a permanent,
				plastic identification card, the Health Benefits Identification (HBID) Card.
				The card is for identification purposes only; providers must verify eligibility
				before they provide services. In instances in which the individual requires
				emergency medical services prior to receiving his or her permanent HBID Card,
				the eligibility office will issue an HBID Emergency Services Letter containing
				the pertinent information that the provider will need to confirm eligibility
				and submit claims for services rendered to that client (see
				N.J.A.C.
				10:49-2.15 ).
(b) Upon notification from a client that his
				or her HBID Card has been lost or stolen, the CWA shall immediately issue a
				replacement card.
(c) A client who
				resides in a State or county institution shall be identified by the FD-34 Form,
				"Validation of Eligibility" (see
				N.J.A.C.
				10:49-2.16 ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.5 - Separation of income maintenance and social services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Income
				maintenance includes responsibility for applications, determining eligibility
				and continuing eligibility and verification of eligibility factors.
(b) Social services are those activities
				directed toward informing applicants and beneficiaries of available services,
				and assisting individuals and families by providing direct service, purchasing
				service or by referral to a community agency.
1. The client shall be as fully informed as
				possible at each contact by staff of each unit of the programs and services for
				which he or she may be eligible.
2.
				Some situations that would call for social services include:
i. A change in circumstances possibly
				affecting need for services;
ii.
				Follow-ups resulting from recommendations of the Disability Review
				Section;
iii. Exploring potential
				for services from other agencies;
iv. Protective services for
				children;
v. Early periodic,
				screening, diagnosis and treatment;
vi. Family planning; and
vii. Any other apparent need for
				services.
3.
				Interrelated activities which specifically involve TANF eligibility or other
				services include, but are not limited to:
i.
				Sharing information concerning IV-D child support and AFDC-related
				Medicaid;
ii. Sharing information
				concerning need of emergency assistance by a family; and
iii. Determinations of gross income and
				family size at time of case closing for post-AFDC-related Medicaid benefit
				purposes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.6 - Payment of funeral and burial expenses; all segments

Current through Register Vol. 56, No. 14, July 15, 2024
Funeral and burial expenses may be provided for AFDC-related
				  Medicaid beneficiaries (all segments) as regulated in N.J.A.C. 10:90-8.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.7 - Reporting of child abuse and neglect

Current through Register Vol. 56, No. 14, July 15, 2024
CWAs are required to report known or suspected instances of
				  child abuse and neglect of a child receiving AFDC-related Medicaid to the
				  Division of Child Protection and Permanency. Instances of abuse and neglect
				  involve situations where a child experiences physical or mental injury, sexual
				  abuse or exploitation, or negligent treatment or maltreatment under
				  circumstances that indicate that the child's health or welfare is
				  threatened.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.8 - Confidentiality of information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No member,
				officer, or employee of the CWA shall produce or disclose any confidential
				information to any person except as authorized below.
1. Information considered confidential
				includes, but is not limited to, the following:
i. Names and addresses, including
				lists;
ii. Information contained in
				the application, reports of investigation, report of medical examinations,
				correspondence and other records concerning the condition or circumstances of
				any person from whom or about whom information is obtained, and including all
				such information whether or not it is recorded; and
iii. Records of evaluation of such
				information.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.9 - Disclosure of records or information for formal proceedings

Current through Register Vol. 56, No. 14, July 15, 2024
Pertinent information and records shall be released to the
				  participants only, in the course of any fair hearing or in the course of any
				  other formal proceeding provided for in Titles 30 and 44, New Jersey Statutes
				  Annotated, and in the Federal Social Security Act.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.10 - Release of information for statistical purpose

Current through Register Vol. 56, No. 14, July 15, 2024
Any statistical data or other information not including any
				  names or personal information may be released.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.11 - Material sent to applicants or beneficiaries of AFDC-related Medicaid program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All materials distributed to program
				applicants or eligible persons shall:
1.
				Directly relate to the administration of the AFDC-related Medicaid
				program;
2. Have no political
				implications;
3. Contain names only
				of individuals directly connected with the administration of the AFDC-related
				Medicaid program; and
4. Identify
				those individuals only in their capacity with the State or the CWA.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.12 - Nondiscrimination

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Title VI of the Federal Civil Rights Act
				of 1964 (
				42
				U.S.C. §§
										2000d et seq.), section
				504 of the Rehabilitation Act of 1973 ( 29 U.S.C. § 70b ), the Age
				Discrimination Act of 1975 (
				42 U.S.C. §§
										6101 et seq.), and the Americans with
				Disabilities Act of 1990, (
				42 U.S.C. §§
										12101 et seq.), Section 1557 of the
				Affordable Care Act of 2010 (ACA), and the regulations issued thereunder by the
				Department of Health and Human Services (45 CFR Parts 80, 84, and 90), prohibit
				discrimination on the basis of race, color, sex, religion, age, national
				origin, or disability in the administration of any program for which Federal
				funds are received. Strict compliance with the provisions of these acts and any
				regulations based thereon is required as a condition to receive Federal funds
				for the assistance programs administered by the CWA.
1. The CWA shall inform all staff members of
				their obligations in regard to the Civil Rights Act of 1964, Section 504 of the
				Rehabilitation Act of 1973, Section 1557 of the ACA of 2010, and the Americans
				with Disabilities Act.
2. All
				persons seeking medical assistance shall be informed of Title VI of the Civil
				Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Section 1557
				of the ACA, and the Americans with Disabilities Act.
3. All persons seeking or receiving medical
				assistance shall be afforded an opportunity to file a complaint alleging
				discrimination on the basis of race, color, sex, religion, age, national
				origin, or disability. Such complaints may be filed directly with the Regional
				Manager, U.S. Department of Health and Human Services, Office of Civil Rights,
				Jacob Javitz Federal Building, 26 Federal Plaza, Suite 3312, New York, New York
				10278, or with the Director, Division of Medical Assistance and Health
				Services, PO Box 712, Trenton, New Jersey 08625-0712.
4. In any instance in which a complaint of
				alleged discrimination is filed with a State or county agency, the complaint
				shall be forwarded immediately to the Director, Division of Medical Assistance
				and Health Services. The Director, upon receipt of any such complaint, shall
				take any such action he or she deems appropriate to the situation. This action
				may include, but is not limited to, the securing of reports from whatever
				sources have knowledge pertinent to the situation and referral to the Division
				of Civil Rights of the New Jersey Department of Law and Public Safety, for
				investigation, evaluation, and recommendation by that agency.
5. The CWA shall afford full cooperation in
				the investigation of complaints of discrimination as may be requested by the
				Federal Department of Health and Human Services, the State Division of Medical
				Assistance and Health Services, or the State Division of Civil
				Rights.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.13 - Extent of prohibited discriminatory practices

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				discriminatory practices prohibited under
				N.J.A.C.
				10:69-9.12 extend to all CWA
				offices.
(b) Prohibited
				discriminatory practices extend to services purchased or otherwise obtained by
				the CWA from other agencies, organizations, and institutions for beneficiaries
				of the program, and to the treatment of clients in facilities in which such
				services are provided.
1. In case of medical
				emergencies, the CWA is authorized to utilize the services of any medical
				institution for the duration of the emergency, even though such institution
				refuses or fails to comply with the requirements prohibiting discriminatory
				actions. Both the following conditions must exist:
i. The emergency must be such that the
				immediate provision of services or other benefits to an individual is necessary
				to prevent his or her death or serious impairment of his or her health;
				and
ii. Such services or other
				benefits are not immediately available from any other medical institution.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.14 - Procedures regarding payments to vendor

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The CWA
				shall establish procedures to ensure that all vendors to whom payment is being
				made, other than medical services, including, but not limited to,
				transportation, will receive on an annual basis a copy of Form WD-1A, A
				Statement Concerning Obligations of Vendors.
1. The CWA shall maintain a record of those
				vendors who have received this form, with the date of mailing.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.15 - Eligibility fraud by applicants and beneficiaries

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To
				protect the CWA and the public, it is essential to exercise appropriate
				controls against the commission of fraud relating to program
				eligibility.
(b) A person is
				presumed innocent until convicted. Therefore, except as provided in (c) below,
				Medicaid coverage shall be continued to an eligible person, even though there
				is reason to suspect that fraud has been committed, while the facts are under
				review by the agency or the law enforcement authority.
(c) Resolution of the question of possible
				fraud requires the cooperation of the beneficiary to protect his or her own
				interest; therefore, a beneficiary's failure or refusal to cooperate in the
				investigation would be grounds for suspending Medicaid coverage pending
				resolution of the issue. If during the investigation of an application for
				Medicaid, substantial evidence of fraud appears, disposition of the application
				shall be deferred pending resolution of the issue.
(d) Statutory authority regarding the
				identification and prosecution of Medicaid fraud may be found in New Jersey
				Statutes Annotated, and includes, but is not necessarily limited to, the
				following:
1.
										2C:20-4 Theft by
				Deception;
2.N.J.S.A. 2C:21-1a
				Forgery;
3.N.J.S.A. 2C:21-3b
				Offering a False Instrument for Filing;
4.
										2C:28-2 False Swearing;
5.
										2C:28-3 Unsworn Falsification to
				Authorities;
6.
										2C:28-7 Tampering with Public
				Records or Information; and
7.
										30:4D-17 Penalty for Medicaid
				fraud
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.16 - Criteria for identifying cases of possible fraud

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Fraud is
				defined as obtaining or attempting to obtain Medicaid coverage to which an
				individual is not entitled by means of willful misrepresentation or by
				intentional concealment of a relevant fact. There are three basic elements that
				must be established:
1. The misrepresentation
				or concealment must have been deliberate and done knowingly. Fraud does not
				exist if the misrepresentation or concealment is the result of an unintentional
				act, a misunderstanding or mental incompetency. Distinction must also be made
				between intent to defraud by the individual and omission, neglect or error by
				the agency's representatives in securing and recording information;
2. The misrepresentation or concealment must
				have been undertaken for the express purpose of receiving or obtaining benefits
				or attempting to receive or obtain benefits; and
3. If the CWA had known the misrepresentation
				or concealment, or attempt to misrepresent or conceal a relevant fact, Medicaid
				coverage would not have been granted.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.17 - County welfare agency responsibility; administrative plan

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The role of
				the CWA is limited to responsibility for determining whether there is a basis
				in fact for believing that fraud may have been committed so that referral to
				the county prosecutor, other proper law enforcement official, or Division of
				Medical Assistance and Health Services for legal action is justified. The
				action taken by the law enforcement official following referral determines what
				further legal action shall be pursued. Whether fraud has actually occurred is a
				question for the courts.
1. The CWA director
				may utilize the power of subpoena given him or her by
				N.J.S.A.
				44:7-20 to secure testimony and records
				pertinent to the investigation and needed to determine true facts.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.18 - Referral by the CWA in cases of suspected fraud

Current through Register Vol. 56, No. 14, July 15, 2024
When the investigation of any case of suspected fraud is
				  completed, the director of the CWA, in consultation with counsel, shall be
				  responsible for determining whether the matter should be referred to the county
				  prosecutor, other proper law enforcement official, and/or the Division of
				  Medical Assistance and Health Services (DMAHS).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.19 - Reports on cases involving fraudulent receipt of Medicaid coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				In cases where the CWA has completed an investigation based upon a belief that
				fraud has been committed, a report shall be routed through the CWA director to
				the Division of Medical Assistance and Health Services. The report shall be
				completed when the CWA determines that no fraud exists, when the case is
				disposed of through administrative action, or when the case is forwarded to the
				county prosecutor.
(b) Upon
				disposition of the case by law enforcement officials (county prosecutor or
				municipal court), a subsequent report shall be completed and routed through the
				CWA director to the Division of Medical Assistance and Health
				Services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.20 - Recovery of incorrectly paid Medicaid benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In
				every fraud case, in addition to any criminal prosecution, recovery of the
				amount of assistance provided for medical care or supplies shall be sought. If
				the beneficiary is involved in a Medicaid managed care plan, the higher of the
				payments made by the managed care plan, or the amount expended by the Medicaid
				program for capitation costs shall be recovered. Recoveries of incorrect
				assistance by the CWAs shall be governed by
				N.J.A.C.
				10:49-14.4(b). Recovery of
				civil penalties shall be pursued by DMAHS in accordance with
				N.J.S.A.
				30:4D-17(c). The threat of
				prosecution should not be used as a means of effecting recovery; nor should the
				fact of a recovery affect the CWA decision concerning proper referral to the
				prosecutor. However, any recovery, or plan for recovery, should be reported to
				the prosecutor whenever such a referral has been made.
(b) The provision of (a) above is not
				intended to limit the responsibility and obligation of the CWA to seek
				recovery, through voluntary agreement or civil action, of funds improperly
				received by a client under circumstances other than fraud.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.21 - Reporting criminal offenses to law enforcement authorities

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Investigation of new applications or investigations for redetermination of
				eligibility may indicate to the CWA that a crime may have been committed.
				Allegations of the suspected commission of a crime may also be made known to
				the CWA through various other sources, including, but not limited to, phone
				calls, written communications, or verbal communications from individuals. In
				matters of reporting of criminal offenses, the CWA shall, at all times,
				maintain full compliance with the provisions of N.J.A.C. 10:69-7, dealing with
				basic principles for safeguarding of information.
(b) The nature of offenses which must be
				reported to local authorities are:
1. Arson,
				manslaughter, murder or any crimes which constitute crimes of the third, second
				and first degrees, such as atrocious assault and battery, carnal abuse, incest
				or rape. (Refer to legal counsel for additional information identifying crimes
				of the third, second and first degrees.); and
2. In order to afford protection to children,
				certain other crimes and abuses as required by Federal, State or local statute
				or regulations must also be reported to the proper authorities.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.22 - Rights of individual under investigation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				CWA shall insure that an individual under investigation shall have the
				following rights:
1. The agency shall insure
				that information obtained from or concerning a person under investigation shall
				be restricted in accordance with
				10:69-9.8. The agency shall take
				special precautions in obtaining information from a third party so that no
				accusations relevant to the alleged fraud are disclosed, including the reason
				for the investigation or the nature of the allegation, without the written
				consent of the individual under investigation.
2. The agency shall insure that investigative
				methods do not infringe on the civil liberties of the individual or interfere
				with due process of law. The agency shall be prohibited from obtaining forced
				entry, conducting residence searches without consent of the client, making home
				visits during normal sleeping hours (generally 10:00 P.M. to 7:00 A.M.) or
				requiring that an individual be subjected to a lie detector test.
3. The individual shall be advised of the
				opportunity, where available, to obtain legal counsel through Legal Services,
				Legal Aid Society, lawyer referral service of the Office of the Public
				Defender.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 9 - OTHER AGENCY RESPONSIBILITIES › Section 10:69-9.23 - Basis for recovery of incorrectly paid benefits for purposes other than for fraud, or third-party liability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Incorrectly
				paid benefits means Medicaid coverage received by or for an eligible unit for
				which they were otherwise not entitled. The overpayment was caused by reasons
				other than fraud or third party liability.
(b) Incorrectly paid benefits may occur
				through administrative error; failure of a client to inform the CWA or designee
				pursuant to Federal regulation of a change in income or circumstances; or when
				the client has received continued Medicaid coverage but has been found
				ineligible to receive such Medicaid coverage or part of such coverage by the
				fair hearing decision.
(c) The CWA
				or designee pursuant to Federal regulation shall seek recovery of all
				overpayments regardless of fault including AFDC-related Medicaid payments
				caused by administrative action or inaction. The CWA or designee pursuant to
				Federal regulation shall recover such incorrectly paid benefits in accordance
				with procedures set forth in this chapter.
(d) Medicaid incorrectly paid benefits to an
				eligible unit, all members of which are no longer receiving AFDC-related
				Medicaid program, shall be recovered by the CWA through a court of appropriate
				jurisdiction if the family does not voluntarily repay the
				overpayment.
(e) In locating former
				beneficiaries who have outstanding incorrectly paid benefits, the CWA shall use
				appropriate data sources such as unemployment insurance files, the Division of
				Taxation, the New Jersey Motor Vehicle Commission, Bendex, and other data
				sources relating to current or former beneficiaries.
(f) For incorrectly paid benefits occurring
				prior to October 1, 1981, the CWA shall recover only if the overpayment
				resulted from willful withholding of information by the beneficiary.
(g) The CWA may waive recovery of
				AFDC-related Medicaid incorrectly paid benefits if the eligible unit is no
				longer receiving AFDC-related Medicaid and the amount overpaid is less than $
				35.00. When the amount of the incorrectly paid benefit to an eligible unit no
				longer receiving AFDC-related Medicaid is $ 35.00 or more, the CWA may waive
				the recovery of the incorrectly paid benefit, if after a reasonable effort to
				recover the incorrectly paid benefits, the CWA determines it is no longer cost
				effective to continue recovery efforts. Recovery of overpayments due to fraud
				may not be waived regardless of the amount of incorrectly paid benefit.
1. Reasonable efforts to recover an
				incorrectly paid benefits include, at a minimum, written notification of the
				amount of and reason for the incorrectly paid benefit and that repayment is
				required.
2. All circumstances
				concerning a waiver of recovery must be fully documented in the case
				record.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 10 - INCOME › Section 10:69-10.1 - Income; financial eligibility standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) As a condition
				of eligibility for the AFDC-related Medicaid program, applicants must comply
				with the income standards set forth in this subchapter.
(b) It is the purpose of this subchapter to
				establish methods for evaluating income eligibility for families and children.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 69 - AFDC-RELATED MEDICAID › Subchapter 10 - INCOME › Section 10:69-10.2 - 7/1/92] Standard of need

Current through Register Vol. 56, No. 14, July 15, 2024
(a) New Jersey has
				established the following monthly Standard of Need:
Standard of Need
Number in
Monthly
Family
Standard
1
$ 410
2
$ 819
3
$ 985
4
$ 1,127
5
$ 1,260
6
$ 1,386
7
$ 1,505
8
$ 1,617
more than 8
add $ 112
each person